Improving quality of intensive care: Optimizing audit & feedback with actionable indicators and an action implementation toolbox

Intensive care units (ICUs) deal with complex, severely ill patients and complex processes which makes the system expensive, vulnerable and prone to error. An ongoing evaluation of the provided ICU care is highly desirable to continuously improve quality of care. Quality indicators can inform health care professionals and organizations about how well they adhere to recommended care. However, formerly used indicators often lacked normative standards, benchmarks, sufficient case-mix adjustment and information to initiate actions. In addition, health care professionals often lack the skills, time, capacity or knowledge to interpret feedback and formulate what improvement action is necessary. To further facilitate the translation of the performance feedback into effective actions supplementary intervention components such as action plans that incorporate measurable targets, or evidence-based strategies to change daily practice have shown to be promising. This thesis aims to i) assist ICU professionals in continuously improving quality of care for critically ill patients and ii) to gain knowledge on how the effectiveness of audit and feedback (A&F) could be increased. We conclude that an electronic A&F intervention based on actionable indicators and extended with an action implementation toolbox has an improved effectiveness and supports ICU professionals in continuously improving quality of care. The suggested actions from the toolbox led to the development of more improvement intentions across a wider range of practice determinants. ICUs without toolbox tended to remain longer in earlier processes of the feedback cycle. All ICUs still experienced barriers relating to the feedback and organizational context.