Quality in anesthesia care: lessons from industry and a proposal for valid measurement and improvement

Quality anesthetic care is a goal fundamental to our tradition and our training, but defining and measuring quality in anesthesia presents special challenges. Industrial models of quality, especially those so fundamental to the re-emergence of post-war Japan, deserve careful study and are discussed at some length, but they clearly have limitations in understanding quality in anesthesiology. We suggest that most current quality efforts are inherently flawed. Whether or not they rigorously attempt to define quality, they are hampered by lack of data concerning outcomes and alternatives, as well as lack of distinction between quality and efficacy. Quality efforts in American medicine and anesthesiology seem mired in a "criterion of potential benefit," which is still central to many of our prescriptions for individual medical care. Current quality improvement efforts do not seem well suited to correct these flaws. Anesthetic care, and that of American medicine in general, is fragmented, enormously costly, and sometimes inappropriate or poor. Anesthesiologists are suspicious of current quality efforts to improve this care. The system often seems more geared to eliminate bad apples than to improve patient care. Because anesthesia is a specialty that facilitates care but seldom "cures," we face greater challenges in studying and defining quality than do other specialties. Because of this, it is imperative that several principles govern future quality improvement efforts in anesthesiology. First, a reasonable balance must be attained between study of outcomes and processes of anesthesia care. Second, anesthesia-specific severity of illness indexing must be developed. Third, and perhaps most important, anesthetic processes and outcomes must be reported on a national level. Fundamental to future quality efforts in our specialty, we believe, is the establishment of a protected National Anesthesia Outcome Registry. This article reviews the industrial and medical history of quality, its measurement and improvement, and attempts to apply principles learned over many decades to anesthesiology.