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CHAPTER 2: Measuring Quality 7

interface with a basic science research program to allow bench or ani- CHAPTER Measuring Quality
mal extensions of hypotheses that are difficult to test in the intensive
care environment. Together the basic and clinical investigative teams Andre Carlos Kajdacsy-Balla Amaral
implement the essential steps in clinical research in critically ill patients: 2 Gordon D. Rubenfeld
formulate a hypothesis, prepare a protocol, obtain institutional review
board approval, obtain funding, perform the study, and communicate
the results.
Many challenges exist in conducting studies in the environment
of the ICU. These include the unpredictable and unscheduled nature KEY POINTS
of events, the need to maintain complex schedules related to routine • Quality is defined as “the degree to which health services for indi-
care in parallel with schedules for study protocols, and the very hetero- viduals and populations increase the likelihood of desired health
geneous nature of patient populations. In the view of many, the greatest outcomes and are consistent with current professional knowledge.”
challenge is conducting studies of promising therapies for which the • The ability to measure quality is an essential component to
precise risks and benefits are unknown, yet doing so in patients in whom improve quality of care.
informed consent is not possible because of their critical illness. Some
would say that such studies simply cannot be done without consent, • Quality of care has multiple domains and no single metric can
but we find this an undesirable acceptance of the current state of our appropriately define quality.
ignorance. We believe that true equipoise exists in the interface between • Quality indicators should represent metrics that have face validity
many clinical problems and their potential treatments (ie, a realization and are actionable by patients, clinicians, and managers.
on the one hand that our understanding of an existing treatment for • Methodological rigor is necessary to avoid spurious interpretations
a disease process is inadequate, yet no secure knowledge that a new and provide proper interpretation of quality metrics.
approach or therapy is completely safe and efficacious). In this circum- • Public reporting quality metrics can have unintended conse-
stance, we believe that prospective, randomized trials offer the only hope quences to the health care system.
of informing our practice of medicine, and that studies in the ICU, even
if conducted with proxy or under some circumstances waived consent, • Quality metrics can be divided into outcome metrics, process met-
are justified. The function of the institutional review board is to foster rics, and structural metrics.
careful deliberation of the merits of each situation and proposed study • Quality metrics that are based on outcomes are widely used to
to ensure that these balances are struck. compare health care systems, but are not necessarily sensitive or
specific to identify outliers and may lead to biased conclusions.
• When rigorously and objectively defined, quality metrics that are
based on processes of care can be more informative on specific
KEY REFERENCES https://kat.cr/user/tahir99/
aspects of quality.
• Brush DR, Rasinski KA, Hall JB, Alexander GC. Recommendations • Many structural aspects of ICUs are associated with quality, but it
to limit life support: a national survey of critical care physicians. is possible for ICUs that do not have these attributes to still per-
Am J Respir Crit Care Med. 2012;186:633-669. form with high quality.
• Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less
is more. Chest. 2008;133:252-263.
• Kahn JM, Hall JB. More doctors to the rescue in the intensive
care unit: a cautionary note. Am J Resp Crit Care Med. 2010;181: DEFINING QUALITY
1160-1161. The definition of quality depends on the field being evaluated. For
• Kajdacsy-Balla Amaral AC, Barros BS, Barros CC, et al. Nighttime example, although they each provide food and housing, the definitions
cross coverage is associated with decreased intensive care mortal- for high-quality hotels, prisons, and hospitals will be considerably differ-
ity. A single center study. Am J Respir Crit Care Med. 2014;189: ent. The International Organization for Standardization defines quality
1395-1401. broadly as “the totality of features and characteristics of a product or
• Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption service that bears on its ability to satisfy stated or implied needs” (ISO
of sedative infusions in critically ill patients undergoing mechani- 8402–1986 standard). In health care, quality has been abstractly defined
cal ventilation. N Engl J Med. 2000;342:1471-1477. as “the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
• Lilly CM. The ProCESS Trial: a new era of sepsis management. with current professional knowledge.” Although a bit vague, this defi-
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N Engl J Med. 2014;370:1750-1751. nition emphasizes two challenging aspects of measuring the quality of
• Malhotra A, Drazen JM. High frequency oscillatory ventilation on health care: (1) the need to improve outcomes and (2) the importance of
shaky ground. N Eng J Med. 2013;368:863-864. evidence. Throughout this chapter, we will focus on these two concepts
• ProCESS Investigators. A randomized trial of protocol-based care to discuss measuring quality through evidence-based processes of care
for early septic shock. N Engl J Med. 2014;370:1683-1693. that should ultimately lead to improved outcomes.
• Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physi-
cal and occupational therapy in mechanically ventilated, criti- WHY DO WE MEASURE QUALITY?
cally ill patients: a randomized controlled trial. Lancet. 2009;373: “Count what is countable, measure what is measurable, and what is not
1874-1882. measurable, make measurable” is frequently attributed to Galileo. The
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ability to manage outcomes or processes of care is fundamentally tied to
being able to measure them. Finding clinically relevant, measurable, and
actionable outcomes and processes in health care is necessary to provide
REFERENCES clinicians with the ability to improve their systems. This is not to say
that all important determinants of quality can be measured or that those
Complete references available online at www.mhprofessional.com/hall that cannot be measured should be ignored. Deming, the grandfather of

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