Quality Assurance and Quality Improvement in Respiratory Care

Respiratory care quality improvement activities usually focus on identifying and resolving problems related to patient care and clinical performance. Usually, a departmental committee develops and carries out its quality improvement plan, under the supervision of the medical director. According to the AARC, the goals of a respiratory care quality improvement plan should include at least the following:

Nine key steps are needed to systematically implement a quality improvement plan. As depicted in the following figure, these steps include: the identification of problem(s), the determination of problem cause(s), the ranking of problems, the development of strategies for problem resolution, the development of appropriate measurement techniques, the implementation of problem resolution strategies, the analysis of intervention results, the reporting of results, and the ongoing evaluation of intervention outcomes.

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Model respiratory care quality assurance plan flow chart (Redrawn from Hastings D: The AARC's model quality assurance plan. AARC Times 12(2):25, 1988.)

Successful implementation of the quality improvement plan demands that the respiratory care service develop criteria addressing the therapeutic goals, appropriateness, and means of evaluating the effectiveness of each specific high-utilization and high-risk procedure. The following box provides an example of such criteria for oxygen therapy.

Quality Assurance Criteria for Oxygen Therapy*

Therapeutic Goals:

  1. To prevent or reverse hypoxemia and tissue hypoxia
  2. To decrease myocardial work
  3. To decrease the work of breathing

Appropriateness of Care

  1. The patient must be diagnosed as having or being at risk of developing hypoxemia and/or tissue hypoxia; or
  2. The patient must be diagnosed as having suffered a myocardial infarction within the last 72 hours; and
  3. Oxygen dosing and mode of therapy will follow the criteria specified in the Respiratory Care Service Policy and Procedure Manual.

Evaluation of the Effectiveness of Therapy

The effectiveness of therapy will be evaluated by comparing the pre-treatment and post-treatment status of the patient according to the following criteria (at least one must apply):

  • Increase in PaO2 or in arterial saturation; or
  • Reversal or absence of cyanosis; or
  • Decrease in heart rate; or
  • Decrease in blood pressure; or
  • Decrease or absence of cardiac dysrhythmias; or
  • Decrease in respiratory rate; or
  • Increase in level of consciousness; or
  • Decrease in carboxyhemoglobin saturation; or
  • Relief of dyspnea.

*Adapted from Larson, K: The well-defined quality assurance plan, AARC Times, 12(2): 1524, 1988.

Problem Identification. Using the quality improvement process just described, various data sources, including the patient's medical record, would be used to determine the extent to which oxygen therapy services are being appropriately used.

Normally, an objective problem indicator, such as "90% of all patients receiving oxygen therapy will meet the appropriateness of care criteria" is helpful in problem identification. If the indicator is not being met (e.g., if only 70% of the patients meet the appropriateness of therapy criteria), a problem exists.

Determining Causes. Once a problem has been identified, its cause must be determined. For example, the fact that only 70% of the patients receiving oxygen therapy meet the specified criteria may result from factors such as the ordering physicians' lack of knowledge of the criteria, their failure to follow known criteria, or their failure to discontinue therapy when indicated.

Resolving Identified Problems. Once the underlying cause is identified, a strategy to resolve the problem must be developed, implemented and evaluated. For example, if the problem with oxygen therapy use is based on the new medical residents' failure to follow the appropriateness of care criteria, proper orientation and/or in-service education may be needed. Once conducted, the impact of the selected strategy on the desired outcome should be assessed. Ideally, evaluation of the outcomes of intervention should be based on the initial problem indicator. For example, we would want to know whether the in-service education program for the medical residents increased the percentage of patients meeting the appropriateness criteria.

Reporting and Ongoing Monitoring. Problem identification and resolution activities, including the relative success of intervention strategies, must be documented and reported regularly. Moreover, even successful interventions must be monitored over time to assure that a given problem does not recur. Only in this manner can the respiratory care service ensure that its services are appropriately utilized and effective in meeting patient needs.