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The movement towards greater accountability in medicine has made quality improvement a routine part of daily clinical practice in the intensive care unit. We review recent advances in the field of quality improvement and discuss some of the challenges to successful quality improvement initiatives in critical care.Regular quality improvement is an essential component of modern critical care medicine; some authors have even suggested an ethical imperative to engage in quality improvement activities. Ideal quality measures are reliable, valid and strongly linked to patient-centered outcomes. In addition to standard quality indicators, clinicians should consider measuring and improving novel targets such as organizational climate, family communication and palliative care. Effective implementation requires a comprehensive environmental scan, multidisciplinary collaboration, and strategies for sustained improvement. Potential pitfalls include emphasizing process measures at the expense of outcome measures and focusing on preventing adverse events at the expense of utilizing efficacious treatments.Integrating quality measurement and improvement with daily clinical practice is among the most important challenges facing critical care. Following established principles will help ensure that quality improvement initiatives are interpretable, successful, and meaningful to patients and families.