Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care.

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

The Impact of Changes in Medicare's Physician Payment System on Critical Care.

In 2015 President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) which repealed the Sustainable Growth Rate (SGR) mechanism for Medicare physician reimbursement and mandated that CMS develop alternative payment methodologies to "reward health care providers for giving better care not more just more care." MACRA makes 3 major changes to Medicare reimbursements: (1) it ends the SGR formula; (2) it establishes a new framework to reward physicians based on performance and health outcomes rather than volume; and (3) it aims to combine existing quality reporting programs into one streamlined system. Beginning in 2019, physicians must enter one of two new tracks for payment: the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). SCCM has a unique opportunity as the largest multidisciplinary critical care organization to comment upon and, ideally, to help develop the new physician payment models specifically for critical care services. The time is now for SCCM and its individual members to become involved in the process.