Quality and performance improvement in critical care
In the past decade, there is an increased focus on quality and safety in health care. Decreasing variation, increasing adherence to evidence based guidelines, monitoring processes, and measuring outcomes are critical for improving quality of care. Intensivists have broad knowledge of hospital organization, and need to be leaders in quality improvement efforts.
Keywords: Quality, intensivist, variation, performance measures, outcomes
"…The objective of having standards is to raise them,"
In the past two decades improvements in life-sustaining technologies (LST) resulted in an increase in the number of intensive care units (ICUs), and patient receiving LST in the ICUs. Care of the critically ill patients is resource-intensive, and 15-20% of hospital budgets are spent in the ICUs. The focus on quality and safety of medical care is increasing because of the high cost of health care and potential for harm. ,,, Poor quality care is not only costly but also causes human suffering because poor quality care results in increase in morbidity and mortality. Quality Improvement (QI) initiatives in the ICU to decrease nosocomial infections and maintenance of normoglycemia have been shown to improve outcomes as well as decrease costs. , Clemmer reported that improvement in quality of care in the ICUs at a tertiary care center resulted in an estimated savings of $2.6 million per year.  During the past decade, in India, there are many evaluations of mortality and incidence of complications, such as nosocomial infections in the ICUs, with an increased emphasis on QI efforts and evaluation of outcomes. ,, Parikh et al, evaluated quality of care at a public hospital in Mumbai, India, and reported a higher than expected mortality which may be related to multiple deficiencies in delivery of care. In addition, the increase in travel tourism for health care to India is increasing, and there is a need to demonstrate outcomes comparable to other countries to compete effectively for this market. Public trust in health care providers could also be adversely affected if the public perceives that the care provided is not of high quality. The Medical Council of India (MCI) and the ministry of health are creating standards of care for physicians.  For these reasons, ICU performance need to be scrutinized closely to evaluate both the effectiveness of ICU treatments and the quality of care delivered in ICU.
The following review includes
Although there is an increase in focus on safety and quality in the past few decades, the concern about quality of health care is very old as indicated by the admonition "first do no harm". Florence Nightingale kept records of her patients and outcomes to assess the impact of care, and suggested that knowledge of outcomes is crucial to improving care. Codman, one of the pioneers in QI in the early 20 th century, reported his outcomes in surgical patients and advocated pubic reporting of outcomes by both physicians and hospitals. The modern QI initiatives started with recognition in other industries that unexplained variation leads to poor quality, and processes that decrease variation and continuous evaluation leads to improved quality. Shewhart and Deming were proponents of continuous evaluation of processes to improve quality and decrease defects.  Donabedian  initiated the structure, process, outcome paradigm to improve health care, and Berwick and others applied these principles to the health care and led efforts to improve quality of care in the United States of America (USA)
The report "To Err is Human" by the Institute of Medicine (IOM) in the United States in 1999, led to an increased focus on safety and quality of care. IOM suggested that care should be safe, effective, patient centered, timely, efficient, and equitable. IOM reported that that one of the primary quality problems is inappropriate use of resources, and suggested efforts to improve the use of resources by focusing on overuse, under use and misuse., As a response to the IOM reports, many institutions initiated QI efforts to improve quality of care.
Quality is defined by the IOM as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Although there has been more emphasis on performances of healthcare providers and quality of care recently, the focus on quality of care is not new. Codman suggested, about 100 years ago, that hospitals must collect data on their outcomes, identify strong and weak points and compare the results with other hospitals. Unexplained variation in patient care is based more on physician biases rather than patient-related factors. In the study of intensive care physicians at a university hospital, Garland et al reported a 43% variation in resource use and costs (» $1,000) between intensivists without a significant difference in mortality or length of stay.  Variation in care delivery makes it very difficult to monitor processes and outcomes.
Although physicians accept improving quality of care as a goal, they are sometimes skeptical of quality improvement efforts and consider participation in QI efforts as a non productive use of their time and view efforts to decrease variation as an interference with their autonomy. Physicians' behavior is influenced by suggestions from a respected colleague or role model, appropriate support for professional skill development, reinforcement by colleagues, feedback from patients, and visible results. Physicians need to agree that processes that influence clinical activity lead to measurable outcomes. Feedback and refining the process based on clinician input would get buy-in from frontline staff. Physician leaders need to be recognized as good clinicians and develop skills in communication, team building/coaching, negotiation and conflict resolution, quality improvement principles, so that they can implement QI initiatives effectively. ,,, Physicians attempting to lead QI efforts need to be cautious on how they interact with other physicians because a wrong approach could lead to failure although the intervention is effective. The story of Ignac Sammelweis, who was a pioneer on hand hygiene but was unable to influence his colleagues, illustrates that the person who wants to initiate change needs to be able to communicate his ideas to both his superiors as well as coworkers in a non-threatening manner, and be cautious in how he conveys the message.  As intensive care physicians interact with many medical specialties and have a better knowledge of hospital organization because of their interaction both with the physicians as well as administrators, they are well suited to become leaders in QI initiatives.
Donabedian proposed reviewing structure, process and outcome to improve quality of care.  The model is described in [Figure 1]. The Structure, in the ICU setting, refers to the type and size of the ICU, nature of staffing and availability of technology. Process issues include communication among staff, use of available technology and trainee guidelines and supervision. Outcomes include resource use, use of diagnostic and therapeutic procedures and mortality. Interventions affecting structure take longer to implement and are more expensive, so initially it is easier to target processes of care, modifying them as needed, and measuring the outcomes affected by the process. Some outcome measures such as length of stay (LOS), mortality, are easy to measure, but are affected by a number of variables and may not be easily attributed to a single intervention.
The success of QI projects depends on identifying projects which all stakeholders find useful and building a team culture. Performance measures and outcomes should be clearly defined, valid, and reliable. Documentation and data collection should be incorporated into daily work routines. Team development and process/outcome definition, followed by an iterative process of implementation, evaluation and process adjustment based on the evaluation are important steps in achieving the goals. Leadership buy-in and support is essential for implementation and success. A comprehensive plan with a description of the goals, plan for implementation, cost and benefits with business plan and timeline will be helpful in obtaining administrative support.
Successful implementation of changes in practice are facilitated by check lists, disease specific pre-printed order sets, daily order sets that include goals for care. Standardized order sets facilitate implementation of best practices in addition to improving compliance with best practices. Establishing standards of care, monitoring processes and outcomes, creation of multidisciplinary teams, data recording as part of routine care, automated retrieval of information by using information technology facilitate QI efforts. A bedside electronic record facilitates data collection and retrieval. The experience of institutions with successful implementation strategies include: leadership support, incentives for senior leaders, physician and nursing leadership in implementing the initiatives, and involvement of bedside caregivers in the design and implementation of a QI projects.
Identification of a clinical process that need be changed-based on benefits/risk/costs; patient care needs, informal discussions and payor priorities
Process measures, protocol, data
Time needed for design, Implementation and reporting outcomes
Reiterative process of Plan, do, Study, Act (PDSA) cycles
The improvement is usually incremental and requires repeated evaluations and refinement of processes. [Figure 2] illustrates the PDSA cycle
QI projects in the ICU
A brief summary of the initiatives, categorized according to the principles of quality listed by IOM is provided in [Table 1]. [Table 2] contains further details of these initiatives.
The process should involve multidisciplinary teams consisting of intensivists, ICU nursing staff and staff of respiratory therapy department with participation from other departments such as Infection Control and Blood Bank. Consensus guidelines which include inclusion and exclusion criteria, algorithms for implementing each of the process elements, definition of outcomes and data collection need to be created, As an example of one of the projects, the algorithm for implementation of daily Spontaneous Breathing Trials (SBT) was shown in [Figure 3]. The experience at University of Pittsburgh Medical Center (UPMC) with SBT indicated that although the compliance with daily SBT was high, the extubation rate is not optimal. So, we are evaluating the reasons for failure to extubate and will modify the guidelines and algorithms based on the experience. It has to be noted that the success of these projects requires sustained support from the administrative and medical leadership, a physician champion, and motivated team. As patients are heterogeneous in their diseases and acuity, co-morbidities and age, any evaluation of quality needs to consider these factors. It would be helpful to collect severity of illness information so that outcomes of patients in different ICUs could be compared but it adds to the costs of obtaining data. Risk adjustment models, such as Acute Physiology And Chronic Health Evaluation (APACHE)  or Simplified Applied Physiology Score (SAPS),  adjust for these risk factors and allow comparison of different ICUs or, in some cases, evaluation of QI initiatives within a single ICU over time.
Ventilator Associated Pneumonia (VAP) bundle: VAP increase length of stay and morbidity. Implementation of all the individual; components of the bundle has been shown to be effective in decreasing VAP. , The components are listed below and the algorithm used at UPMC is shown in [Figure 3],[Figure 4],[Figure 5].
Sepsis Bundle: Standardized management of sepsis decreases costs and improves mortality.  Shorr reported that mortality was 20% lower, LOS was five days shorter, and costs were ≈ $ 5,000 lower in sepsis patients treated by protocol. 
Central Line Associated Bacteremia (CLAB) Bundles: Shannon et al reported that CLAB not only increases morbidity and but also resulted in a loss to the hospital because the reimbursement is lower than the costs. Implementation of the CLAB bundle resulted in a decrease of 825 (7.7 to 1.4 infections/1000 catheter days).  Pronovost et al reported that implementation of all elements of the bundle decrease CLAB rate from 7.7 to 1.4 infections/1000 catheter days. 
The components of the bundle are
Communication: Pronovost et al reported that use of check list of daily goals during rounds improved communication and outcomes.  Discussion of daily goals during multi disciplinary rounds would help in clarifying issues and facilitate communication between staff and physicians.
Daily communication goals:
Another tool to improve communication is to standardize format of communication between staff and physicians by following the SBAR tool
Rapid Response Team (RRT): Foraida et al and others reported that implementation of RRT response resulted in a decrease in cardio respiratory events leading to cardiac arrest and improved survival. RRT helps to identify patients at risk and provide early resuscitation.  The composition of RRT is variable but usually consists of an ICU nurse, respiratory therapist and a physician skilled in airway management. The criteria for calling at RRT at University of Pittsburgh Medical Center (UPMC) are listed below
Acute Neurologic change
Other QI measures that could be evaluated in the ICU include:
The Institute of Medicine in the U.S. reported that there is a quality chasm in healthcare and suggested that the delivery of healthcare should be improved, so that it is safe, effective, patient-centered, timely, efficient and equitable. Both medical leadership and staff need to work together to achieve such a healthcare system. Effective implementation of existing treatments that were shown to be beneficial is more cost effective than implementing newer treatments that are marginally more effective. Intensivists, because of their broad knowledge of the hospital and interactions with multiple specialties are well suited for leading efforts to improve quality of care.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]