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  • Improving ICU performance demands a systems-oriented approach embodied in total quality management (TQM).
  • In most ICUs this requires a major paradigm shift away from the discredited notion that most omissions, errors, and other problems are the fault of individuals, and embraces the idea that meaningful and sustained improvement comes from transforming structures and processes into those that make it hard for people to make mistakes.
  • Creating an effective program of TQM is much easier in an ICU having the resources to hire personnel and purchase information systems.
  • The most difficult, labor-intensive, and expensive part of TQM is data collection, but there are ways to make this less burdensome.
  • Every ICU should implement a system of TQM that is multidisciplinary and inclusive, has the vigorous support of hospital and ICU leadership, and has sufficient personnel and economic support to succeed.


Intensive care units (ICUs) are an important component of modern health care. This importance derives from large costs that are both human and economic. Approximately one third of adult deaths in the U.S. occur in acute care hospitals,1 and as many as half of these occur in ICUs.2,3 An even greater fraction of people spend time in an ICU during the final 6 months of life.3 Among patients admitted to ICUs, 8% to 17% die there, though for some diagnoses the ICU mortality rate is much higher.4–6


Beyond death rates, suffering is common among ICU patients. Half or more of ICU patients endure substantial pain.7–9 Bergbom-Engberg and Haljamae found that 30% of patients surviving mechanical ventilation recall agony, panic, or both.10 Among oncology patients in an ICU, 30% to 75% experienced dyspnea, hunger, anxiety, insomnia, or thirst, with increased suffering during even such innocuous procedures as turning.9 Substantial dissatisfaction among relatives and friends of ICU patients11–13 indicates that suffering in critical illness is not limited to the patients themselves.


To go along with these human costs, the economic costs of ICU care are staggering. Comprising just 8% of acute hospital beds,14,15 ICU care consumes 20% of total inpatient expenditures,15–17 equivalent to 0.9% of the gross domestic product of the United States, or $91 billion in 2001.18 ICUs are a smaller portion of the health care systems in other industrialized countries, but still represent an important segment of medical care and its costs.16,19–23


A necessary starting point for improving ICUs is to recognize that problems of quality are common and serious. A recent Institute of Medicine Roundtable24 stated that:


Serious and widespread quality problems exist throughout American medicine. These … occur in small and large communities alike, in all parts of the country and with approximately equal frequency in managed care and fee-for-service systems of care. Millions of Americans are not reached by proven effective interventions that can save lives and prevent ...

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