Health care providers are struggling with the need to manage increases in both utilization and costs. Critical care is disproportionately utilized by our ageing population, new drugs and life-support technologies are expanding available treatment options, and there is an increasing acceptance of organ transplants. Lessons from industry demonstrate that poor quality leads to avoidable increases in costs. An important mechanism for managing the growing imbalance between available resources and patient need is to improve efficiency and therefore deliver better quality services at reduced costs.

Outcomes are clearly altered by the process of health care. Standards, policies, and practice parameters are tools that improve this process. Process improvement involves the definition of activities which transform inputs (patients with health care needs, equipment, etc.) into outputs (including information, diagnostic and treatment decisions) that are associated with outcomes realized by patients and others who are affected by the care ( Fig 1).

Fig. 1 Definition of inputs and outputs associated with outcomes in process improvement.

Standards, policies, and practice guidelines define expectations for clinical practice, create consistency in the method of delivery, and promote continuity of care. Their use improves care because intensive care units that have well-defined protocols, a medical director to co-ordinate activities, well-educated nurses, and strongcollaboration between nurses and physicians demonstrate the best outcomes (Knaus.ef.a/ 1986).

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