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Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators
  1. Maartje L G de Vos1,2,
  2. Sabine N van der Veer3,
  3. Wilco C Graafmans2,
  4. Nicolette F de Keizer3,
  5. Kitty J Jager3,
  6. Gert P Westert4,
  7. Peter H J van der Voort5
  1. 1Scientific Center for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands
  2. 2Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
  3. 3Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
  4. 4Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
  5. 5Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
  1. Correspondence to Maartje L G de Vos, Scientific Center for Care and Welfare (Tranzo), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands; m.l.g.devos{at}


Background In multisite trials evaluating a complex quality improvement (QI) strategy the ‘same’ intervention may be implemented and adopted in different ways. Therefore, in this study we investigated the exposure to and experiences with a multifaceted intervention aimed at improving the quality of intensive care, and explore potential explanations for why the intervention was effective or not.

Methods We conducted a process evaluation investigating the effect of a multifaceted improvement intervention including establishment of a local multidisciplinary QI team, educational outreach visits and periodical indicator feedback on performance measures such as intensive care unit length of stay, mechanical ventilation duration and glucose regulation. Data were collected among participants receiving the intervention. We used standardised forms to record time investment and a questionnaire and focus group to collect data on perceived barriers and satisfaction.

Results The monthly time invested per QI team member ranged from 0.6 to 8.1 h. Persistent problems were: not sharing feedback with other staff; lack of normative standards and benchmarks; inadequate case-mix adjustment; lack of knowledge on how to apply the intervention for QI; and insufficient allocated time and staff. The intervention effectively targeted the lack of trust in data quality, and was reported to motivate participants to use indicators for QI activities.

Conclusions Time and resource constraints, difficulties to translate feedback into effective actions and insufficient involvement of other staff members hampered the impact of the intervention. However, our study suggests that a multifaceted feedback program stimulates clinicians to use indicators as input for QI, and is a promising first step to integrating systematic QI in daily care.

  • Audit and feedback
  • Continuous quality improvement
  • Critical care
  • Quality measurement
  • Performance measures

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