FUTURE DIRECTIONS FOR IMPROVING QUALITY

Efforts to improve quality of care by anesthesiologists should focus on the development of valid and reliable measures of quality that provide insight into multiple domains of quality, such as those outlined in the IOM report. For example, professional societies can convert existing guidelines into measures of quality and evaluate performance on those measures. Caregivers can systematically measure return to work, postoperative pain, use of β-blockers, and specific complications. These measures must maintain a balance between the burden of data collection and the validity of the measure. There is probably no such thing as a perfect measure; the measure is valid as long as the measure provides insight into care and providers believe that they can use the data to improve the care that they provide to patients. Advances in information technology, including software designed for quality measurement, probably will be developed in response to the JCAHO initiative and decrease the burden of data collection in the future.

We need to train providers in the methodology of improvement. The quality improvement model developed by Nolan and used by Berwick and Bataldin is the most widely accepted, but in our experience, few physicians and nurses are aware of this important conceptual model. Nolan's model includes a reflective component and an active component.^[82] The reflective component seeks to identify aims, devise measures, and change strategies by asking questions. What is our goal? How will we know when we reach our goal? What changes will we make to achieve our goal? The active component uses learning cycles to plan and test changes in systems and processes that usually are referred to as Plan, Do, Study, Act (PDSA) cycles. This quality improvement model attempts to analyze and improve processes, initially testing the change on a small scale before wide dissemination. In our department, we have incorporated training in the methodology of quality improvement in our fellowship program, and we require our fellows to participate in at least one improvement initiative. Professional societies should develop training programs to increase provider awareness and provide them with the skills needed to conduct rigorous quality improvement initiatives in their ICUs.