Part 1: Quality of care--what is it?

Performance-based budgeting in the public sector: an illustration from the VA health care system

This paper estimates frontier cost functions for US Department of Veterans Affairs (VA) hospitals in FY2000 that are consistent with economic theory and explicitly account for cost differences across patients' risk, level of access to care, quality of care, and hospital-specific characteristics. Results indicate that on average VA hospitals in FY2000 operate at efficiency levels of 94%, as compared to previous studies on US private sector hospitals that average closer to 90% efficient. Using these cost frontiers, management systems potentially could be implemented to enhance the equitable allocation of the VA medical care global budget and systematically distribute funds across hospitals and networks. The paper also provides recommendations to improve the efficiency of delivering health care services applicable to public sector organizations.

Reduced risk of surgical site infections through surveillance in a network

OBJECTIVE

To estimate the effect of multicentre surveillance for nosocomial infections on patients' risk of surgical site infection (SSI).

DESIGN

Prospective multi-centre cohort study, from January 1996 to December 2000.

SETTING

Acute care hospitals in The Netherlands.

STUDY PARTICIPANTS

All 50 hospitals performing surveillance for one of seven selected procedures in the Dutch surveillance network for nosocomial infections PREZIES were invited. Thirty-seven hospitals participated (74%) and provided information on 21 920 operations, after which 885 (4%) SSI occurred.

INTERVENTIONS

The surveillance comprised the following: Development of surveillance methodology by multidisciplinary team; use of a standardized registration protocol and software; regular training of data collectors; anonymous inter-hospital comparison of infection rates and feedback of results; appointment of one contact person per hospital, responsible for data collection; and dissemination of results to other health care professionals. Regular discussion of both successful and failing prevention strategies that had been instituted based on the surveillance results.

OUTCOME MEASURE

Risk of SSI.

RESULTS

The risk of infection was reduced for patients who had an operation during the fourth surveillance year (RR = 0.69; 95% confidence interval (CI) = 0.52-0.89) and decreased further for patients operated on during the fifth surveillance year (RR = 0.43; CI = 0.24-0.76) as compared with patients who underwent surgery within one year of the start of surveillance in their hospital. No significant risk reduction was observed for patients operated on during the second and third surveillance years.

CONCLUSION

Surveillance, supported by participation in a surveillance network, reduced the risk of SSI in surgical patients registered in the Dutch surveillance network PREZIES. Our results suggest that infection control teams need to be perseverant and that surveillance programmes should be given time before evaluation.

Patients' perception of preoperative information by interactive computer program-exemplified by cholecystectomy

Patients' perception of preoperative information by interactive computer program informing about cholecystectomy was assessed. Patients were asked to qualify the computer program after hospital discharge by an anonymous questionnaire. Two hundred and fifty-seven of 278 consecutive patients completed the questionnaire resulting in a response rate of 92%. Sixty-three percent were very satisfied and 37% were satisfied, whereas none were dissatisfied or undecided. Patients' satisfaction was not associated with sex, age, surgeon or prior knowledge of computers. Most of the patients considered the clarity of text and illustrations and the volume of information as good or excellent and found the information well adapted to their prior knowledge. Ninety-eight percent stated that they would like to be informed again by an interactive computer program in case of another surgical intervention. Thus, interactive computer programs seem to be a valuable adjunct to written and oral information in the preoperative informed consent procedure.

Development of a questionnaire to assess the quality of care in Dutch dialysis centers from the patient's perspective

This study aimed to develop and test a questionnaire in order to assess the quality of care in Dutch dialysis centers from the patient's perspective. The questionnaire is referred to as the Quality of Care in Dialysis centers Questionnaire. Focus group sessions were organized and the results were transformed into a 68-item test version of the Quality of Care in Dialysis centers Questionnaire. Factor analyses and item reduction were performed to construct the Quality of Care in Dialysis centers Questionnaire. The questionnaire has four dimensions: doctors, nurses, other staff members and facilities; with eight descriptive items plus one item to measure satisfaction per dimension. A visual analog scale was added to determine overall satisfaction. The Quality of Care in Dialysis centers Questionnaire is used in Dutch dialysis centers. Further research should be conducted to establish preference weights per dimension on the basis of the visual analog scale scores.

The Effect of Medicare Health Care Systems on Women With Breast and Cervical Cancer

OBJECTIVE

Two common health care delivery systems in the United States are fee-for-service and managed care systems, including health maintenance organizations (HMOs). Differences may exist in patient outcomes depending upon the health care delivery system in which they are enrolled. We evaluated possible differences in the stage at diagnosis for breast and cervical cancer between 2 Medicare health care delivery systems (ie, fee for service and HMO) over the period 1985-2001.

METHODS

We used a linkage of 2 national databases: the Medicare database from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database to evaluate differences in stage at diagnosis between HMO and fee for service for breast and cervical cancer.

RESULTS

We studied 130,336 Medicare-aged women with breast cancer (83% Medicare fee for service) and 6,758 women with cervical cancer (87% Medicare fee for service). We found an earlier stage of diagnosis for HMO patients, which remained significant after adjusting for potential confounding variables. Women enrolled in HMOs with breast cancer were 17% more likely and those with cervical cancer 35% more likely to be diagnosed at an in situ stage of diagnosis than fee-for-service patients. It is of note that when women had other cancer diagnoses, no statistically significant differences were seen in stage at diagnosis for either cancer between fee-for-service and HMO patients.

CONCLUSION

Differences exist in stage at diagnosis between Medicare patients enrolled in HMOs compared with fee for service. This is likely due in part to use of or access to care.

Association of transplant center and physician factors on mortality after hematopoietic stem cell transplantation in the United States

The effect of the organization and delivery of health care at medical centers, referred to as “center effects,” with clinical outcomes after hematopoietic stem cell transplantation (HSCT) is not clear. We examined the association between center and treatment provider factors and mortality after HSCT. We surveyed 163 (87% response rate) United States transplantation centers that performed HLA-identical sibling HSCT for leukemia or autologous HSCT for lymphoma between 1998 and 2000 among patients at least 18 years old. One hundred thirteen (69%) centers performed HLA-identical sibling transplantations, whereas 162 (99%) performed autologous transplantations. Factors associated with decreased 100-day mortality in the allogeneic setting include a higher patient-per-physician ratio (P = .003) and centers where physicians answer calls after office hours (P = .03). Medical school affiliation was not associated with increased 100-day mortality except in centers where students/residents are present without fellows (P = .02). Center effects were weaker in autologous HSCT at 1 year. Differences in 100-day mortality in patients receiving transplants in centers with favorable versus unfavorable factors were greater in allogeneic than autologous HSCT. Greater physician involvement in patient care is important in producing favorable outcomes after HSCT. To more clearly establish the role of the factors we identified, further studies are recommended.

What is quality in a transplant program?

Abstract Hematopoietic stem cell transplantation (HSCT) as a field of medicine has been subject to rapid development and evolution since its inception. Traditionally, HSCT has been used for therapy of a diverse group of malignancies, bone marrow failure states, and inherited disorders. The rapid evolution of transplantation technology coupled with the diverse outcomes associated with a heterogeneous group of patients has stymied the development of consensus over objective programmatic indicators of quality, especially as they pertain to outcomes. In some regard, the lack of consensus has caused transplant programs to respond to a more consumer-driven paradigm of evaluation. The community of providers of transplantation therapies has responded by establishing standards for accreditation of facilities and uniform presentation of programmatic data. Rapid acceptance of the need for meaningful quality programs to address all aspects of the transplant facility has moved HSCT to the forefront of implementing standards for medical practice. Because definition of optimal outcomes in HSCT is likely to remain elusive, it is imperative that providers involved with HSCT continue to take a leadership role in defining program quality through further research.

Proyecto nacional para la gestión clínica de procesos asistenciales.Tratamiento quirúrgico de la hernia inguinal

INTRODUCTION

The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators.

OBJECTIVE

To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction.

MATERIAL AND METHODS

A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review.

RESULTS

Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks.

CONCLUSIONS

Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.

Research agendas in global emergency medicine

As the global culture moves forward into the 21st century with increasing interaction of populations through direct contact and electronic interchange, those citizens of our planet who have not benefited from the material gains that have been realized in the "mature economy" countries will increasingly seek equity on all levels, beginning with the most fundamental aspect of health care. There is a need to develop a capacity for treatment of urgent and emergent health conditions globally, a need that will only increase with advancing global economic development.

Quality of prostate carcinoma care in a statewide public assistance program

BACKGROUND

The authors evaluated the feasibility of measuring quality of care in a statewide public assistance program for men with prostate carcinoma.

METHODS

The sample consisted of 84 men who were followed for > or = 6 months after receiving primary treatment for early-stage prostate carcinoma (55 received radical prostatectomy and 29 received radiotherapy) through a free public program for low-income, uninsured men. Quality was assessed by chart review with 16 indicators previously developed and validated at the RAND Corporation, as well as by telephone and mail surveys that included the University of California at Los Angeles Prostate Cancer Index short form.

RESULTS

Quality of care measurement was feasible for 13 (81%) indicators from electronic chart abstraction, administrative documents, and patient questionnaires. Communication between specialist and primary physician was better for men treated with radiotherapy than with surgery (84% vs. 45%, P = 0.004). Subjects treated in private institutions were more likely than those treated in public institutions to have > or = 2 follow-up visits with the treating physician or institution within 1 year of treatment (93% vs. 63%, P = 0.003) and to have documentation of communication with the primary care physician (90% vs. 40%, P << 0.0001). Disease-specific, health-related quality of life 6 months after treatment did not appear to differ between public and private facilities.

CONCLUSIONS

The authors found the application of quality of care indicators to be feasible in a statewide public assistance program, but with some differences between public and private providers. These quality of care indicators identified target areas for improvement.

Quality management in health care: a 20-year journey

In this article, the total quality programme in the Spanish healthcare system (1986-1992) and the subsequent quality improvement steps that have led to definition and implementation of such an integrated framework, seeking a quality management system and patient safety, are discussed.

Level of education and patient opinion: significant differences in perceptions of health care

BACKGROUND

As part of the general competencies set forth by the Accreditation Council for Graduate Medical Education (ACGME), residents must have an understanding of systems-based practice, which is demonstrated by an awareness of-and responsiveness to-the comprehensive health care system. Residents must be able to effectively access and use system resources to provide care that is of optimal value. Essential to understanding and implementing systems-based practice is an awareness of how different patient populations perceive health care; one key factor that influences patients' perceptions of health care is their level of education.

METHODS

We surveyed 2900 adult patients in the Cincinnati, Ohio area and stratified them into 2 groups based on their level of education. Group 1 included patients with some high school education or a high school degree. Group 2 included patients with some college education, an undergraduate degree, or graduate/professional-level coursework. We then compared the groups' perceptions of common health care issues, including physician compensation, patient obligation for medical bills, and increased cost for the freedom to choose a physician.

RESULTS

Of 395 respondents, a higher percentage of Group 2 patients, compared with those in Group 1, understood that physicians do not collect 100% of what they bill (p < 0.001) and that businesses do influence the amount a physician is paid by insurance companies (p = 0.009). Conversely, a higher percentage of Group 1 patients thought that physicians are overpaid (p = 0.030) and that they keep a large portion of what they charge (p < 0.001). Further, fewer Group 1 respondents felt obligated to pay medical bills not covered by insurance (p = 0.002); they also were less willing to pay more for better medical care (p = 0.002) or for the freedom to choose a physician (p = 0.015).

CONCLUSIONS

This study indicates that patients with a lower level of education believe that physicians are overpaid and that they keep a large portion of insurance reimbursement. These findings may explain why fewer patients in this group feel that they are obligated to pay medical bills not covered by insurance and why they are less likely to pay more for better medical care or for the freedom to choose a physician.

Use of patient and hospital variables in interpreting patient satisfaction data for performance improvement purposes

Satisfaction scores of 349 patients being discharged from a state psychiatric hospital were examined in relation to available norms for the instrument used and selected patient and hospital variables. Mean item scores fell within the less-than-satisfied category on both total and factor scores. Regression analyses indicated minimal effects of patient attributes. Two hospital factors (restraint rate on patient's unit and accessibility of psychosocial groups) significantly predicted satisfaction, with the former having an unexpected positive relationship to satisfaction. Clinicians were able to use the survey data to improve care, but patients' tendency toward undifferentiated positive or negative responding hindered the prioritizing of change efforts.

Quality care and practice variation: the roles of practice guidelines and public profiles

Goals of the quality-of-care initiative are to improve the structure, process, and outcome of health care. The effectiveness of methods to improve quality have been largely unverified. Most methods are costly to implement and time-consuming to perform; some threaten professional autonomy. The characteristic feature of modern medicine that fuels the debate over quality is the variation in the delivery of health care. This review examines the "variation phenomenon" in medicine and the roles that practice guidelines and physician profiling have in improving health care, in general, and for adult cataract, in particular.

The meaning of quality in health care: a conceptual analysis

During the past three decades, there has been an ongoing debate on the quality of health care. Defining quality is an important part of it. This paper offers a review of definitions and a conceptual analysis in order to understand and explain the differences between them. The analysis results in a semantic rule, expressing the meaning of quality as an optimal balance between possibilities realised and a framework of norms and values. This rule is postulated as a formal criterion of meaning, e.g. when (correctly) applied people understand each other. The rule suits the abstract nature of the term "quality." Quality doesn't exist as such. It is constructed in an interaction between people. This interaction is guided by rules in order to transfer information, e.g. communicate on quality. The rule improves our ability to discuss the debate on quality and to develop a theory grounding actions such as quality assurance or quality improvement.

Methodological challenges associated with patient responses to follow-up longitudinal surveys regarding quality of care

OBJECTIVE

To illustrate, using empirical data, methodological challenges associated with patient responses to longitudinal surveys regarding the quality of process of care and health status, including overall response rate, differential response rate, and stability of responses with time.

DATA SOURCES/STUDY SETTING

Primary patient self-report data were collected from 30,308 patients in 1996 and 13,438 patients in 1998 as part of a two-year longitudinal study of quality of care and health status of patients receiving care delivered by 63 physician organizations (physician groups) across three West Coast states.

STUDY DESIGN

We analyzed longitudinal, observational data collected by Pacific Business Group on Health (PBGH) from patients aged 18-70 using a four-page survey in 1996 and a similar survey in 1998 to assess health status, satisfaction, use of services, and self-reported process of care. A subset of patients with self-reported chronic disease in the 1996 study received an enriched survey in 1998 to more fully detail processes of care for patients with chronic disease.

DATA COLLECTION/EXTRACTION METHODS

We measured response rate overall and separately for patients with chronic disease. Logistic regression was used to assess the impact of 1996 predictors on response to the follow-up 1998 survey. We compared process of care scores without and with nonresponse weights. Additionally, we measured stability of patient responses over time using percent agreement and kappa statistics, and examined rates of gender inconsistencies reported across the 1996 and 1998 surveys.

PRINCIPAL FINDINGS

In 1998, response rates were 54 percent overall and 63 percent for patients with chronic disease. Patient demographics, health status, use of services, and satisfaction with care in 1996 were all significant predictors of response in 1998, highlighting the importance of analytic strategies (i.e., application of nonresponse weights) to minimize bias in estimates of care and outcomes associated with longitudinal quality of care and health outcome analyses. Process of care scores weighted for nonresponse differed from unweighted scores (p<.001). Stability of responses across time was moderate, but varied by survey item from fair to excellent.

CONCLUSIONS

Longitudinal analyses involving the collection of data from the same patients at two points in time provide opportunities for analysis of relationships between process and outcomes of care that cannot occur with cross-sectional data. We present empirical results documenting the scope of the problems and discuss options for responding to these challenges. With increasing emphasis in the United States on quality reporting and use of financial incentives for quality in the health care market, it is important to identify and address methodological challenges that potentially threaten the validity of quality-of-care assessments.

Health Services Research in Neurology

This chapter covers the principles of health services research, which is critical for understanding and reducing the burden of neurological disease across populations. The goal of neurologic health services research is to create a scientific basis for measurably improving the care that is provided to patients with both chronic and acute neurological conditions. It is multi-disciplinary research that draws on the expertise of neurologists trained in clinical research methods, economists, biostatisticians, epidemiologists, sociologists, and other social scientists. Typical sources of data for health services research studies are surveys and interviews, medical records, and administrative data sets. Most health services researchers employ a combination of quantitative and qualitative research methods, and they work in collaboration with health care administrators and organizations in which health care is provided in the US. The chapter encompasses the design and execution of studies of access to care, quality of care and outcomes research, effectiveness, and cost-effectiveness.

Primary care clinic size and patient satisfaction in a military setting

Patient satisfaction is a fundamental parameter of quality in health care. Identification of aspects of care that influence patient satisfaction may be used to design changes in health delivery systems, thus improving quality of care. The objective of this study was to examine the relationship between the patient's assessment of quality of health care and the size of primary care clinics (PCCs) (measured as number of monthly patient visits) as well as the physician workload (measured as number of visits per physician per month). This study was a cross-sectional study using PCCs' characteristics and patient satisfaction surveys. One hundred one PCCs were evaluated. There was a negative correlation between all satisfaction indices and the number of primary care physicians in the clinic and the number of monthly visits to the clinic. In contrast, there was no significant correlation between the actual workload per physician. In general linear models, clinic size correlated significantly and negatively with patient satisfaction even after correction for other factors. The study concluded that patient satisfaction in the medical settings of the Israel Defense Forces is adversely affected by large clinic size but is not affected by physician workload.

Hypertensive patients' willingness to participate in placebo-controlled trials: implications for recruitment efficiency

BACKGROUND

Underenrollment and selective enrollment plague many clinical trials. Little is known about why hypertensive patients agree or refuse to participate in placebo-controlled trials (PCT) of antihypertensive drugs, whether the prospect of receiving placebo influences willingness to participate (WTP), or whether patients who participate differ from those who do not.

METHODS

We described a hypothetical PCT of a new antihypertensive drug to 126 patients who would be eligible for ongoing phase III trials. We solicited patient motivations and concerns regarding trial participation by using open-ended questions, assessed the patients' stated WTP, and used logistic regression to determine patient characteristics associated with WTP. We reassessed WTP in 62 patients after revealing, in random order, that 10%, 30%, and 50% of patients would receive placebo.

RESULTS

The most commonly cited motivations for participating included personal health benefits (40%), helping other patients (37%), and contributing to scientific knowledge (15%). The most common concerns were having to stop current medications (56%), inconvenience/annoyance (38%), fear of known side effects (35%), and the possibility of receiving placebo (24%). Overall, 47% of patients (95% confidence interval, 38% to 56%) were willing to participate. Younger patients (57% versus 37%; P =.01), nonsmokers (50% versus 24%; P =.04), and patients who had participated in research previously (77% versus 20%; P =.009) were all significantly more willing to participate. Fewer patients were willing to participate as the percentage who would receive placebo increased (P =.02), but randomly assigning fully half of patients to placebo still yielded maximal recruitment efficiency.

CONCLUSIONS

Hypertensive patients participate in trials for altruistic and personal health reasons. Differences between patients who do or do not participate may influence trial outcomes. The proportion of patients receiving placebo influences some patients' enrollment decisions but is not a key determinant of recruitment efficiency.

Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?

BACKGROUND

There is evidence to support the existence of an inverse relation between mortality after coronary artery bypass graft (CABG) surgery and procedure volume. It is unclear whether all patients benefit equally from having CABG surgery performed at high-volume centers. The objective of this study was to determine whether the volume-outcome association for CABG surgery is modified by patient risk.

METHODS

This retrospective cohort analysis was conducted using data from the Cardiac Surgery Reporting System database on all patients (20,078) undergoing CABG surgery in New York State who were discharged in 1996. The main outcome measure was in-hospital mortality as a function of procedure volume after adjusting for severity of disease. Logistic regression modeling was used to explore the interaction between patient risk and procedure volume.

RESULTS

There is a significant interaction between procedure volume and patient risk (p = 0.01). The final model exhibits excellent discrimination (C statistic = 0.818) and goodness-of-fit (Hosmer-Lemeshow statistic = 6.02; p = 0.645). Very low (<0.5%) and low-risk (0.5%-2.0%) patients exhibit a greater reduction in CABG mortality than high (5.0%-10.0%) and very high risk (>10%) patients at high-volume centers relative to low-volume centers. Among the highest risk patients (>25% risk of mortality), higher risk patients have better outcomes at higher volume centers.

CONCLUSIONS

For the vast majority of patients, low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. Low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. However, before generalizing these findings to other states, this study should be repeated using other regional population-based clinical databases.

Utilization of services by chronically ill people in managed care and indemnity plans: implications for quality

Because incentives for managed care organizations favor cost containment, concerns have been raised that quality of care has suffered, especially for chronically ill people. This study compares utilization rates of managed care and indemnity patients with three chronic conditions, using five years of claims records (1993-97) from private plans and Medicare in one market. Findings show that for all three conditions, managed care patients were more likely to see both primary care physicians and specialists within a year, but less likely to use a hospital emergency department or to be an inpatient. Assuming that patients with these illnesses should see a physician annually and that good primary care reduces the need for emergency and inpatient services, it appears that the patterns of care used by chronically ill managed care patients in this market do not reflect lower quality than that received by similar indemnity patients.

Measuring quality of care and performance from a population health care perspective

Population health care is health information and clinical services provided to individuals of a defined population. From a population health care perspective, quality of care involves the health status of the entire population, and thus issues of access, cost of care, and efficiency matter. In this paper, we describe the definitions of quality health care and the framework for measuring quality, with emphasis on the performance of organizations involved in the delivery and assurance of population health care. We describe quality measurement sets and systems, criteria for the choice of measures, data sources, and how quality measurements are used to improve health care and outcomes from a population health care perspective.

Use of quality indicators to evaluate the care of patients with localized prostate carcinoma

BACKGROUND

The goal of quality assurance in health care is to preserve and improve patient care. Recently, RAND developed a set of evidence-based candidate indicators for evaluating the quality of care for patients with localized prostate carcinoma; however, the feasibility and sensitivity of these indicators have not been tested in a clinical setting. The objectives of this study were to evaluate the feasibility of measuring these quality indicators and to determine their sensitivity to change in practice patterns over time.

METHODS

One hundred sixty-eight men who presented in either 1995 or in 2000 and were treated for localized prostate carcinoma were selected randomly from the University of Michigan tumor registry. A combination of electronic data base review and explicit chart review was used to assess the feasibility of measuring compliance for each indicator. For each indicator in which assessment was feasible, compliance with the RAND indicators was determined for patients in both years. Multivariate regression analysis was used to adjust for potential confounding effects of disease stage, tumor grade, prostate specific antigen (PSA) level, patient age, and therapy.

RESULTS

Based on review of available clinical data, measurement of compliance was feasible for 19 of 22 RAND candidate quality indicators (86%). For five indicators, significant differences in documentation (compliance) were detected between 1995 and 2000 (P < 0.05). Treatment received and higher PSA levels were associated independently with documentation of compliance for several indicators (P < 0.05).

CONCLUSIONS

Measurement of the majority of the RAND quality indicators for the treatment of patients with localized prostate carcinoma was feasible, and improvements in several indicators were observed between 1995 and 2000. Demonstration of such variation, even within a single institution, suggests that the indicators are sufficiently sensitive to detect differences in practice patterns.

Teaching performance improvement: an opportunity for continuing medical education

Practicing physicians generally are not engaged in either the methods of performance improvement for health care or the measurement and reporting of clinical outcomes. The principal reasons are lack of compensation for such work, the perception that the work of performance improvement adds no value and is a waste of time, the lack of knowledge and skill in the use of basic tools for outcomes measurement and performance improvement, the failure of medical educators to teach these skills, and the inability of mentors to model their use in practice. In this article, an overview of the history of quality improvement or performance improvement in general and the adoption of two methods of improvement (Plan-Do-Study-Act and SIX SIGMA) by health care is given. Six simple tools that are easy to understand and use and could be used in every continuing medical education (CME) program are then explained and illustrated. Postgraduate medical educators and CME program directors must step up to the challenge of teaching these skills. By learning to include them in planning, evaluation, policy making, and needs assessments of CME programs, the skills of every physician could be improved. Additional goals of every CME program could be accountability for outcomes, reduction of errors, alignment of incentives, and advocacy for the very best in evidence-based health care. To develop activities that affect physician practice and population health, CME professionals must partner with performance improvement experts for needs assessment and evaluation of outcomes data. An understanding of performance improvement principles helps those in performance improvement and those in CME to determine which educational activities might be expected to influence physician competency and performance.

A 10-year review of quality improvement monitoring in pain management: recommendations for standardized outcome measures

Quality measurement in health care is complex and in a constant state of evolution. Different approaches are necessary depending on the purpose of the measurement (e.g., accountability, research, improvement). Recent changes in health care accreditation standards are driving increased attention to measurement of the quality of pain management for improvement purposes. The purpose of this article is to determine what indicators are being used for pain quality improvement, compare results across studies, and provide specific recommendations to simplify and standardize future measurement of quality for hospital-based pain management initiatives. Pain management quality improvement monitoring experience and data from 1992 to 2001 were analyzed from 20 studies performed at eight large hospitals in the United States. Hospitals included: the University of Wisconsin Hospital and Clinics, Madison; Texas Medical Center, Houston; McAllen Medical Center, McAllen, TX; San Francisco General Hospital, San Francisco; Rush-Presbyterian-St. Luke's Medical Center and Northwestern Memorial Hospital, Chicago, IL; Memorial Sloan Kettering Cancer Center, New York; and Kaiser Sunnyside Medical Center of Kaiser Permanente Northwest, Clackamas, OR. Analyses of data led to consensus on six quality indicators for hospital-based pain management. These indicators include: the intensity of pain is documented with a numeric or descriptive rating scale; pain intensity is documented at frequent intervals; pain is treated by a route other than intramuscular; pain is treated with regularly administered analgesics, and when possible, a multimodal approach is used; pain is prevented and controlled to a degree that facilitates function and quality of life; and patients are adequately informed and knowledgeable about pain management. Although there are no perfect measures of quality, longitudinal data support the validity of a core set of indicators that could be used to obtain benchmark data for quality improvement in pain management in the hospital setting.

[Clinical and urologic management]

The concept of clinical management try to incorporate to the physicians the importance of their decessions regarding the dinamical and complex process of efficiency and health expenses. In this article the authors carry out a reflexive analysis of the reliable repercussion of this process into the healthy people, governmental authorities and assistencial setting of patients. It establish the involvement of the doctor in management, clinical management and it concludes the regulatory function to achieve the true clinical efficiency which harmonizes the relationship between the assistencial process and the corresponding resources consumption.

The morbidity and mortality conference: the delicate nature of learning from error

The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.

"Emerging unwanted side effects of quality control, or the value of the immeasurable qualities of medical care"

The author reviews briefly the sociocultural aspects of the quality control movements and how they relate to the medical profession. The "ethos" of the neurosurgical practice and the way to harmonize the new paradigms of modern medicine and the need to define parameters to evaluate quality are discussed.

[Relation between activity volume and surgeon's results: myth or reality?]

The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retrieved and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated. A new approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.

Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic

OBJECTIVE

To examine the effect of Spanish interpretation method on satisfaction with care.

DESIGN

Self-administered post-visit questionnaire.

SETTING

Urban, university-affiliated walk-in clinic.

PARTICIPANTS

Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems.

MEASUREMENTS AND MAIN RESULTS

Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. "Language-concordant" patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P < .01 and P = .007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P > .2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02).

CONCLUSIONS

Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.

An approach to hospital quality improvement

This study demonstrates many of the important features and challenges of improving hospital care. The unique confluence of software technology advances and increasingly complex clinical needs have made possible a redesign of the process by which discharge documentation is generated and disseminated. Using knowledge of the patients' experience of hospital care, a multidisciplinary team identified communication at the time of discharge as a key interaction point in the system of care. With this need in mind, the team identified an aim of improving the accuracy and timeliness of discharge data and their dissemination. The project leveraged existing information technology to help satisfy the general aims of recording only useful information only once and reducing wait times for information [14]. The ability to manage structured medication data and translate this information and specialized care instructions into patient-directed language facilitated the creation of a document that would ensure that patients knew what was expected of them after discharge. Implementation of a discharge form requires understanding all of the constituencies within a medical center. It was therefore necessary to put together a team that included representation from all the groups who interact with this discharge information. The authors proceeded with a small-scale test of change during which they identified training and education needs that would be useful as the new process expands to other areas of the hospital. The case illustrates how in one project a team needs to address all of the challenges to improving hospital quality. The discharge form clearly required understanding the patient's perspective. The approach taken by the team to change the discharge form also showed detailed understanding of the process of discharging a patient from the hospital. Many microsystems are involved in this process and the change that was implemented took into account the needs of each of those subsystems and drew on resources from the macroorganization (computer information system). Measurement was embedded into the system for monitoring. Organizational culture was addressed in that the organization itself was moving in the direction of greater use of electronic information for better patient care. Finally, multiple staff members needed to come together to accomplish this task, all working together as a team. They created an implementation plan that allowed them to do the work in staged, planned efforts, and to learn from each endeavor. Was the change an improvement? The team was able to implement successively a change in the discharge process as measured by utilization of the new form. Will the quality of care improve? Probably, although that remains to be seen. Improvements in care do not need to be sophisticated, they do not need to be elaborate, and they do not need to involve new devices or new technologies. Improvements start with thinking about the way work is done and reflecting on how the work might be done differently to meet and exceed patients' needs and expectations.

Measuring health care quality: comparing and contrasting the medical and the marketing approaches

Health care quality, a key concept for medical practice and research, is also a widely used construct in health care administration and marketing research. We explored discipline-specific differences in the definition of quality, with the intent of finding a more unified approach. We summarized definitions and basic conceptual approaches to quality in both disciplines and then compared them on several attributes: basic goals, sources of measurement, role of patient perceptions, role of health care personnel, and need for risk adjustment. We developed a conceptual model combining the 2 approaches. Both disciplines could benefit from broadening their outcome measures. Patient satisfaction deserves more attention from medical researchers, whereas marketing approaches should go beyond using patient satisfaction as the only outcome of interest. It is conceptually feasible to integrate medical and marketing approaches to quality, with important insights resulting from this integration.

Prospective preference assessment: a method to enhance the ethics and efficiency of randomized controlled trials

The concomitant problems of underenrollment and selective enrollment limit the efficiency of many randomized controlled trials (RCTs). In addition, the traditional informed consent process is often inadequate to respect research participants' autonomy. Past efforts to overcome these problems are not universally applicable. A new method, called prospective preference assessment (PPA), is suggested as a way to simultaneously enhance participant accrual, identify groups of patients to whom a trial's results may apply, and promote participants' interests. PPA is a method by which investigators would evaluate potential trial participants' motivations for and concerns about enrolling in a planned trial prior to formal recruitment. The information provided by PPA would then be used to (1) modify the final trial design and conduct to make enrollment more attractive, and (2) identify ways in which the patients who do enroll may differ from those who do not, thereby elucidating the trial's generalizability. The methodologic and ethical advantages of this method are described, and potential barriers to the method's implementation are addressed. The added costs of prospectively assessing the views of potential research participants prior to initiating RCTs are considered in relation to the method's ability to enhance the value of the information to be obtained. It is concluded that PPA is a feasible approach to a more democratic and efficient research process and that its adoption would be consistent with current trends in health care.

Attitudes of patients undergoing surgery toward alternative medical treatment

BACKGROUND/OBJECTIVES

There has been an increased interest in complementary and alternative medical (CAM) therapies in the scientific literature and the popular press for the last decade. We undertook a survey study to assess the prevalence of CAM therapies in a surgical patient population as well as their interests toward CAM therapies during the preoperative period.

METHODS

A total of 1000 questionnaires were administrated to the patients in the presurgical holding area of Yale-New Haven Hospital. A total of 857 surveys were returned (85.7%).

RESULTS

Two hundred and seventy-five (275) patients undergoing surgery (32%) reported having used CAM therapies. The most common CAM therapies in patients undergoing surgery were reported to be massage therapy (15.2%), followed by herb therapy (9.7%), relaxation (8.3%), and acupuncture (6.6%). A significant proportion of patients (42%) indicated their willingness to use acupuncture as a treatment modality for anxiety during the preoperative period. Those surgical patients who expressed an interest in using acupuncture as a preoperative anxiety treatment modality are younger than those who have no interest (47 +/- 16 vs. 53 +/- 19, p = 0.0001). In addition, those patients who used CAM therapies had a significant interest in using acupuncture as a preoperative anxiety treatment modality as compared to individuals who had no experience in CAM therapies (66.3% vs. 29.9%, p = 0.0001). A logistic regression model that included various demographics as predictors demonstrated that age and education level were significant factors that determined the use of CAM therapies in our surgical patients population. In our survey, however, gender does not play a significant role in the usage of CAM therapies.

CONCLUSIONS

Alternative medicine use is reported to be a common phenomenon prior to surgery. A significant number of patients are willing to accept acupuncture as treatment for anxiety during the preoperative period.

Continuous quality improvement in the ambulatory endoscopy center

What does quality assessment have to do with the practicing gastroenterologist? Why should one spend the time and effort to incorporate CQI activities into an already busy practice? First and foremost, quality improvement should directly benefit the patient by ensuring that they receive the highest quality of care possible. For example, comparing endoscopic use or outcomes, such as procedure success or complications, with national standards or other endoscopists in the same community may identify physicians who could benefit from additional training. Similar analyses may likewise identify outstanding physicians who might serve as resources for other physicians. Surveys of patient satisfaction may reveal deficiencies, which might be unknown to a physician who is otherwise technically excellent; deficiencies that would never have been uncovered by traditional measures of quality. Second, applying the techniques of CQI to study one's own practice can provide a competitive edge when vying for managed care or corporate contracts. In this regard, CQI can be used to document physician or practice performance through tracking of endoscopic use, procedure success and complication rates, and patient satisfaction. Finally, the rising concern among various patient advocacy groups has led to an increased emphasis on quality improvement, and in most cases it is a required activity as part of the accreditation process. Steps to quality improvement There is more to quality improvement than simply selecting and implementing a performance improvement plan. A number of steps have been suggested to achieve fundamental improvement in the quality of medical care [3]. The first is to use outcomes management for improvement rather than for judgment. One of the major criticisms of QA is that it will be used to judge physicians providing care. It is feared that CQI will be used to identify poor performers who will then be punished. This strategy leads to fear and inhibits an honest pursuit of improvement. Second, learning must be viewed as a process. A quality improvement plan that is successful in one setting may not be as favorable in another situation. Clinicians must be able to focus on their individual situations and adapt what others have implemented to their own practice. Third, the most important aspect of the quality improvement is the implementation step. It matters little if elegant studies of endoscopic complications or patient satisfaction are completed if the information is not used to improve the delivery of health care to every single patient. The delivery of medical care continues to evolve. Resources are becoming increasingly scarce and the progressive rise of health care expenditures suggests a need for control. In this zeal for cost constraint, quality must not be sacrificed. This new-found attention to quality must be extended to the level of the individual practitioner to ensure that individual patients' interests are protected and the best possible care is delivered regardless of the economic implications. As providers of health care, endoscopists need to take an active role in these efforts both in understanding and implementing the techniques of quality assessment into their practices. If physicians are not actively involved in data collection and measurement to improve the quality and value of their own work, someone else will undoubtedly assume this role.

Evaluation of a guided protocol for quality improvement in identifying common geriatric problems

OBJECTIVES

Many common geriatric problems are underrecognized and undertreated. A simple and reliable tool to facilitate a standard approach to evaluating geriatric patients might improve the quality of medical care delivered to geriatric patients. The objective of this study was to evaluate a standardized, semistructured quality-improvement protocol (the guided geriatric care protocol) for the assessment of common geriatric problems.

DESIGN

Sequential comparison cohorts, with chart review to evaluate study measures before and after introduction of the guided geriatric care protocol.

SETTING

The outpatient consultative geriatric assessment center of Yale-New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

One hundred consecutive new patients before and 100 consecutive new patients after introduction of the guided geriatric care protocol.

MEASUREMENTS

Number and type of problems identified and recommendations made during the clinical encounter, duration of the clinical encounter, clinician acceptance.

RESULTS

The two patient groups were similar in sociodemographics, cognitive and functional status, and reasons for evaluation. Significantly more problems were identified after (mean 5.51) than before (mean 3.49) introduction of the guided geriatric care protocol (P< .001); likewise, significantly more recommendations were made after (mean 10.45) than before (mean 8.48) introduction of the protocol (P< .001). The duration of the clinical encounter did not differ significantly between the two groups. The protocol was well accepted by participating clinicians.

CONCLUSIONS

Use of the guided geriatric care protocol assured a standard approach to evaluating common geriatric problems and may have led to the identification and treatment of more problems than usual care without increasing the duration of the clinical encounter. A quality-improvement tool that standardizes the evaluation of common geriatric problems, if validated in other clinical settings, holds the potential to improve the quality of care for vulnerable older patients.

Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk

OBJECTIVE

To evaluate the effect of recurrent nerve dissection on the incidence of recurrent laryngeal nerve injury (RLNI) and to analyze the performance of individual surgeons.

SUMMARY BACKGROUND DATA

Dissection of the recurrent nerve is mandatory in total thyroidectomy, but its relative merit in less extensive resections is not clear. The reported rates of RLNI differ widely; this may reflect a variation in the performance of individual surgeons.

METHODS

The authors studied the incidence of RLNI in primary surgery for benign thyroid disease during three periods in a single center. In period 1 (1979-1990; 9,385 consecutive patients, 15,865 nerves at risk), the recurrent nerve was not exposed. In period 2 (1991-1998; 6,128 patients, 10,548 nerves at risk), dissection of the recurrent nerve was the standard procedure. Global outcome and individual performance in these two periods were compared and presented to the surgeons. The effect of this quality control procedure was tested in 1999 (period 3; 930 patients, 1,561 nerves at risk).

RESULTS

Exposure of the recurrent nerve significantly reduced the global rate of postoperative and permanent RLNI. Some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent RLNI rates ranged from 0% to 1.1%). The documented significant differences in individual performances did not affect the outcome in period 3. The extent of nerve dissection was a source of variability; the rate of permanent RLNI averaged 0.9%, 0.3%, and 0.1% for surgeons who only localized, partially exposed, and completely dissected the recurrent nerve, respectively.

CONCLUSIONS

Recurrent nerve dissection significantly reduces the risk of RLNI. Extensive dissection facilitates visual control of nerve integrity during resection and is therefore superior to a more limited exposure of the nerve. Quality control can improve the global outcome and identify the variability in individual performance. This cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes.

A policy analysis of the introduction and dissemination of external peer review (visitatie) as a means of professional self-regulation amongst medical specialists in The Netherlands in the period 1985-2000

By examining the introduction and dissemination of external peer review through site-visits (visitatie) amongst Dutch medical specialists, this paper sets out to deepen our insight into the dynamics of professional self-regulation and health care policy making. We explore how visitatie has been used in the political process between medical specialists and the state, serving as a strategy in protecting the autonomy of physicians. In the late eighties and early nineties, factors both internal as well as external to the medical profession all together determined the start and spread of visitatie. The conflict between state and doctors over the specialists' income, the introduction of the market oriented policies, new visions on quality assurance, the debate on the future of medical specialistic care and a new legal framework on quality assurance, challenged the medical community to find ways to reconfirm the public's trust in the self-regulating mechanism of the profession. One answer is found in carrying out 300-400 visitaties annually. During the past years, many stakeholders have perceived visitatie as a credible instrument in assuring quality patient care. The dynamics of professionalization and measurable impact of visitatie will determine whether or not it is here to stay.

Cardiac surgery report cards: comprehensive review and statistical critique

Public report cards and confidential, collaborative peer education represent distinctly different approaches to cardiac surgery quality assessment and improvement. This review discusses the controversies regarding their methodology and relative effectiveness. Report cards have been the more commonly used approach, typically as a result of state legislation. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, although states with report cards have reported significant decreases in risk-adjusted mortality, it is unclear whether this improvement resulted from public disclosure or, rather, from the development of internal quality programs by hospitals. An additional confounding factor is the nationwide decline in heart surgery mortality, including states without quality monitoring. Finally, report cards may engender negative behaviors such as high-risk case avoidance and "gaming" of the reporting system, especially if individual surgeon results are published. The alternative approach, continuous quality improvement, may provide an opportunity to enhance performance and reduce interprovider variability while avoiding the unintended negative consequences of report cards. This collaborative method, which uses exchange visits between programs and determination of best practice, has been highly effective in northern New England and in the Veterans Affairs Administration. However, despite their potential advantages, quality programs based solely on confidential continuous quality improvement do not address the issue of public accountability. For this reason, some states may continue to mandate report cards. In such instances, it is imperative that appropriate statistical techniques and report formats are used, and that professional organizations simultaneously implement continuous quality improvement programs. The statistical methodology underlying current report cards is flawed, and does not justify the degree of accuracy presented to the public. All existing risk-adjustment methods have substantial inherent imprecision, and this is compounded when the results of such patient-level models are aggregated and used inappropriately to assess provider performance. Specific problems include sample size differences, clustering of observations, multiple comparisons, and failure to account for the random component of interprovider variability. We advocate the use of hierarchical or multilevel statistical models to address these concerns, as well as report formats that emphasize the statistical uncertainty of the results.

Identifying predictors of high quality care in English general practice: observational study

OBJECTIVES

To assess variation in the quality of care in general practice and identify factors associated with high quality care.

DESIGN

Observational study.

SETTING

Stratified random sample of 60 general practices in six areas of England.

OUTCOME MEASURES

Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate.

RESULTS

Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.

CONCLUSIONS

Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Developing and implementing measures of quality of care in the intensive care unit

As consumers, payers, and regulatory agencies require evidence regarding quality of care, the demand for intensive care unit (ICU) quality measures will likely grow. ICU providers and professional societies may need to partner with experts in quality measurement to develop and implement quality measures. This essay outlines the steps for developing and implementing quality measures and provides examples of potential ICU quality indicators. Outcome measures, in particular mortality rates, require risk adjustment, making data collection burdensome and broad implementation unlikely. On the other hand, structure and process measures may be feasible to implement broadly. Given the steps for developing quality measures outlined in this essay and the growing evidence in the literature regarding the impact of ICU care, the future should realize the development and implementation of ICU quality indicators that are rigorously developed and provide insights into opportunities to improve the quality of ICU care.