Quality in ICU

This weeks question is on measuring quality in ICU:

What are the key quality indicators that medical staff should be aware of?

What are the CQUINs that the medical staff should be aware of and involved in?


Defining quality in healthcare: an overview

One of the first pioneers in quality in health care measures was Avedis Donabedian. He was a health services researcher at the University of Michigan.  He developed a conceptual framework, now known as Donabedian’s Triad. This is key concept underpinning most quality measurement activities.  The Triad divides quality measures into structure, process, and outcome. Structure being how is care organized, process being what is done, and outcomes being what happened to the patient. 1-3

Institutions have also tried to define quality in healthcare. The American Institute of Medicine (IOM) published a major report published in 2001. Crossing the Quality Chasm described quality as: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”  It described six aims for a quality health care system: patient safety, patient-centeredness, effectiveness, efficiency, timeliness and equity.4

Lord Darzi’s published a report in 2008 entitled: High Quality Care for All.5 In this report Lord Darzi defines quality of care as clinically effective, personal and safe. Quality was described as protecting patient safety by eradicating healthcare acquired infections and avoidable accidents. It is about effectiveness of care, from the clinical procedure the patient receives, to their quality of life after treatment. It is also about the patient’s entire experience of the NHS and ensuring they are treated with compassion, dignity and respect in a clean, safe and well-managed environment. The UK’s independent regulator of healthcare, The Care Quality Commission, defines quality in healthcare as: Safe, Effective, Caring, Responsive and Well-Led.6

Quality in healthcare means different things to different people. As outlined above there are many definitions of quality. Quality is an inherently difficult thing to demonstrate and measure with precision.

ICU Specific Measures:

Structure, Process, Outcome model of quality (my personal preferred quality model)

Structure and process:

The Guidelines for the provision of intensive care (GPICS) is the single best document with standards. Auditing against these standards in my opinion reflects upon structure and process quality.

Outcome Measure: (3 sub categories)

1) Patient outcome data:

The ICNARC funnel plot of SMR (like it hate it) is important.

Readmission rate.

2) Safety data:

Critical incidents with governance and improvement

Iatrogenic infection rates

3) Patient satisfaction data:

Patient and relative survey data


1 Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44(Suppl.)):166-206. doi:10.2307/3348969.

2 Donabedian A. The evaluation of medical care programs. NY Acad Med 1968;44:117-24.

3 Donabedian A.  The quality of care.  How can it be assessed?  JAMA 1988; 270:1743-8.

4 Committee on Quality of Health Care in America, IOM.  Crossing the Quality Chasm:  A New Health System for the 21st Century.  Washington D.C.:  National Academy Press, 2001.

5 Department of Health. High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health; 2008.

6 Care Quality Commission. The state of healthcare and adult social care in England 2013 http://www.cqc.org.uk

B – 

Thankyou A,

I do think GPICS will be used as a quality benchmark from now on (if not already being done so) in conjunction with the D16.

Do our departmental leads have a view/further information on how quality is measured or should be measured in our departments?

Also with regards to CQUINs, at a junior medical level is there anything we can do to improve our compliance with these targets?


CQUINS for 2015/16 on the NHS England website. Only three are really relevant to us, (dementia, aki and sepsis) and even then only quite tangentially.

All of these primarily require an organisational, rather than individual response- though the action required devolves to the individual (eg completion of the dementia screening tool/activation of the sepsis pathway/completion of edan). However, the extent to which this truly reflects clinical quality rather than current political mores is debatable.

Arguably of more relevance is the more prosaic stuff- correct completion of antibiotic prescriptions, hand washing, VTE prophylaxis screening, MRSA screening, asepsis etc. These are less sexy and individually often seem pointless or unnecessarily pedantic, but ultimately form part of a larger system that is designed to improve outcome. Marginal gains, rather than flashy new initiatives. Not everything that is good is associated with a commissioning standard or level one evidence base.

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