HISTORICAL MEASURES OF QUALITY IN ANESTHESIOLOGY

Prior efforts to measure performance have predominantly focused on outcome measures, including in-hospital mortality rates.^[50] To facilitate comparison of performance across hospitals, a significant amount of effort has been devoted to developing sophisticated risk-adjustment models.^{[51] [52] [53]} Although important, hospital mortality alone provides an incomplete picture of quality in that it does not provide insight into most domains as outlined by the IOM report. Because events are rare, longer periods of observation are required to provide precise estimates, and as a result, feedback to providers is infrequent, and more time is needed before change can be implemented to improve care.

Donabedian, one of the fathers of quality measurement and improvement, proposed that we measure quality of health care by observing the structure (i.e., how care is organized), the processes (i.e., what we do), and the outcomes (i.e., results we achieve) of health care.^[54] Each type of measure has advantages and disadvantages.^[55] In critical care, there is evidence that the organizational characteristics of ICUs can affect patient morbidity and mortality and the costs of care. For example, use of an intensivist, presence of a pharmacist in ICU rounds,^[56] and increased nurse-to-patient ratios^[54] all represent important opportunities to improve patient care. Nevertheless, changes in organizational structure are slow to implement, in part because of perceived costs and a shortage of qualified providers.^[53]

Process measures evaluate how we provide care, may be easier to measure and implement, and can provide important insight into care.^[57] One example is the percentage of patients on mechanical ventilation who have the head of the bed elevated. Because care provided for all patients receiving mechanical ventilation is evaluated, the period of observation is shorter. Process measures can be used to provide immediate feedback to providers regarding their performance, allowing for rapid improvements in care. There are several additional important advantages of evaluating process measures; they generally have face validity for providers, meaning that they believe they can use the data to improve care, and because risk adjustment is less important, broad implementation is feasible.^[57]

How Are Measures of Quality Developed?

Quality measures can be used for external reporting to regulatory agencies or for internal (within the clinic, hospital, or health system) improvement efforts. We and others have published methods to develop quality measures.^{[25] [27] [28] [58] [59]} In this chapter, we focus on how to develop practical quality measures that can be used in routine practice and provide feedback to providers. Developing a quality measure includes the following steps:

1. Prioritize the clinical areas to evaluate.
2. Select the type of measures.
3. Write definitions and design specifications.
4. Develop data collection tools.
5. Pilot test data collection tools, and evaluate the validity, reliability, and feasibility of measures.
6. Develop scoring and analytic specification.
7. Collect baseline data.

These steps are outlined in Table 81-3 and described in our book on quality measurement.^[60]

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