# Development and 2025 re-evaluation of a Japanese quality indicator set for adult intensive care: a modified RAND/UCLA Delphi study

## TL;DR

This study developed and updated a set of quality indicators for adult intensive care units in Japan to improve care standards and enable national benchmarking.

## Contribution

The paper presents a re-evaluated and updated Japanese ICU quality indicator set using a modified RAND/UCLA Delphi method in 2025.

## Key findings

- A 2018 consensus set of 38 ICU quality indicators was established through expert ratings and meetings.
- In 2025, 37 of the 2018 indicators were retained as Appropriate, with one removed and one new indicator added.
- The updated 2025 core set provides a foundation for national benchmarking and quality improvement in Japanese ICUs.

## Abstract

Quality indicators (QIs) support measurement and improvement of ICU care; however, until 2017 there was no comprehensive, evidence-based QI set tailored to frontline adult ICU practice in Japan. Because evidence and practice evolve, periodic updating is required. We developed a Japanese ICU QI set in 2017–2018 and conducted a formal re-evaluation in 2025 to confirm current validity and update the core set.

We used a modified RAND/UCLA appropriateness method. First, an initial list of candidate QIs was generated through a systematic literature review and major clinical guidelines. Next, a multidisciplinary panel of 14 Japanese experts (including intensivists, a nurse, a physiotherapist, and a clinical engineer) rated the appropriateness of these indicators using a nine-point Likert scale (Round 1). Following Round 1, a face-to-face consensus meeting was held to discuss, refine, add, or delete indicators based on scientific evidence, clinical importance, and feasibility, followed by Round 2 to finalize the 2018 consensus set. In 2025 (Round 3), the panel re-rated all indicators from the 2018 set using the same rating and classification framework and also rated newly proposed indicators reflecting contemporary practice.

The systematic review yielded 44 initial candidate QIs. After the two-round rating process and the expert panel meeting, a 2018 consensus set of 38 QIs was established (13 structure indicators, 10 process indicators, and 15 outcome indicators). In Round 3 (2025), 37 indicators remained Appropriate, whereas one indicator was reclassified as Uncertain and was not retained in the updated core set. One newly proposed indicator was rated Appropriate and added, resulting in an updated 2025 core set of 38 indicators. All selected indicators were deemed appropriate and relevant for the Japanese ICU setting by the expert panel.

Using a rigorous modified RAND/UCLA appropriateness method and a 2025 re-evaluation, we developed and updated a feasible, contextually adapted Japanese ICU QI set. The updated core set, with operational definitions and specified data sources, provides a foundation for national benchmarking and continuous quality improvement in Japanese ICUs.

330 words.

The online version contains supplementary material available at 10.1186/s40560-026-00863-w.