Evaluating Critical Care: Using Health Services Research to Improve Quality (Update in Intensive Care Medicine)

Measuring the quality of a complex service like critical care that combines the highest technology with the most intimate caring is a challenge. Recently, con­ sumers, clinicians, and payers have requested more formal assessments and comparisons of the quality and costs of medical care [2). Donabedian [1) pro­ posed a framework for thinking about the quality of medical care that separates quality into three components: structure, process, and outcome. An instructive analogy for understanding this framework is to imagine a food critic evaluating the quality of a restaurant. The critic might comment on the decoration and lighting ofthe restaurant, how close the tables are to each other, the extent ofthe wine list and where the chef trained. These are all evaluations of the restaurant structure. In addition, the critic might comment on whether the service was courteous and timely - measures of process. Finally, the critic might comment on outcomes like customer satisfaction or food poisoning. Similarly, to a health care critic, structure is the physical and human resources used to deliver medi­ cal care. Processes are the actual treatments offered to patients. Finally,outcomes are what happens to patients, for example, mortality, quality of life,and satisfac­ tion with care (Table 1). There is a debate about which of these measurements is the most important measure of quality. Front Matter....Pages I-XIII Front Matter....Pages 1-1 Introduction — Critical Care: Problems, Boundaries and Outcomes....Pages 3-5 Health Services Research: A Domain where Disciplines and Decision Makers Meet....Pages 6-19 Front Matter....Pages 21-21 The Structure of Intensive Care....Pages 23-40 Process of Care Assessment and the Evaluation of Outcome from Intensive Care....Pages 41-50 Severity of Illness....Pages 51-68 Measuring Treatment Outcomes in Intensive Care: Mortality, Morbidity, and Organ Dysfunction....Pages 69-85 Health-Related Quality of Life: During and Following Critical Care....Pages 86-103 Quality of Life and Longer Term Outcomes....Pages 104-118 Front Matter....Pages 119-119 Comparing ICU Populations: Background and Current Methods....Pages 121-139 A Hospital-Wide System for Managing the Seriously Ill: A Model of Applied Health Systems Research....Pages 140-154 Funding and Support....Pages 155-166 Hypothesis Generation: Asking the Right Question, Getting the Correct Answer....Pages 167-184 The Integration of Evidence Based Medicine and Health Services Research in the ICU....Pages 185-197 Using Systematic Reviews to Inform Decision Makers....Pages 198-208 Consensus Methods and Consumer Opinon....Pages 209-221 Benchmarking in the ICU: The Measurement of Costs and Outcome to Analyze Efficiency and Efficacy....Pages 222-243 Assessment of Medical Devices....Pages 244-254 Health Informatics....Pages 255-269 Databases, Registries and Networks....Pages 270-278 Front Matter....Pages 279-279 Organizational Effects on Outcomes....Pages 281-291 Front Matter....Pages 279-279 Geographical Differences in Outcomes....Pages 292-308 Disaggregating Data: From Groups to Individuals....Pages 309-320 Driving Improvements: Quality Management in the ICU....Pages 321-335 Applied Health Services Research: Translating Evidence into Practice....Pages 336-356 Translating the Evidence: Creating and Sustaining Change....Pages 357-374 Back Matter....Pages 375-379 This book describes how the integrated approach offered by health services research can improve the quality of care provided to critically ill patients. By focusing on the needs of the patient, health services research links conventional scientific disciplines, systems research, education, and management, with the aim of translating developments in knowledge into sustained change in culture and practice. Intensive care has much to offer in this respect, as it can both benefit from and contribute to the collaborative methodology of health services research. Although the contributions are directed at critical care, the content is relevant to all health care disciplines, including health services administration