Table.

Institutional and health-care system approaches to improving care of the critically ill

	Example	Advantages	Disadvantages
Approach
Education	Clinical education for managers and policy-makers	Inexpensive; improve relationship between clinician and lay manager	Difficulty for managers to find time; lack of rigorous evidence of benefit
	Public education (informed patients/lay carers)	Explicit, transparent; aids performance assessment and benchmarking	Lack of interest until health care needed
Guidelines	Organisational guidelines (admission, discharge, staffing levels etc)	Inexpensive; explicit and transparent; take context into account	Difficulty achieving consensus; limited scientific evidence available; may encounter clinician resistance
Performance reporting	Risk-adjusted outcomes and processes (eg, CHAI in UK)	Objective; allows meaningful comparisons of providers	Uncertainty as to adequacy of adjustment
	Public disclosure of information	Empowers public; increases accountability to public	Limited impact; little patients' choice feasible for acute illnesses
Financial and sociobehavioural incentives	Reward based on outcomes	Providers have little option but to respond to financial incentives	Dependent on accurate, risk-adjusted measures; may encourage gaming such as patient selection; financial instability
	Disclosure of performance to peers	Clinicians want to be seen by peers to be providing good-quality care	“Bad apples” may not be bothered by peers' views
Regulation	Accreditation (eg, JCAHO in US)	Relatively easy as focused on inputs or structural factors	Lack of association between inputs and outcomes; lack of evidence of effectiveness
	Inspection (eg, CHAI)	Allows in-depth assessment of structures, processes and outcomes Acts as strong incentive for clinicians and providers to use guidelines	Expensive; may damage staff morale if seen as unfair May encourage defensive medicine; huge additional financial cost to health care providers
Legal requirements	Litigation	Establishes direct link between poor quality care and consequences	May encourage defensive medicine; little evidence of effect on quality of care; expensive for health system
Reorganisation of service delivery	Staff substitution	Increase efficiency, staff satisfaction, and morale	Resistance from professions who feel threatened
	Increased availability and flexibility of services	Strong support from clinicians; no requirement for behaviour change by clinicians	Expensive; complexity of management of flexible services; supplier-induced demand
	Regionalisation by levels of care	Consistent with future staffing restrictions (eg, working hours, training)	Resistance from clinicians providing low-level care; more patients transferred

CHAI=Commission for Healthcare Audit and Inspection. JCAHO=Joint Commission on Accreditation of Healthcare Organizations.