Assessment of competence: developing trends and ethical considerations.

PURPOSE OF REVIEW: This review explores new concepts in competency assessment in anesthesiology, the associated ethical challenges, and directions for new research. RECENT FINDINGS: Many new tools for the assessment of competence are currently in development to address changes in medical education curricula. The assessment of competence currently focuses on technical skills, nontechnical skills, and the interaction of both through the use of simulation, with increasing emphasis on validity and reliability testing. SUMMARY: The search for objective measures of competence is well underway. Current methods require substantial investment of resources, and further research into more efficient and financially feasible tools of assessment is needed. As these assessments become more common in use, the ethical challenges raised by defining competency in high-stakes clinical practice situations will need to be addressed.

The Surgical Care Improvement Project Antibiotic Guidelines: Should We Expect More Than Good Intentions?

Since 2006, the Surgical Care Improvement Project (SCIP) has promoted 3 perioperative antibiotic recommendations designed to reduce the incidence of surgical site infections. Despite good evidence for the efficacy of these recommendations, the efforts of SCIP have not measurably improved the rates of surgical site infections. We offer 3 arguments as to why SCIP has fallen short of expectations. We then suggest a reorientation of quality improvement efforts to focus less on reporting, and incentivizing adherence to imperfect metrics, and more on creating local and regional quality collaboratives to educate clinicians about how to improve practice. Ultimately, successful quality improvement projects are behavioral interventions that will only succeed to the degree that they motivate individual clinicians, practicing within a particular context, to do the difficult work of identifying failures and iteratively working toward excellence.

Health Care Pollution And Public Health Damage In The United States: An Update.

An up-to-date assessment of environmental emissions in the US health care sector is essential to help policy makers hold the health care industry accountable to protect public health. We update national-level US health-sector emissions. We also estimate state-level emissions for the first time and examine associations with state-level energy systems and health care quality and access metrics. Economywide modeling showed that US health care greenhouse gas emissions rose 6 percent from 2010 to 2018, reaching 1,692 kg per capita in 2018-the highest rate among industrialized nations. In 2018 greenhouse gas and toxic air pollutant emissions resulted in the loss of 388,000 disability-adjusted life-years. There was considerable variation in state-level greenhouse gas emissions per capita, which were not highly correlated with health system quality. These results suggest that the health care sector's outsize environmental footprint can be reduced without compromising quality. To reduce harmful emissions, the health care sector should decrease unnecessary consumption of resources, decarbonize power generation, and invest in preventive care. This will likely require mandatory reporting, benchmarking, and regulated accountability of health care organizations.

Transforming The Medical Device Industry: Road Map To A Circular Economy.

A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.

Prediction of rate and severity of adverse perioperative outcomes: "normal accidents" revisited.

The American Society of Anesthesiologists Physical Status classification system has been shown to predict the frequency of perioperative morbidity and mortality despite known subjectivity, inconsistent application, and exclusion of many perioperative confounding variables. The authors examined the relationship between the American Society of Anesthesiologists Physical Status and both the frequency and the severity of adverse events over a 10-year period in an academic anesthesiology practice. The American Society of Anesthesiologists Physical Status is predictive of not only the frequency of adverse perioperative events, but also the severity of adverse events. These nonlinear mathematical relationships can provide meaningful information on performance and risk. Calculated odds ratios allow discussion about individualized anesthesia risks based on the American Society of Anesthesiologists Physical Status because the added complexity of the surgical or diagnostic procedure, and other perioperative confounding variables, is indirectly factored into the Physical Status classification. The ability of the American Society of Anesthesiologists Physical Status to predict adverse outcome frequency and severity in a nonlinear relationship can be fully explained by applying the Normal Accident Theory, a well-known theory of system failure that relates the interactive complexity of system components to the frequency and the severity of system failures or adverse events.

Indicators of anesthesia safety and quality.

In 1999, the Institute of Medicine shocked the world by claiming that medical error was among the leading causes of death in the United States. In contrast, anesthesiology was cited as an area in which there have been impressive gains in safety and quality. The mechanisms to which these impressive gains have been attributed include practice guidelines, anesthesia simulators, and benchmarking. Unfortunately, the current literature offers little evidence that these systematic approaches to patient safety have resulted in measurable improvements in quality, but efforts continue in the development of traditional and non-traditional quality indicators.