EVIDENCE REGARDING QUALITY OF CARE IMPROVEMENT FOR GROUPS OF PATIENTS

There are multiple approaches to improving quality of care^[36] ( Table 81-2 ). These include evidence-based medicine (EBM) and evidence-based clinical practice guidelines, professional education and development, assessment and accountability, patient-centered care, and total quality management.^[37]

The premise of EBM and evidence-based clinical practice guidelines is that we can improve clinical decision-making and patient care by incorporating the best available evidence with patient values and provider preferences.^[38] In anesthesiology and critical care, guidelines and protocols have been successful in improving performance with some care processes. For example, sedation and ventilator weaning protocols have been shown to decrease the duration of mechanical ventilation and ICU length of stay^{[39] [40]} (see Chapter 71 and Chapter 74 ). Nevertheless, significant barriers exist to the practice of EBM and use of evidence-based clinical practice guidelines, including a lack of provider awareness that the guidelines exist, a lack of provider agreement, and a lack of provider ability to implement the guidelines.^[41] As a result, efforts to implement guidelines

TABLE 81-2 -- Approaches to improving quality of care

Approach	Assumptions
Evidence-based medicine, clinical practice guidelines, decision aids	Provision of best evidence and convincing information leads to optimal decision-making and optimal care.
Professional education and development, self-regulation, recertification	Bottom-up learning, based on experiences in practice and individual learning needs, leads to performance change.
Assessment and accountability, feedback, accreditation, public reporting	Providing feedback on performance relative to peers and public reporting of performance data motivate changes in performance.
Patient-centered care, patient involvement, shared decision-making	Patient autonomy and control over disease and care processes lead to better care and outcomes.
Total quality management and continuous quality improvement, restructuring processes, quality systems, breakthrough projects	Improving care comes from changing the systems, not from changes in individuals.
Adapted from Grol R: Improving the quality of medical care: Building bridges among professional pride, payer profit, and patient satisfaction. JAMA 286:2578–2585, 2001.

are often not successful, and improvements in the processes of care have been disappointing. ^{[37] [42]} Few studies have evaluated the impact of EBM or evidence-based guidelines on patient outcomes.

Professional education and development strategies address the complexity of clinical practice and propose improvement based on professional self-regulation and ownership by clinicians.^[36] Although classic continuing medical education approaches are relatively ineffective, new approaches, resembling simulation and including interactive forms of education and small group learning, have been effective for changing clinical performance.^[43] Nevertheless, additional research is needed to evaluate the cost-effectiveness of these new approaches because they require significant resources for implementation and maintenance.^[36]

A third approach to improving quality of care emphasizes regular assessments of clinical performance and public accountability. The assumption is that providers will change practice when their performance is compared with that of their peers or presented for others to see. This approach is popular among purchasers, insurers, regulators, and accreditors (www.jcaho.org; www.qualityforum.org). Providers, however, have concerns regarding the reliability and validity of the quality measures used. Consequently, this approach has done little to improve overall performance in health care.^{[44] [45]}

Patient-centered care emphasizes the need to empower patients to participate in medical decision-making. Methods employed include patient-satisfaction surveys, complaint procedures, needs assessments, decision aids, and risk tables for "shared decision-making."^[36] In critical care, for example, there are several validated tools for evaluating the satisfaction of patients and their families.^{[46] [47] [48]} Whether or how these data change performance is less clear. Moreover, patients' desire to participate in care varies among cultures. Given the complexity of ICU patient care, it is unlikely that a single empowerment method can be generalized across different settings, different patient populations, and different situations.

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Total quality management (TQM) and continuous quality improvement (CQI) proposes an integrated approach to improving patient care. TQM and CQI emphasize that the greatest opportunity for improvement is found by focusing on the health care system's organizational characteristics rather than on individuals. In TQM, providers measure performance, change what they do, and evaluate the impact of that change.

The underlying principle for all of these approaches is that if we want to improve the quality of care that we provide, providers must be able to measure their performance. Nevertheless, health care providers have limited ability to obtain feedback regarding performance in their daily work, in part because of a lack of information systems and a lack of agreement on how to measure quality of care.^[49] As a result, many of us in health care in general and in the ICU in particular do not have access to performance data and consequently do not know the results we are achieving (or failing to achieve). For example, if asked what our ICU mortality rate is or our average duration of mechanical ventilation, many of us may not know.