title: Using quality improvement methods to optimize resources and maximize productivity in an anesthesia screening and consultation clinic.
abstract: OBJECTIVE
  The anesthesia preoperative screening and evaluation of a patient prior to surgery is a critical element in the safe and effective delivery of anesthesia care. In this era of increased focus on cost containment, many anesthesia practices are looking for ways to maximize productivity while maintaining the quality of the preoperative evaluation process by harnessing and optimizing all available resources. We sought to develop a Nurse Practitioner-assisted Preoperative Anesthesia Screening process using quality improvement methods with the goal of maintaining the quality of the screening process, while at the same time redirecting anesthesiologists time for the provision of nonoperating room (OR) anesthesia. The Nurse practitioner (NP) time (approximately 10 h per week) directed to this project was gained as a result of an earlier resource utilization improvement project within the Department of Anesthesia. The goal of this improvement project was to increase the proportion of patient anesthesia screens conducted by NPs to 50% within 6 months.
  
  
  METHODS
  After discussion with key stakeholders of the process, a multidisciplinary improvement team identified a set of operational factors (key drivers) believed to be important to the success of the preoperative anesthesia screening process. These included the development of dedicated NP time for daily screening, NP competency and confidence with the screening process, effective mentoring by anesthesiologists, standardization of screening process, and communication with stakeholders of the process, that is, surgeons. These key drivers focused on the development of several interventions such as (i) NP education in the preoperative anesthesia screening for consultation process by a series of didactic lectures conducted by anesthesiologists, and NP's shadowing an anesthesiologist during the screening process, (ii) Anesthesiologist mentoring and assessment of NP screenings using the dual screening process whereby both anesthesiologists and NP conducted the screening process independently and results were compared and discussed, (iii) Examination and re-adjustment of NP schedules to provide time for daily screening while preserving other responsibilities, and (iv) Standardization through the development of guidelines for the preoperative screening process. Measures recorded included the percentage of patient anesthesia screens conducted by NP, the percentage of dual screens with MD and NP agreement regarding the screening decision, and the average times taken for the anesthesiologist and NP screening process.
  
  
  RESULTS
  After implementation of these interventions, the percentage of successful NP-assisted anesthesia consultation screenings increased from 0% to 65% over a period of 6 months. The Anesthesiologists' time redirected to non-OR anesthesia averaged at least 8 h a week. The percentage of dual screens with agreement on the screening decision was 96% (goal >95%). The overall average time taken for a NP screen was 8.2 min vs 4.5 min for an anesthesiologist screen. The overall average operating room delays and cancelations for cases on the day of surgery remained the same.
  
  
  CONCLUSIONS
  By applying quality improvement methods, we identified key drivers for the institution of an NP-assisted preoperative screening process and successfully implemented this process while redirecting anesthesiologists' time for the provision of non-OR anesthesia. This project was instrumental in improving the matching of provider skills with clinical need while maintaining superior outcomes at the lowest possible cost.
authors.affiliation: Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA. anna.varughese@cchmc.org
authors.forename: Anna M
authors.initials: AM
authors.lastname: Varughese
authors.forename: Nancy
authors.initials: N
authors.lastname: Hagerman
authors.forename: Mari E
authors.initials: ME
authors.lastname: Townsend
mesh_terms: D000758:Anesthesia / Q000941:ethics / Q000592:standards*; D000761:Anesthesia Department, Hospital; D001291:Attitude of Health Personnel; D004526:Efficiency; D006285:Health Planning; D006801:Humans; D008611:Mentors; D009722:Nurse Practitioners; D009873:Operating Rooms / Q000458:organization & administration; D010348:Patient Care Team; D011300:Preoperative Care / Q000592:standards*; D058996:Quality Improvement / Q000941:ethics / Q000458:organization & administration*; D012017:Referral and Consultation