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. 2018 Nov 7;18(1):838.
doi: 10.1186/s12913-018-3648-y.

Effects of a Multifaceted Intervention QI Program to Improve ICU Performance

Free PMC article

Effects of a Multifaceted Intervention QI Program to Improve ICU Performance

Anders Ersson et al. BMC Health Serv Res. .
Free PMC article


Background: To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation.

Methods: During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period.

Results: • Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.

Keywords: Cost-effectiveness; Critical care; ICU; LEAN; Organisation; Outcome; Quality improvement.

Conflict of interest statement

Ethics approval and consent to participate

According to Swedish law, ethical approval is not required for QI–projects and monitoring of normal clinical practice. However, this project was performed according to ethical standard so that all clinical data were anonymously collected and there were no possibilities to identify individual patients in the dataset. All treatments were performed in compliance with standard evidence-based clinical practice and at the discretion of the treating physician.

At admittance, all patients and their relatives were informed, verbally and in writing, that during the ICU stay, clinical data were continuously recorded and reported to regional and national ICU databases. This is a standard, nationally agreed procedure for performance and quality monitoring and part of normal ICU routines. The information also pointed out that given consent to this data retrieval was voluntary and could be withdrawn at any time. In that case, all data would be erased.

Consent for publication

Not applicable as not any details, images, or videos relating to an individual person is presented.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Fig. 1
Fig. 1
Schematic graphics of the Value Flow Mapping
Fig. 2
Fig. 2
Frequency of diagnoses 2008 and 2014, grouped by major area
Fig. 3
Fig. 3
Cumulative survival (y-axis; 0–1) in months (x-axis) 2008 and 2014

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