Establishing Standardized Facility and System Sedation Committees in a Large Healthcare System

In a large healthcare system, there are advantages to leveraging standardized sedation committees, a standardized sedation audit tool and convening all facility sedation committees to report to a system committee. To ensure consistent practices across the system, the System Safe Procedural Sedation Committee provides an opportunity to identify sedation safety trends, address sedation concerns which may impact all facilities, work toward solutions, opportunities for improvement, system policy updates and standardization across all entities. Safe procedural sedation administration by non-Anesthesia providers must be structured, evaluated and follow regulatory standards. An open dialogue between non-Anesthesia and Anesthesia physicians enhances collaboration and relationships.

Problem: Standardize sedation committees and sedation audit tool across a large health system. Additionally, convene all sedation committees from each facility into a system sedation committee to identify sedation trends, concerns, opportunities for improvement and system policy review and revisions.

Measurement: Audit tool for data collection based on system sedation policy and regulatory requirements. Standardized committee charter at both the facility and system level.

Analysis: The audit tool was drafted based on the system sedation policy and shared with system representatives. Audit tool changes were made based on feedback. Results and opportunities for improvement are shared at the facility level sedation meetings and may be brought to the system meeting.

Implementation: Standardized sedation committee charter, system sedation committee charter and audit tool for all facilities where conscious sedation is used. Obstacles included resistance to use of standardized audit tool format. Discussed audit tool feedback with facilities. Tool changes made as needed. Key stakeholders present, provide rationale for changes.

Results/Discussion: Opportunities to identify and address sedation trends and concerns across the system, work toward solutions, and collaborate on system sedation policy review has been beneficial. Providing an open dialogue between non-Anesthesia and Anesthesia providers enhances engagement and teamwork across the system.

Director Quality Improvement Service Lines at WellSpan Health
Director Quality Improvement Service Lines - WellSpan Health

Speaker Type: Poster Presentations On-Demand