A systematic approach to develop a core set of parameters for boards of directors to govern quality of care in the ICU
International Journal for Quality in Health Care, Volume 30, Issue 7, 1 August 2018
Hospital boards are legally responsible for the quality of care delivered by healthcare professionals in their hospitals, but experience difficulties in overseeing quality and safety risks. This study aimed to select a core set of parameters for boards to govern quality of care in the intensive care unit (ICU).
Two-round Delphi study.
Two university hospitals in the Netherlands.
An expert panel of 12 former ICU patients or their family members, 12 ICU nurses, 12 ICU physicians and 12 members of boards of directors and quality managers.
Participants indicated the relevance of existing parameters for assessing the quality of ICU care for governance purposes (round 1) and selected 10 quality parameters that together provide boards of directors with a good representation of quality of care in their ICU (round 2).
We identified 122 quality parameters related to care in the ICU, which we limited to a short list to present to participants in round 1. The response rate was 94% in round 1 and 85% in round 2.
The final set consisted of the 10 most frequently selected quality parameters per hospital. Five parameters were included in both sets; all related to patient safety and continuous quality improvement.
Parameters in the core set were mostly qualitative and generic, rather than quantitative and ICU-specific in nature. To engage in a true dialog about quality of care, boards are more interested in the story behind the numbers than in just the numbers themselves.
Hospital boards have a legal and moral responsibility to ensure high quality of care delivered by healthcare professionals in their hospitals. They are the ones held accountable by government and insurers but experience difficulties in overseeing quality and safety risks. Problems such as insufficient resources, gaps in board members’ experience and skills and difficulties to oversee the quality of care in the entire hospital make it difficult for boards to govern the quality of healthcare in their hospital.
Currently, hospitals measure and collect hundreds of quality parameters. Their large number however limits their use: it is difficult to obtain an overview and to recognize signals, meaning an important opportunity to continuously improve care is missed. For boards of directors, especially, many of these parameters are of limited use, due to their detailed and specific nature.
Professionals experience a growing pressure to provide requested information, which compromises the internal use of those quality indicators. To improve quality and fight the waste of energy, enthusiasm and (financial) resources, it is paramount that the generated information is actually used by healthcare professionals, managers and directors.
This project was aimed at providing boards of directors with insight into quality and safety of care in the intensive care unit (ICU), in order to timely recognize possible quality problems. We selected the ICU as the focus of the project because it is one of the hospital’s core departments, in which critically ill patients are cared for with high-risk interventions. Suboptimal quality and safety of care have a tremendous impact on this patient group as well as for the hospital, in the form of critical incidents and legal claims. The ICU cares for many different types of patients and is therefore an important cog in the hospital’s machine. When quality of ICU care is good (or bad), this will affect other departments in the hospital.
Because of the complexity of ICU care, the importance of a core set of key quality parameters for boards of directors is clear. However, it is unknown which quality information and parameters are suitable for boards of directors to govern quality of ICU care. To assist boards, we systematically asked an expert panel of boards members, patients and their family members and healthcare professionals to determine which quality information is relevant for good governance. The aim of this study was to select a core set of parameters for boards of directors to govern quality of care in the ICU.
To select a core set of quality parameters, we used the modified Delphi method. This systematic, iterative methodology is used to collect and distill knowledge on a specific topic from a panel of experts. In multiple rounds, experts are confronted with each other’s ideas and viewpoints. This method has important advantages: it can be carried out via questionnaires, meaning it is both time efficient as well as anonymous, which avoids the possible negative impact of power imbalances and participant dominance. We performed separate Delphi studies in two Dutch academic hospitals between March and June 2016. The Delphi studies were conducted separately to allow for tailoring of the core set to the local setting and the needs and desires of each hospital’s stakeholders. Our modified Delphi study consisted of four steps, described below.
Ethical approval was sought from the Research Ethics Committee of the Radboud University Nijmegen Medical Centre (registration number: 2016/2525); the committee judged that ethical approval was not required under Dutch National Law. All participants received written information about the project and its aims and were subsequently invited to participate.
Step 1. Extraction of quality parameters from the available quality information
The basis for the selection of the core set was all available quality information pertaining to the ICU. From January to March 2016, two researchers (AO and MZ) systematically inventoried all quality information registered in both hospitals. Quality information is generated for different information-requesting stakeholders, with different goals (quality improvement, governance and accountability), and is varied in nature (structure, outcome, or process indicators).
From this inventory, two researchers (AO and MZ) extracted the quality parameters that could be used to govern quality of care in the ICU. In consultation with the head of each participating ICU, we limited the long list by removing doubles (parameters registered for separate stakeholders, with (partially) overlapping definitions) and quality parameters very likely to be considered ‘not relevant’. The resulting list of quality parameters was divided into seven domains:
organization of ICU care;
effectiveness of ICU treatment;
incidence and prevention of complications and iatrogenic injury;
learning from complications and incidents;
functioning of individual healthcare professionals and teams;
experiences of patients and family;
patient outcomes and functional status after discharge.
The domain names, quality parameter names, parameter descriptions and the domain allocation were reviewed by each ICU department head and modified if necessary. The resulting list served as the basis for the questionnaire of Delphi round 1.
Step 2. Delphi round 1: relevance of quality parameters
The Delphi panels consisted of 24 experts in each hospital:
6 former ICU patients and family members of former ICU patients;
6 ICU nurses;
6 managers or board members (including ICU department head, quality managers, hospital board of directors).
The former patients and family members were recruited through a post-ICU care polyclinic (which sees patients 3 months (or longer) after ICU discharge for a follow-up appointment) and through the foundation for Family and patient Centered Intensive Care, meaning patients had not necessarily been admitted to the ICUs of hospital A or B. The physicians and nurses were selected on the basis of their proven interest or expertize in quality of care (for example, membership of a quality assurance committee). All experts invited agreed to participate.
In the first round, the expert panel received a questionnaire with the list of quality parameters with a brief description, divided into seven domains. The participating professionals received a link to an online version of the questionnaire via e-mail. The patients and family members were sent a Word document or printed version and were guided through the process via telephone (by AO).
The experts were instructed to individually rate each quality parameter on a nine-point Likert scale (ranging from ‘not at all relevant’ to ‘very relevant’) by asking: ‘For each parameter, indicate how relevant you think this information would be for a board member to determine quality of care in the ICU.’
Based on the relevance scores, the parameters were divided into three categories:
A convincing majority of participants considered the parameter relevant: at least 70% of participants scored 7, 8 or 9 and the median was at least 8.
Extremely skewed distribution: at least 30% of participants scored 1, 2 or 3 and at least 30% of participants scored 7, 8 or 9.
Somewhat skewed distribution: at least 70% of participants scored 7, 8 or 9 and the median was 7 or lower.
Exclusion (all other cases)
Parameters in the ‘non-exclusion’ or ‘equivocal’ categories were included in the questionnaire of round 2 [11, 12].
Step 3. Delphi round 2: selection of a core set of quality parameters
In this second round, the experts received the questionnaire via e-mail. If so desired, patients and family members were again guided through the completion process by phone. They were presented with the remaining quality parameters divided into the same domains as in round 1, and were asked the following: ‘In the questionnaire we invite you to select 10 quality parameters from the remaining parameters. Ten quality parameters that provide a board member with sufficient means to enter into a dialog with healthcare professionals about the quality of care in the ICU.’
For each quality parameter in the questionnaire we presented the distribution of round 1 participant scores across the Likert scale, the percentage of participants that scored the parameter in the highest tertile and the median score. (For a fragment from the second round questionnaire, see the online Supplemental Material.)
The 10 most frequently selected parameters in each hospital formed the two core sets.
Step 4. Feasibility study
To evaluate the usefulness of the identified core set of quality parameters, we performed a feasibility study in both hospitals. To this purpose, we filled each core set with data from the previous 2 years. Where relevant, we displayed trends through time or a comparison with national averages. Per parameter, we added a concise description of the most notable observations or the main problem points, with planned improvement actions and current state of affairs, where present. If possible, we displayed information in figures or tables, with the use of signal colors green, orange and red. We discussed draft versions with each ICU department head and subsequently modified the core set where needed.
In both hospitals, the complete core set was used in a conversation between ICU management (department head and financial manager/nursing manager) and a member of the board of directors. A researcher (AO) observed this conversation and asked short evaluation questions afterwards
For the results and discussion and to access the whole document, please click here: International Journal for Quality in Health Care, Volume 30, Issue 7
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