The Structure of Intensive Care

Abstract

Measuring the quality of a complex service like critical care that combines the highest technology with the most intimate caring is a challenge. Recently, consumers, clinicians, and payers have requested more formal assessments and comparisons of the quality and costs of medical care [2]. Donabedian [1] proposed a framework for thinking about the quality of medical care that separates quality into three components: structure, process, and outcome. An instructive analogy for understanding this framework is to imagine a food critic evaluating the quality of a restaurant. The critic might comment on the decoration and lighting of the restaurant, how close the tables are to each other, the extent of the wine list and where the chef trained. These are all evaluations of the restaurant structure. In addition, the critic might comment on whether the service was courteous and timely --- measures of process. Finally, the critic might comment on outcomes like customer satisfaction or food poisoning. Similarly, to a health care critic, structure is the physical and human resources used to deliver medical care. Processes are the actual treatments offered to patients. Finally, outcomes are what happens to patients, for example, mortality, quality of life, and satisfaction with care (Table 1). Table 1 Domains of ICU Structure 1. Material resources {\textbullet} Physical Layout {\textbullet} Technology 2. Human Resources {\textbullet} Physicians {\textbullet} Nurses {\textbullet} Non-physician clinicians 3. Organizational Structure {\textbullet} Admission policy - closed versus open {\textbullet} Governance style {\textbullet} Specialty units and teams