# Developing a Decision-Making Framework to Improve Healthcare Service Quality during a Pandemic
## 2 Literature Review
### ICU Service Quality Improvement Criteria, Alternatives, and Stakeholders
#### 2.3.1 Criteria  
Table 1 lists the selected criteria for improving quality of patient service in an ICU. Multiple studies expressed that the patients' health and service quality directly correlated to inadequate staffing levels [28; 29]. According to [PERSON] et al. [30], inadequate staff can produce less revenue per patient, while overstaffing leads to high operational and capital costs. For this, the determination of optimal staffing level is an important task in the healthcare sector [31]. Moreover, the ICU staff can be more prone to make mistakes due to the high level of stress and work fatigue due to the pandemic [32]. Before admitting the patient to the ICU, the severity of patients is generally determined using the appropriate scale. For example, the Canadian Triage and Acuity Scale (CTAS) classifies the patients to Level 1--Resuscitation, 2--Emergent, 3--Urgent, 4--Less urgent, and 5--Non-urgent based on the severity. These prioritizations help to identify high-risk patients and balance the staff workload and hospital revenue. To determine the patient's length of stay in the ICU, [PERSON] et al. [33] performed the Markov chain analysis. This type of analysis can be helpful to forecast the number of expected patients in any specific period and to take effective action to prevent congestion [34; 35]. Many ICU patients need regular follow-up after discharge and require home care treatment. ICU discharge patients may need walkers, oxygen, and other medical equipment \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Notation** & **Citeria** & **Explanation** & **Reference** \\ \hline CR1 & Physicians and medical staff capacity & Identifying an optimal number of physicians and staff is a critical task. Physicians and other medical staff need to be hired based on the unit’s capacity & [24; 28; 29] \\ \hline CR2 & Operational cost & The cost incurred to run the facility, including the cost to operate the equipment, wages for staff, power sources, and other miscellaneous associated costs. & [30; 31] \\ \hline CR3 & Extra capacity & It is difficult for ICU to accommodate all incoming patients during peak periods. The trauma department provides extra capacity where high-risk patients can be held until a bed becomes available in the ICU. & [4; 25; 30; 32] \\ \hline CR4 & Severity of patients & Severity is determined based on the patients’ medical complications and CTAS score. & [30; 32] \\ \hline CR5 & Estimation of patient length of stay & Patient length of stay is approximated based on the severity of their condition. & [32; 33] \\ \hline CR6 & Scheduling admission & Scheduling admission performed based on the severity of the patient is one of the key approaches to reduce congestion in the ICU. & [24; 34; 23] \\ \hline CR7 & Required equipment for home care & Necessary medical equipment is required to treat patients safely in their homes. & [35] \\ \hline CR8 & Personal home care procedures & Procedures to be followed after discharge, including emergency preparedness, drug consumption regimens, regular monitoring of body condition, and consulting appointments with physicians and others. & [32; 33; 36] \\ \hline CR9 & Patient satisfaction & Feedback is an invaluable tool for improving treatment quality. Patients and their families are requested to provide feedback regarding the service that they received, as it provides an index of patient satisfaction. & [37; 38; 39] \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Selected criteria for improving quality of patient service in an ICU. to monitor their health condition. For this, personal home care procedures including post-discharge activities such as drug consumption procedures; regular doctor consulting plans; and additional service from a social worker, physiotherapist, or nurse can play a vital role [35,36]. All these personal care procedures can reduce the possibility of re-admission and reduce the workload of ICU physicians and staff and overall ICU operations.