Health Services ResearchQuality measurement at intensive care units: which indicators should we use?
Introduction
Interest in measuring the quality of health care is increasing among both health care professionals as well as managers. To quantify the desired (positive) and undesired (negative) consequences of activities in heath care, measurement of outcome is essential [1]. Indicators may provide insight in the structure and process aspects of care that are related to outcome [2].
A quality indicator is a screening tool to identify potential suboptimal clinical care [3]. Quality indicators provide a measure of quality of structure, process, and outcome of care [4], and can serve as instruments to improve health care [5]. Structure indicators are related to the resources and means to be able to give treatment and care. Process refers to the activities related to treatment and care. Outcome is defined as changes in the state of health of a patient that can be attributed to an intervention or to the absence of an intervention. The classification has been proven feasible and easy to apply in the clinical situation for both workers in the medical field as well as for research professionals and managers [5]. However, the condition of the patient at admission has to be considered separately, because of its great impact on patient outcome [5]. In this study, the focus is on internal indicators, which are used by professionals and managers of the intensive care units (ICU) to monitor quality of care [6]. The focus is not on performance indicators to evaluate the hospital achievements for, for example, care consumers.
The ICU is an area in a hospital that constitutes substantial risk of morbidity and mortality [7]. The underlying disease of intensive care patients may partly determine outcome of care, but also treatment at the ICU will have an effect on outcome. To reduce the risks of iatrogenic and organizational adverse effects on patient outcome, quality management is important in the ICU. Indicators can provide insight in quality of care and guide improvement of care on ICUs. It is important that an indicator meets several criteria: reliability, validity, responsiveness, relevance, significance, and utility [8].
The purpose of this study is to develop a comprehensive set of structure, process, and outcome indicators that measures aspects of all domains of the quality of care at ICUs and to evaluate the feasibility of the registration of these indicators.
Section snippets
Methods
The whole process of defining a set of indicators was carried out by an expert panel, which included physicians and researchers. This expert panel defined the aim of the indicators and the procedure for selection. Indicators were selected based on several criteria: its relation with quality of care (valid), the reproducibility of the measurement (reliable), the responsiveness of the indicator (also including variability among hospitals), and the feasibility of the registration. These criteria
Results
To achieve a limited and balanced set of quality indicators, a selection was made in several steps, resulting in a set of 11 indicators (Fig. 1).
Discussion
In the current study, a set of quality indicators for intensive care was defined, which after implementation in clinical practice may beneficially influence the quality of care at ICUs. The indicators identified on the basis of the literature study were evaluated, and additional indicators were selected by a panel of experts. This expert panel selected a set of 12 indicators on the basis of a questionnaire and consensus. A feasibility study was done to evaluate the registration of these
Acknowledgment
The authors would like to acknowledge the members of the expert panel: Mrs DHC Burger, MD; Mr AA Corsten, MD; Mrs FE van Dijk, PhD; Mr E de Jonge, MD, PhD; Mr ARH van Zanten, MD; Mr JP Gielen; Mr KH Polderman, MD, PhD, for help in developing a set of structure, process, and outcome indicators for the ICUs in Dutch hospitals. This study was funded by the Dutch Inspectorate of Health Care.
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