When surgery centers develop quality improvement (QI) programs, they should consider including anesthesia on the team.

Anesthesiologists significantly affect several important measurements in a surgery center’s QI program, including dizziness, falls, and burns, says Leopoldo V. Rodriguez, MD, FAAP, FASA, medical director of the Surgery Center of Aventura in Aventura, FL.

“We have significant influence on those [quality measures] because we’re the ones medicating patients. If they get dizzy, they’ll fall. We also manage the oxygen at the facility. If we give too much oxygen to the patient, then that can cause a physical burn,” says Rodriguez, director of the Ambulatory Anesthesiology Performance Improvement Program and chair of the Ambulatory Anesthesiology Quality Committee – Envision Physician Services in Plantation, FL.

The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 mandated CMS to focus on quality. The agency has implemented the Quality Payment Program as an incentive-based initiative to reward value.

The program achieves process and outcome measures through its merit-based incentive payment system and the advanced alternative payment models. It was designed to reward high-performing clinicians and help low-performing clinicians improve their practices to improve their value. It also is expected to achieve high-quality care at a lower cost.1 Professional organizations, including the American Society of Anesthesiologists (ASA), have developed performance and outcome measures that assist with objective data collection.

Anesthesiologists need a seat at the QI table because there are many areas in which anesthesiologists can contribute to QI. For example, they can develop treatments for patients with sleep apnea, and they can improve patient transfers and enhance care for patients with multiple diseases, according to Rodriguez.

“Things like transfer also are influenced by anesthesiologists because if we select the right patient for a procedure at a facility, it is less likely that the patient will be transferred to the hospital for medical reasons or that there will be a medical complication,” he explains. “The anesthesiologist is managing the entire patient. In the past, patients used to be healthy, but now they’re sicker, and a significant number of patients have multiple diseases — like heart diseases, coronary diseases, pacemakers, diabetes, hypertension, strokes, or simply are old with physical deterioration, which we call frailty.”

Selecting patients properly is one way to reduce medical complications during surgery. Another is to select the proper method of anesthesia for each patient, Rodriguez says. “Anesthesiologists have to risk-stratify patients,” he advises. “They should select patients who will have surgery in the surgery center and select patients who are less likely to be transferred to the hospital. That’s part of CMS’ conditions of participation.”

The ASA Committee on Ambulatory Surgical Care and the Society for Ambulatory Anesthesia created a technical expert panel that is developing quality measures for ambulatory anesthesiology.

The panel is focusing on developing measures related to assessing and managing blood sugar stability, frailty, and mitigation techniques for obstructive sleep apnea.1

Anesthesiologists can look at measures like smoking cessation and offer education by phone before surgery to encourage patients to follow smoking cessation programs, Rodriguez says. “The most significant thing an anesthesiologist does is control the way the patient breathes during surgery,” he explains. “There are several things we do to examine the airway of the patient. If the patient has a difficult airway, then we have algorithms we have to follow, which include having an extra person in the room to manage the difficult airway.”

Another significant presurgery task for anesthesiologists involves paralyzing the patient’s muscles. “After putting the patient to sleep, we have administered muscle relaxants,” Rodriguez says. “The complication that was happening frequently in patients is that it was difficult to assess patients if they recover from administration of a paralytic a couple of hours later.”

One quality measure is called the muscle relaxation administration assessment of return to normal function. The methodology used to assess the patient’s return from relaxation is subjective. If someone determines the patient is ready and is incorrect, the patient could wake up in the recovery room with weakness and too much pain.

A nurse might give the patient a narcotic medication, as ordered by the anesthesiologist, but that drug could block the patient’s breathing as oxygen levels drop, leading to hypoxia. The patient then would need resuscitation. This scenario can be prevented with the use of neostigmine, a reversal agent, but there have been shortages of the drug, leading to poor outcomes, Rodriguez notes.

“At the end of an operation, before waking up patients, they’d use neostigmine, but it was difficult to find,” he explains. “Sometimes, patients would stay in the operating room a little longer because of the drug shortage.” Neostigmine was cited by anesthesia professionals in surveys of 2012 and 2013 as one of the drugs most often on their drug shortage list.2

From a QI standpoint, anesthesiologists can review data and documentation. If they notice an increase in patients intubated in the recovery room, anesthesiologists can analyze records and note a possible cause, such as the absence of neostigmine, Rodriguez says. “You either document the patient’s strength or document that the patient was given a reversal agent to make sure the patient was not weak,” he adds.

Another anesthesiologist’s quality measure relates to nausea and pain. Patients are assessed for risk of nausea. One common assessment tool is the Apfel scoring system for people at high risk of postoperative nausea and vomiting.3 For example, a nonsmoking woman with a history of motion sickness or vomiting who will receive postoperative opioids is at high risk for nausea after a procedure, according to Rodriguez. “When you use an assessment table, and the patient has three or more of the items listed, then you give the patient two medications to prevent nausea,” he says.

Physicians and surgery centers also share a quality measure related to hypothermia. They have to document at the end of the procedure that the patient’s temperature is normal, above 35.5° C to 36.5° C, he says. “The importance of this measure is if a patient has surgery, comes out, and is hypothermic,” Rodriguez explains. “The patient will be shivering. When you have shivering, that increases the oxygen consumption of the body.”

The patient’s body is contracting muscles to compensate for the low temperature, reducing blood flow. The wound needs blood flow for the healing process and to help prevent infection. “From the facility or physician’s point of view, the ultimate goal is to improve care by preventing complications,” Rodriguez says.


  1. Rodriguez LV, Bloomstone JA, Maccioli GA. Outcomes in ambulatory anesthesia: Measuring what matters. Anesthesiol Clin 2019;37:361-372.
  2. Greenberg S, Brull SJ, Rao P, et al. The neostigmine shortage: A clinical conundrum with few drug alternatives. Anesthesia Patient Safety Foundation Newsletter, October 2015. Available at: http://bit.ly/2ZFz7sg. Accessed Aug. 28, 2019.
  3. Sherif L, Hegde R, Mariswami M, Ollapally A. Validation of the Apfel scoring system for identification of High-risk patients for PONV. Karnatka Anesthesiol J 2015;1:115-117.