Anesthesia Consultation Program

Why a consultation program?
America can be proud of its hospitals and those who staff them.  However, modern times have brought about a climate of change.  Hospitals and their staff are making new demands on anesthesiologists.  They seek different services. They ask for increased services.  As hospitals have faced increasing demands by government, by their insurance carriers and by the Joint Commission, physicians have been called upon to provide a variety of medico-administrative services in such areas as quality assurance, credentialing, delineation of continuing education and the management of a department.

Economic pressures also have been a major problem for both hospitals and physicians as government and third-party payers struggle to cope with ever increasing demands for high-quality health care.  In addition, medical staffs are changing as our educational institutions continue to produce younger physicians who seek to practice newer techniques based on their recent experience and training.

These and many other issues are not easily managed, and often a neutral party may be the best resource to a hospital before deciding on a course of action.

History
The ASA Anesthesia Consultation Program came into existence as a result of the Society's need to respond to calls for help from medical staffs concerned with the quality of anesthetic care in their hospitals.  Accordingly, the ASA Committee on Quality Management and Departmental Administration developed an innovative national program whereby it would make available experienced, practicing anesthesiologists to conduct on-site consultations at requesting hospitals.

The Anesthesia Consultation Program became operational in 1982 following approval by the ASA Board of Directors and House of Delegates. Since that time, the Committee on Quality Management and Departmental Administration has been asked to assist more than 180 U.S. hospitals and their medical staffs to improve their quality of anesthetic care.

Follow-up questionnaires have reported excellent satisfaction with the consultations performed.

What is the Anesthesia Consultation Program?
The ASA Anesthesia Consultation Program consists of a group of Board-certified anesthesiologists who are mostly past or present members of the Committee on Quality Management and Departmental Administration.  Included are several Past Presidents of ASA, and many are chiefs or former chiefs of anesthesiology departments.  They come from all parts of the United States and work in institutions ranging from a 100-bed community hospital to a 1,000-bed medical teaching center.

Many of these consultants are well known as speakers at anesthesia meetings across the country, and each is actively involved in patient care.  All are thoughtful, experienced clinicians who bring years of experience to the program.  It is from this group that two of these individuals are appointed as an Ad Hoc Subcommittee to perform an Anesthesia Consultation.  Of course, no one serves as a consultant when such service would involve even the appearance of a conflict of interest.

How does the program work?
Though the first contact may be an informal query by letter or telephone, an Anesthesia Consultation requires a written request from both a hospital administrator and either the chief of the medical staff or the chair of the department of anesthesiology.  This official request is sent to the ASA Executive Office in Park Ridge, Illinois, and is then forwarded to the Chair of the ASA Committee on Quality Management and Departmental Administration for appointment of an Ad Hoc Subcommittee.

Prior to an Anesthesia Consultation, the requesting parties must enter into a formal, written agreement with ASA, providing for the payment of the consultants' fees and expenses and also indemnifying ASA and the members of the Ad Hoc Subcommittee.  In turn, the Society agrees to perform a careful, unbiased on-site evaluation of the quality of anesthesia care rendered in the hospital and to hold confidential any information obtained in the course of the consultation.

What type of hospital requests an anesthesia consultation?
ASA has consulted for all types of hospitals, ranging from small rural institutions to big urban medical centers.  The smallest to date has been 40 beds, the largest more than 1,200.  Approximately 45 percent of our requests come from medium-sized institutions with between 250 and 500 beds.  About 35 percent of the requests are made by hospitals with less than 250 beds, and 20 percent by large institutions.  About half of the hospitals give less than 5,000 anesthetics per year; a quarter give more than 10,000.

Institutions with less than 400 beds account for the majority of the total on-site consultation visits conducted since the program began.

What are the duties of the consultants?
Basically, they observe, they review, they recommend.  They interview administrators, all anesthesia staff, physicians, nurses and other hospital employees.  They inspect patient records, anesthesia charts and other relevant institutional and departmental documents.  They quietly observe the work of the anesthesiology department in operating rooms, delivery suites, postanesthesia care units and intensive care units.  They constantly question those they meet, and make it a priority to interview people with a variety of viewpoints.  They are particularly careful to try to understand conflicting views of any controversy.

Following the Anesthesia Consultation, the members of the Ad Hoc Subcommittee draft a report.  This report is then reviewed by the Chair or Vice-Chair of the Committee on Quality Management and Departmental Administration and also by the Society's legal counsel to ensure that the final document addresses the concerns raised by the hospital and its staff and clearly reports the Subcommittee's findings, as well as the basis for these findings.  More importantly, the report includes feasible recommendations on how to address any deficiencies.

In keeping with ASA's pledge of confidentiality, copies of the final report are furnished only to those who sign the official request from the hospital, i.e., a representative of the hospital corporation, usually the administrator, and a representative of the hospital medical staff, usually its Chief of Anesthesia or President.

What has been found in previous consultations?
Upon reviewing the consultations that have been performed, what is found?  Usually, we encounter good anesthesiologists working in hospitals that are providing high-quality care to patients across the country. It is most rare to find an institution where everything is negative.  When weaknesses are found in one area, they are usually offset by strengths in other areas.

The consultants have encountered a variety of problems relating to the practice of anesthesia.  Sometimes these center on issues of competence.  Are the anesthesiologists practicing with appropriate, up-to-date knowledge?  Are there issues of an anesthesiologist's ability to perform various technical procedures?  Are there problems with the preoperative evaluation of patients or with the provision of postoperative care?  What is the appropriate coverage for anesthesia needs of patients?  Sometimes it appears that obstetric anesthesia is not given proper coverage or that epidural anesthesia is not available.  Occasionally, there are problems with night, weekend, holiday or in-hospital emergency coverage.  At times, it appears that the department leadership could be improved, specifically in such areas as competency evaluation, delineation of clinical privileges or a chief's ability to lead the department in providing contemporary anesthesia practice.  Can the chief deal effectively with issues of safety, quality assurance and continuing education, and the provision of the appropriate resources for a department?  Issues about the use of nonphysician anesthetists to provide technical assistance in an anesthesiologist's practice often arise.  Common issues include the adequacy of medical direction, the ratio of physicians to nonphysician anesthetists and the use of anesthetists to perform functions that are more properly the practice of medicine.

A major problem continues to be quality assurance.  Indeed, only 15 to 20 percent of the time is it found that a department has an effective quality assurance program.  Sometimes there is no program, or there may be one in name only.

Also, the quality of the anesthesiology department's leadership, organization and management has become an issue in the changing environment of health care.

How long is the overall process for a consultation, and what does it cost?
It is customary for the complete process of an Anesthesia Consultation to take approximately 12 weeks. The Ad Hoc Subcommittee usually visits the requesting hospital within six weeks of the receipt of the request, and the confidential written report is forwarded not more than six weeks later.

The cost for an Anesthesia Consultation is: One day consultation $10,280; Two day consultation $28,156; Three day consultation $33,249.  The number of days on site depends on the size of the institution and the complexity of its problems.  The cost to the requesting institution is the cost of operating this program.  ASA does not seek a profit.

If you are interested in requesting an Anesthesia Consultation or require more information, please contact Sandy Cincotti, s.cincotti@asahq.org. 

American Society of Anesthesiologists
Committee on Quality Management and Departmental Administration
520 N. Northwest Highway
Park Ridge, Illinois 60068-2573