Management strategies to effect change in intensive care units: lessons from the world of business. Part I. Targeting quality improvement initiatives.

The business community has developed strategies to ensure the quality of the goods or services they produce and to improve the management of multidisciplinary work teams. With modification, many of these techniques can be imported into intensive care units (ICUs) to improve clinical operations and patient safety. In Part I of a three-part ATS Seminar series, we argue for adopting business management strategies in ICUs and set forth strategies for targeting selected quality improvement initiatives. These tools are relevant to health care today as focus is placed on limiting low-value care and measuring, reporting, and improving quality. In the ICU, the complexity of illness and the need to standardize processes make these tools even more appealing. Herein, we highlight four techniques to help prioritize initiatives. First, the "80/20 rule" mandates focus on the few (20%) interventions likely to drive the majority (80%) of improvement. Second, benchmarking--a process of comparison with peer units or institutions--is essential to identifying areas of strength and weakness. Third, root cause analyses, in which structured retrospective reviews of negative events are performed, can be used to identify and fix systems errors. Finally, failure mode and effects analysis--a process aimed at prospectively identifying potential sources of error--allows for systems fixes to be instituted in advance to prevent negative outcomes. These techniques originated in fields other than health care, yet adoption has and can help ICU managers prioritize issues for quality improvement.