ete tta st ..T

1
?e??te? ????t?ta? st? ?.?.T

• ?a???? ?. ????a??e??
• ??e?µ???????? ??tat????????
• ?p??????? ?a????t?? ????
• ?a?ep?st?µ?a?? ?.?.T, G?? ???

2
???e?µµata ?p??es??? ??e?a? st? ???????!

Overall Health Care in U.S. (RAND)
Breast cancer screening (65-69)
Outpatient ABX for colds
Hospital acquired infections
Hospitalized patients injured through negligence
Post-MI b-blockers
Defects per million
Airline baggage handling
Detection treatment of depression
Adverse drug events
Anesthesia-related fatality rate
U.S. Industry Best-in-Class
1 (69)
2 (31)
3 (7)
4 (.6)
5 (.002)
6 (.00003)
s level ( defects)
Source modified from C. Buck, GE
3
???? t?? s?st?µat?? pa????? ?p??es??? ??e?a?

• 44,000 98,000 pe?a????? et?s??? (???)
• ??st????? 3.5 d?? et?s??? (???)
• S??t????? pe??ss?te???? ap? t?? ?a????? t??
  µast??, t? AIDS ?a? ta t???a?a
• 15 t?? ?a??? ?fe????ta? se a?epa??? ep?t??es?
  ?at????? p???e??
• 85 ?fe????ta? se e??e??e?? t?? s?st?µat?? ?a?
  t?? d?ad??as??? p?? de? ep?t??p??? st??? ??at????
  ?a ep?te??s??? s?st? t?? d???e?? t???!

To Error is Human, Crossing the Quality Chasm,
Preventing Medication Errors The IOM Health Care
Quality, 1999, 2001, 2006
4
S?µß?µata se as?e?e?? ?.?.T
Valentin A, et al. Patient safety in intensive
care. ICM (2006) 3215911598
5
S?µß?µata se as?e?e?? ?.?.T
Valentin A, et al. Patient safety in intensive
care. ICM (2006) 3215911598
6
?a?eµß?se?? ?a? ???t?t?ta
?e??ss?te?e? pa?eµß?se?? epeµß?se??!
Metnitz PGH et al. More interventions do not
necessarily improve outcome in critically ill
patients. Intensive Care Med (2004) 3015861593
7
?a?eµß?se?? ?a? ???t?t?ta
Metnitz PGH et al. More interventions do not
necessarily improve outcome in critically ill
patients. Intensive Care Med (2004) 3015861593
8
?e???? st???e?a ??a t?? ??e?a

• ??st?? f???t?da? ßa???? pas???t?? ?.?.? 47
  d??, 1 t?? ???!
• ???? t? 10-20 t?? ?at????? ep?????? st??????ta?
  se epa??? ?a? a???p?sta ded?µ??a (evidence
  based)!
• ???? t? 55 t?? as?e??? ?aµß????? t??
  e?de?????µe?? a????
• McGlynn EA, et al. The quality of health care
  delivered to adults in the United States. N Engl
  J Med 2003 348263545.

9
????t?ta ?a? ?p??es?e? ??e?a?

• ?pa?t?s? t?? ???????a? ??a t? p?? ?a? p?s? ?a??
  ?? ?.?.T ?????? t?? d???e?? t???
• ?a ded?µ??a s???st??? ?t? ? p???t?ta pa?????
  ?p??es??? ??e?a? µp??e? ?a ße?t???e?
• Presidents Advisory Commission on Consumer
  Protection and Quality in the Health Care
  Industry. Quality first better health care
  forall Americans. http//www.hcqualitycommission.g
  ov/final/
• Kohn, L. To err is human building a safer health
  system. Institute of Medicine Report Washington
  National Academy Press, 1999
• Schuster M. How good is the quality of healthcare
  in the United States? Milbank Q 1998 76 51763
• Institute of Medicine. Crossing the quality
  chasm a new healthsystem for the 21st century.
  Washington National Academy Press, 2001
• Chassin M. The urgent need to improve healthcare
  quality. Institute of Medicine Roundtable on
  Health Care Quality. JAMA 1998 280 1005

10
???t?µata

• ?? e??a? p???t?ta?
• ?? e??a? p???t?ta st?? ??e?a?
• ?? e??a? ?.?.T?
• ?? e??a? p???t?ta st? ?.?.T?

11
?? e??a? ?.?.T?

• ?a???? ?p??es??? ??e?a? se e?d??? d?aµ??f?µ???
  ???? e?t?? ??s???µe??? µe d?µ? ?a? ??????s? p??
  ?a ??e? t? d??at?t?ta ??a f???t?da ?a? ?p?st?????
  t?? ??t???? ?e?t??????? se ßa??? p?s???te?
  as?e?e?? p?? ????? p?a?µat??? ? d???t??? ???d???
  ?a??t??

12
?? e??a? ??s???µe?a ?a? ?.?.T?

• ???a? ?p??es?e? ??e?a? ?a? ?pa?te?ta?
• S?ed?asµ?? d?µ?? (structure design)
• ??????s? d?ad??as??? (processes organization)
• ??t??s? ap?te?esµat???t?ta? (outcomes)
• ?e??te? ep?p?d?? ?a? p???t?ta? (standards,
  quality)

13
S??p?? ???a??sµ?? ?a????? ?p??es???

• ?? ???a??sµ?? pa????? ?p??es??? ????? ?e?????
  s??p? ?a ??a??p????? t?? apa?t?se?? t?? ???st?
• ? ????a d?af??? t?? pa????? ?p??es??? ??e?a? µe
  t?? ???e? ?p??es?e? e??a? ?? a??e? t??
  ??at???s?? t?? ??e?a? ?a? t?? ????

14
?p??es?e? ??e?a? ?a? ??????µ???

• ? d?at???s? t?? ??e?a? ?a? t?? ???? e??a? ?????
  ?p?????s?
• p?? de? p??pe? ?a s?et??eta? ap???ta µe
  ??????µ??? µe???? pa????? p?? st??????? t??
  pa???? ?p??es??? ??e?a?
• ?a? de? ??e? ?aµ?a s??s? µe t?? ?????a t??
  ???d??? p?? st??e???? ????? ???a??sµ?? pa?????
  ?p??es???

15
??af???? µe ?????? ???a??sµ??? pa????? ?p??es???

• ?d??aµ?a ep?????? ????? ??s??e?a? ???? ßa???? ?
  epe????sa? ?at?stas??
• ?a???e? pa????? ?p??es??? ??e?a? ap? s?µf???e?
  taµe???-??s???µe???-???t??? sta ?p??a ? as?e???
  de? ??e? ????
• ?????a d?ad??as??? ??????s?? t?? ?p??es???
  ??e?a?
• ??af???? st?? ???µe? ep?????? ?at???
• ????? s????s? aßeßa??t?ta ????

16
????t?ta pa????? ?p??es??? ??e?a? ???sµ??

• ? p???t?ta t?? f???t?da? e??a? ? ßa?µ?? st??
  ?p??? ?? ?p??es?e? ??e?a? p??? t?? p????sµ?
  a??????? t?? p??a??t?ta ??a t? ep???µ?t?
  ap?t??esµa (??e?a) s?µf??a µe t?? t?????sa
  ?at???? ???s?
• ? ???sµ?? a?t?? t????e? ?d?a?te?a t?? a??a t??
  s??e????µe??? ?at????? e?pa?de?s??

Donabedian A. The definition of quality and
approaches to its assessment. Ann. Arbor (MI)
Health Administration Press 1980.
17
S?stat??? p???t???? f???t?da? ??e?a? st? ?.?.T

• ?. ??e?d??e?µ??? ?at???? te????? a?t?µet?p?s? ?
  p???t?ta e?a?t?ta? ap? t? ?s?????? p??sd???µe???
  ?f?????/???d????
• ?. ??ap??s?p??? d?ad??as?a ? p???t?ta e?a?t?ta?
  ap? t? ta?t?s? t?? ??µ?µ?? p??sd????? t??
  as?e???? µe t??? ??????????? ?a? epa??e?µat?????
  ?a???e?

18
???sµ?? p???t?ta? st?? ??e?a

• ?p???t?? ???sµ?? epa??e?µat??? ???t???a, de?
  ?aµß??? ?p??? t? ??st??
• ??at?µ??e?µ???? ???sµ?? e??µ???s? as?e??? ??a
  t?? s???pe?e? t?? ?e?ape?a? s?µpe???aµßa??µ????
  ?a? t?? ??st???
• ?????????? ???sµ?? ?aµß??e? ?p??? t? ??st??
  a??µ? ?a? a? de? p????e? ap? t?? s???e???µ???
  as?e??
• ?ts?, ? ??at??? p?? ???e? ?a d?se? t? ?a??te??
  ??a t?? as?e?? t?? µp??e? ?a s??????ste? µe t??
  ep?ta??? t?? ???????a? p???te?a?

19
??????? s?st?µ?t?? p???t?ta?
??st?p???s? ????t?ta?
??ap?st?s? e??e??e??
??t??????a µ??a??sµ?? ???e?µµ?t?? pa?eµß?se??
?e?t??s? ????t?ta?
??ad??as?e?
S??e??? ?e?t??s? ????t?ta?
??µ??
?????? ??e???? ????t?ta?
20
?e??te? e?t?µ?s?? p???t?ta? st? ?.?.T

• ???t???a ??a de??te? p???t?ta?
• S?µa?t????
• ???????
• ????p?st??
• ?ata???t??
• ??µ??e?s?µ??
• ?f??t??

Curtis JR et al. Intensive care unit quality
improvement A how-to guide for the
interdisciplinary team. Crit Care Med 2006
34211218
21
????? d?a?e???s?? pa????? ?p??es??? ??e?a? se
?.?.T ?a? p???t?ta
??µ?, S?????t?s? ???????s? (structure)
??ad??as?e? (processes)
?p?te??sµata (results)
22
????? d?a?e???s?? pa????? ?p??es??? ??e?a? se
?.?.T ?a? p???t?ta

• ?. ??µ?, s?????t?s?, d??????s? (structure) ?.?.T
• ?????, a???µ?? ??eßat???, ste????s?, te???????a
  µ??a??µata, ??????s? d?ad??as???, µ?t???, 24???
  ?e?t?????a, st?at??????, s?st?µata p????f??????
  ?a? ??????s??, a?t???µ?a

23
?. ??µ?, s?????t?s?, d??????s? (structure) ?.?.T
µp??e? ?a ep??e?s??? t?? p???t?ta?

• ? Ste????s? se ?at???? ?a? ??s??e?t?? s?et??eta?
  µe t?? ???t?t?ta, t?? ep?p????? ?a? t?? d????e?a
  ??s??e?a?
• Pronovost PJ et al. Physician staffing patterns
  and clinical outcomes incritically ill patients
  a systematic review. JAMA 2002 288 215162.
• Pronovost P et al. ICU nurse staffing and therisk
  for complications after abdominal aortic surgery.
  Eff Clin Pract 2001 4 100205.

24
?. ??µ?, s?????t?s?, d??????s? (structure) ?.?.T
p?? e????eta? ? p???t?ta?

• ?pa?te?ta?
• ?p??efa??? ??tat????????
• ?µ?da pa?a???????s?? ep?stas?a? p???t????
  ??????s?? ?e?t?????a? ?.?.T

25

• The leader must know everything that went
  wrong, every day.
• ---Paul ONeill

26
????? d?a?e???s?? pa????? ?p??es??? ??e?a? se
?.?.T ?a? p???t?ta

• ?. ??ad??as?e? (processes) d?ast????t?te? t??
  d?µ?? ?µ?da ??e?a? st? s???e???µ??? ????
  te???????a µ??a??µata pa?eµß?se??
  epeµß?se??
• F???t?da pa?a???????s? ??s??e?t??
• ??????s? ??at???
• Te?ape?a ??at??? ??s??e?t?? te??????
• ?paf? µe as?e?e?? ?a? s???e?e?? ??at???
  ??s??e?t??

27
?. ??ad??as?e? (processes) st? ?.?.T ße?t??s?
p???t?ta?

• ?d???e? (Guidelines), S?st?se??
  (Recommendations), ???t?????a (Protocols)
• ???f??a?? ??a ??FT
• Gast??p??stas?a
• ??????? VAP
• ??????? ???µ??e?? ap? e?da??e?a???? ?a?et??e?
• ?p?d?sµe?s? ap? t?? a?ap?e?st??a ß?se?
  p??t???????
• ??t?µet?p?s? s????
• ??d?? µet????s?? a?µat?? ?a? pa?a?????
• ????µ? e?te???? s?t?s?
• ??ap?e?µe??? ????? se ARDS
• ?a??????t??? ?e?ape?a

Berenholtz SM, et al. Qualitative Review of
Intensive Care Unit Quality Indicators. Journal
of Critical Care, 2002 17 1 2002 1-15
28
????? d?a?e???s?? pa????? ?p??es??? ??e?a? se
?.?.T ?a? p???t?ta

• G. ?p?te??sµata (results) e??a? ? ??ßas? t??
  d?ad??as??? (processes) p?? p?a?µat?p??e? ? d?µ?
  (structure)

29
G. ?p?te??sµata (results) de??te? p???t?ta?

• T??t?t?ta
• ??a?µat??? vs. ???ß?ep?µe?? ???t?t?ta (APACHE II,
  SAPS II, MPM II)
• ?e??t?? T??t?t?ta? SMR (Standardized Mortality
  Ratio)
• ??a?µat??? ???t?t?ta
• ??aµe??µe?? T??t?t?ta (?p???????µe??
  ap? t? de??t? ßa??t?ta? e?sa????? SAPS II)

1, 1 0.1
30
G. ?p?te??sµata (results) de??te? p???t?ta?

• NEMS (Nine Equivalents of Nursing Manpower use
  Score)
• ?e??t?? e??as?a??? f??t?? t?? ??s??e?t????
  p??s?p????
• ???µ??e??
• VAP 18/1000 a?ap?e?st????µ??e?
• CRI 4/1000 ?a?et????µ??e?
• ???µ??e?? ap? p???a??e?t??? µ????ß?a ?
• ?µe??s?? ??st?? ??s??e?a? ?

Misset B et al. A continuous quality-improvement
program. ICM 2004 30395
Curtis JR et al, Intensive care unit quality
improvement. Crit Care Med 200634211
31
G. ?p?te??sµata (results) de??te? p???t?ta?

• ?p?p????? p?e?µ????? eµß???, a?µ???a??a
  pept????, p?e?µ????a?a? 5
• ?s?µßat? µet????s? 5
• ???? s??ta?????f?s?? ? e?t??es?? s??ta??? 5
• ?p?p????? d?a???st???? p???e?? ?
• ?????e?a ??s??e?a? gt 7 ?µ??e? ?
• ?????e?a µ??a????? ae??sµ?? 4 ?µ??e?
• ?pa?e?sa???? µ?sa se 48 ??e? 4
• ?pa?ad?as?????s? se 24 ??e? 12

Thijs LG. Continuous quality improvement in the
ICU ICM 1997 23125-127
32
G. ?p?te??sµata (results) de??te? p???t?ta?

• ??ep???µ?te? e????e?e? fa?µ????
• ?p??ß?ept? ap?d?as?????s? 15/1000 ?µ??e?
• ??t?µet?p?s? p???? 100
• ?pa???? ?atast??? 85
• ?µe??s?a d?a??p? ?atast???? 80
• ????? ??µata ????p??pe?a st? ???at?
• ?. ?a? ?.?????
• ??a??p???s? s???e???
• ??a??p???s? as?e???

Garland A. Improving the ICU. CHEST 2005
12721652179
33
?.?.T p??? ?a? µet?!
???? ?/? ?.?.?
?et? ?t????a ?.?.F
?.?.T
34
St???? ße?t??s?? p???t?ta? st?? ??e?a
S??e????µe?? ?at???? ??pa?de?s?

• ?p?te?esµat???t?ta ?at????? pa?eµß?se?? what
  works?
• ?ata?????t?ta ?at????? ap?f?se?? using what
  works
• ??t??es? ?at????? p???e?? doing well what works
• St???? ?e?ape?a? se s??s? µe a?t? p?? ?a ???aµe
  ?a ?????µe clarifying the values that tell us
  what we wish to do
• Berwick DM. Med Care 1989 27763

35
???pt??? p?????µµat?? p???t???? ße?t??s?? se ?.?.T

• ????t??, ?µ?da, ep??efa???
• ???te?a??t?te?, ep????? ?????
• ???et??µas?a t?? ?????
• ?????e?s? pe??ß?????t??
• ??µ??????a s?st?µat?? s??????? ded?µ????
• ??µ??????a s?st?µat?? a?af???? ded?µ????
• ??sa???? st?at?????? t??p?p???s?? s?µpe??f????
• ????????s? ?a? efa?µ??? s?st?µat?? p???t?ta?
  ?.?.T
• ?fa?µ??? s?st?µat?? s??????? ded?µ????
• ???p?p???s? st?at?????? a??a??? s?µpe??f????
• ?p?d??? ??es?a? ?a? ?µad???? d???e??? st? ?.?.T
• ?p?d??? ?p?st?????? ap? t?? d?????s? t??
  ??s???µe???

Curtis JR et al. Intensive care unit quality
improvement Crit Care Med 2006 34211218
36
??st?p???s? p???t?ta?
37
?e?t??s? p???t?ta?
38
?p?te?esµat???t?ta µ?t??? ße?t??s?? p???t?ta?
?????e?a ??s??e?a?
39
?p?te?esµat???t?ta µ?t??? ße?t??s?? p???t?ta?
?etaf??? se ?.?.T
40
?p?te?esµat???t?ta µ?t??? ße?t??s?? p???t?ta?
??s??e?t??? ????
41
S?µpe??sµata

• ? apa?t?s? ??a ?a??te?? p???t?ta ?p??es??? ??e?a?
  e??a? a??a??µe?? ?a? p?est???
• ? p???t?ta pa????? ?p??es??? ??e?a? µp??e? ?a
  ße?t???e?
• ??? ap? t?? a?a?????? ???? ?e?ape??? a??? ap? t??
  ?ata???s? t?? p?? ?a p??sf????µe ap?te?esµat???
  t?? ?d? ?p?????se? ?e?ape?e?
• ?? e??a??µe??? se ?p??es?e? ??e?a? p??pe? ?a
  ?????? p??a ?e?ape?a, p??, p?te ?a? p?? ?a
  ße?t??s??? t?? t??p? p?? t?? p??sf?????

42
S?µpe??sµata

• ? p???t??? ße?t??s? t?? ?p??es??? ??e?a? apa?te?
  p???ep?st?µ????? ?a? ?µad??? d???e?? p?? p??pe?
  ?a e??a? e?tat??? ?a? s??e????µe??
• ??a? ap??? t??p?? e??a? ? pa?a???????s?
  e?t??es?? ?a?????t?? d??ad?
• G?af??? pa??stas? t?? ?????? p?? apa?te?ta? ??a
  t?? e?t??es? s???e???µ???? p?????
• ?ata??af? t?? ep?p?????
• ? epeµßat???a? (procedurelist)!! university of
  Chicago

43
Continual improvement is an unending
journey. -Lloyd Dobens and Clare Crawford-Mason,
Thinking About Quality
44
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