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.
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.