The weekly Quality Improvement (QI) conference serves as the forum to present critical events involving an anesthesia provider (“index cases”) as well as updates on performance benchmarks and changes in practice. Index cases are identified through self-report in EPIC, incident reports and 30-d mortality reports. Cases are reviewed by three anesthesiologists in a REDCap database with the goal to identify causative human errors, non-human failures and room for practice improvement. A Quality Review Committee adjudicates all cases and determines which will be reviewed in the weekly QI conference, the teaching points, and potentially further actions. The QI conference is based on a critical case analysis and places the cases into context by determining their prevalence at CHW. Best practice is discussed among the participants based on literature review and personal experience, and necessary steps, e.g., change in individual practice, additional training, or systems changes are determined. Members of surgical specialties, nursing staff or administration may be in attendance. 

Anesthesia practice at CHW requires the individual anesthesiologist to provide excellent and timely patient care in patients of very different age, size and health and in a wide variety of settings. The weekly QI conference is the means to guarantee continued education by reviewing frequent problems, alerting providers to rare events, and providing information on new anesthesia drugs and equipment as well as changes in surgical and imaging practice. Timely summary and distribution of new information through the weekly QI meetings is essential to maintain competency of all providers in all areas. Similarly, this conference significantly enhances the learning experience of anesthesia residents and fellows who would not otherwise be exposed to the same variety of cases. Finally, the conference allows discussion of anesthesia and surgical management together with the respective surgical/ imaging service, which is an important opportunity to improve collaboration and case management.