Supervision quality is a function of the anesthesiologist, not the surgical procedures assigned to the anesthesiologist, the hours worked together, and/or the numbers of cases supervised simultaneously. (Image source: Thinkstock)

Supervision quality is a function of the anesthesiologist, not the surgical procedures assigned to the anesthesiologist, the hours worked together, and/or the numbers of cases supervised simultaneously. (Image source: Thinkstock)

Supervision of anesthesiology residents and/or Certified Registered Nurse Anesthetists (CRNAs) is a major daily responsibility of most anesthesiologists. The quality of this supervision should be evaluated and understood. For example, is the quality of supervision different if an anesthesiologist is supervising 3 CRNAs compared to 1 resident who is caring for a patient with high acuity?  Does the quality differ if an anesthesiologist is supervising an individual whom he or she has worked with frequently versus not as often?  Finally, if supervision is inadequate, how should that individual be monitored?  Over a period of six months, Dr. Franklin Dexter, Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa, and colleagues assessed the quality of supervision provided by each anesthesiologist working in operating rooms as evaluated by the anesthesiology resident(s) and CRNA(s) with whom they worked the previous day.  They used a 9-question instrument that took about 90 seconds to complete.

An analysis of the quality of this supervision was published in this month’s issue of Anesthesia & Analgesia in the article “Influence of Provider Type (Nurse Anesthetist or Resident Physician), Staff Assignments, and Other Covariates on Daily Evaluations of Anesthesiologists’ Quality of Supervision.”  The authors also used this study to monitor the supervision performance of anesthesiologists, the results of which were also published in this month’s issue of Anesthesia & Analgesia in the article titled “Bernoulli Cumulative Sum (CUSUM) Control Charts for Monitoring of Anesthesiologists’ Performance in Supervising Anesthesia Residents and Nurse Anesthetists.”

Anesthesiology residents and CRNAs were selected if they cared for patients under the supervision of an attending anesthesiologists for at least 60 minutes.  The mean monthly evaluation completion rates exceeded 85% for both anesthesiology residents and CRNAs.  The authors found that the scores differed between anesthesiology residents and CRNAs, so supervision scores were analyzed separately for residents and CRNAs.  Differences among anesthesiologists were heterogeneous.  A potential concern was that the daily assignments influenced supervision scores. Although mean supervision scores differed markedly among anesthesiologists, supervision scores were negligibly influenced by staff assignments (e.g., how busy the anesthesiologist was with other operating rooms and how many times an anesthesiologist had been assigned to work with a rater).

Bernoulli cumulative sum (CUSUM) charts were analyzed both automatically and daily to monitor the supervision scores. When significantly low, these metrics could be used to send an alert to the anesthesiologists in charge about substandard supervision. Confidential feedback could also be provided to the anesthesiologist. Neither of these applications were tested, but they suggest ways in which simple tests could help improve the quality of supervision of residents and CRNAs.