Small steps beyond benchmarking

This paraphrased quote from the former president of the Institute of Healthcare Improvement Donald Berwick eloquently clarifies that we need to compare ourselves in order to optimize the outcome for our patients. In our view this is only the first step in quality improvement. In many countries intensive care units (ICU) quality registries exist for benchmarking.(1,2) The first step in the improvement of quality of care starts with measuring and comparing care structures, processes and outcome indicators with other ICUs. Turning the light on. This process identifies care structures, processes or subgroups of patients in which the outcome is not as good as the average ICU population in the benchmark. This is input for the “Plan phase” of the Plan-Do-Check-Acta (PDCA)-cycle. Obviously, many other explanations than differences in quality of care might explain these differences between ICUs.(3) Differences in indicators can be caused by data quality; differences in case-mix; chance (small samples); residual confounders. Therefore, the first step is to look at the data quality. Are all participating ICUs in the benchmark actually comparing the same variables or do we use different definitions or registration methods. If we cannot agree on what we are comparing than benchmarking is useless. Let’s assume that these differences are considered to be real and not part of data quality problems, case mix differences, or chance. The following step is to identify weaknesses and solutions in the process of care (the “Do-phase” in the PDCA-cycle). Many ICUs consider this to be the most difficult part of quality improvement. Often, they do not know where to start and excuses prevail: “We have been doing this for years, so it cannot be wrong”, “The solution isn’t perfect, either”, “No money”, “Too busy”, etc. Indeed, identifying a process that can be improved with impact on the quality of care is one of the most difficult steps in quality improvement. To overcome this barrier a quality registry should support ICUs in implementing improvements by offering a “toolbox” with possible actions. Such a “toolbox” should include a list of possible bottlenecks derived from process evaluations, accompanied by a set of preferably evidence-based suggestions for concrete change.(4) Dylan W. de Lange1,2, Dave A. Dongelmans2,3, Nicolette F. de Keizer2,4