You have taken over the directorship of a district hospital ICU. Part of your mandate is to establish a Quality Assurance program.
(a) How will you achieve this?
When moving into a new role it may take time to assess the individual needs of the unit and staff. Changes will need to be introduced sequentially and with the cooperation of the staff. Quality assurance projects will need to be learning experiences and productive rather than punitive.
The candidate was expected to discuss the elements of an organised program and what he/she would do including:
- ICU Morbidity and Mortality data collection and review
- Incident Monitoring data collection and review
- Hospital Outcome data collection and review
- Staff working hours, retention, continuing education
- Occupational safety record
- Appointment of a Quality Assurance Coordinator
CICM have (on their own website) an article by L.I. Worthley on this very topic. Given that an examiner wrote the article, one might expect it to contain some material relevant to this question.
In addition, one can find a NSW Health policy document which provides some information about what a quality assurance program should look like. However, the most relevant document turned out to be this review article from Crit Care Med (2006)
The following points have been compiled from this article, and several others.
Preparation of a quality assurance project:
- Identify critical areas of interest and collect data about meaningful outcomes.
- Prioritise potential projects
- Prepare a plan for the identified projects, with a task list, budget considerations, a timeline, and clearly defined leadership with central reporting
- Clearly define the measured variables
- Assess the logistics of collecting this data
- Create a data collection system, eg. a regularly maintained database of adverse events
Collection of quality data
- Assess the current quality of care using the established data collection methods
- Morbidity and mortality data collection
- Incident monitoring
- Patient and family satisfaction surveys
- Staff satisfaction surveys
- Feedback from external non-ICU services and prehospital staff
Assessment of quality data
- Morbidity and mortality audit - regulargly
- Incident review meetings - regularly
- Encourage the attendance and contribution from all staff
Generation of recommendations
- Evidence-centered literature search for solutions to identified problems
- Consultation with relevant specialists and with local medical staff
- Evaluation of evidence-based recommendations for improvement, and their cost-benefit analsysis
- Assessment of the tolerability of their implementations, the logistics of this and changes to funding.
- The presentation of recommendations at department meetings to encourage discussion
Monitoring and audit
- Ongoing data collection
- Regular review of outcome trends and assessment of effective and ineffective QA strategies
Structure of the QA program
- Education of all staff to be involved in incident reporting
- Specific staff groups responsible for data colelction
- Specific staff allocated the task of ensuring high data quality
- A leader for the project, who reports to the head of department
- Data entry and database maintenance staff
Worthley, L. I. "Quality control, audit, adverse events and risk in the intensive care unit." (2000): 304. Critical Care and Resuscitation Volume 2 Issue 4 (2000 Dec)
Brook, Robert H., Elizabeth A. McGlynn, and Paul Cleary. "Measuring quality of care." (1996). New England Journal of Medicine, v. 335, no. 13, September 26, 1996, pp. 966-970
McMillan, Tracy R., and Robert C. Hyzy. "Bringing quality improvement into the intensive care unit." Critical care medicine 35.2 (2007): S59-S65.
Curtis, J. Randall, et al. "Intensive care unit quality improvement: A" how-to" guide for the interdisciplinary team*." Critical care medicine 34.1 (2006): 211-218.