A Proper Large-Scale Quality Improvement Study in a Middle-Income Country

The vast majority of studies testing an intervention to improve quality/safety of care are conducted in high-income countries. However, a cluster RCT of 118 Brazilian ICUs (6,761 patients) has recently been reported.[1] The intervention was compound (multi-component), involving goal setting, clinician prompting, and multi-disciplinary ward rounds. Although mortality and other patient outcomes were not improved, clinical processes (e.g. use of appropriate settings on the ventilator and avoidance of heavy sedation) did improve. The nub of my argument is that clinical outcomes are insensitive indicators of improved practice, and we should be content with showing improved adherence to proven care standards – the argument is laid out numerically elsewhere.[2] The safety and quality movement is doomed so long as we insist on showing improvements in patient level outcomes.

— Richard Lilford, CLAHRC WM Director

References:

  1. Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet). Effect of a Quality Improvement Intervention with Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients. JAMA. 2016;315(14):1480-90.
  2. Lamont T, Barber N, de Pury J, et al. New approaches to evaluating complex health and care systems. BMJ. 2016; 352: i154.
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