Quality and Safety in Health Care for Children

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Chapter 2 Quality and Safety in Health Care for Children

Ramesh C. Sachdeva

The Need for Quality Improvement

There is a significant quality gap between known and recommended evidence-based care, and the actual care that is delivered. Adults receive recommended care slightly higher than 50% of the time and children receive recommended care only about 46% of the time. This quality gap exists due to a chasm between knowledge and practice—a chasm made wider by variations in practice and disparities in care from doctor to doctor, institution to institution, geographic region to geographic region, and socioeconomic group to socioeconomic group.

Historically, success in medicine was viewed as advances in technology, identification of new treatments, and the generation of new evidence to improve care. Although these facets of medical advances continue to be important, it is estimated that it takes about 17 yr for new knowledge and research findings to be adopted into clinical practice. This widens the quality chasm. Further, the Institute of Medicine’s (IOM) report, “To Err is Human: Building a Safer Health System” highlights that ∼44,000 to 98,000 patients die in U.S. hospitals each year because of preventable medical errors. These errors were more likely to occur in environments such as operating rooms, emergency departments, and intensive care units. Preventable medical errors have an economic cost of 17 to 29 billion dollars per year. These gaps in quality and related high costs will only be solved when physicians and health care systems adopt the emerging new science of quality improvement.

What is Quality?

The IOM defines quality of health care as the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This definition incorporates 2 key concepts related to health care quality: the direct relationship between the provision of health care services and health outcomes; and, the need for health care services to be based on current evidence.

To measure health care quality, the IOM has identified Six Dimensions of Quality all of which relate to quality of care. The Six Dimensions of Quality are effectiveness, efficiency, equity, timeliness, patient safety, and patient-centered care. Quality of care needs to be effective, which means that health care services should result in benefits and outcomes. Health care services also need to be efficient, which incorporates the idea of avoiding waste and improving system cost efficiencies. Health care quality should improve patient safety, which incorporates the concept of patient safety as 1 of the key elements within the Six Dimensions of Quality. Health care quality must be timely, thus incorporating the need for appropriate access to care. Health care quality should be equitable, which highlights the importance of minimizing variations due to ethnicity, gender, geographic location, and socioeconomic status. Health care quality should be patient-centered, which underscores the importance of identifying and incorporating individual patient needs, preferences, and values in clinical decision-making.

The IOM framework of the Six Dimensions of Quality emphasizes the concept that all Six Dimensions of Quality need to be met for the provision of high quality health care. Health care that maximizes outcomes but is not efficient (i.e., not cost-effective) is not quality care. Health care that is highly efficient but limits access is also not high quality. These concepts can be viewed as the overall value proposition—that is, the value created for a patient. From the standpoint of the practicing physician, these Six Dimensions of Quality can be categorized into clinical quality and operational quality. To provide high-quality care to children, both aspects of quality—clinical and operational—must be met. Historically, physicians have viewed quality to be limited in scope to clinical quality with the goal of improving clinical outcomes, and have considered efficiency optimization and access as the role of health care plans, hospitals, and insurers. Conversely, health care organizations, which are subject to regular accreditation requirements, viewed the practice of clinical care delivery as the responsibility of physicians and limited their efforts to improve quality largely in process improvement to enhance efficiencies. This is further magnified as many office based pediatricians have independent clinical practices and are limited in their interaction with hospitals only when they care for hospitalized children.

This traditional perspective is changing. The evolving health care system in the USA requires physicians, health care providers, health care organizations, and hospitals to partner together to measure, demonstrate, and improve the overall quality of care to the patients they serve. With many regulatory and accreditation changes on the horizon such as Maintenance of Certification requirements of the American Board of Pediatrics (ABP) and the planned Maintenance of Licensure by U.S. state licensing bodies, physicians will be required to understand and implement quality improvement principles into their clinical practice and report the quality of their care delivered by them in a transparent manner.

Definitions of Quality-Related Terms

Quality includes many concepts—quality measurement, quality reporting and benchmarking, process improvement, performance, and outcomes improvement using quality initiatives (Table 2-1).

Table 2-1 DEFINITIONS OF QUALITY-RELATED TERMS

Quality “… the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” U.S. Institute of Medicine

Quality Initiative “… systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings.” Hastings Center

Performance Measure “… yardsticks by which all health care providers and organizations can determine how successful they are in delivering recommended care and improving patient outcomes.” U.S. Institute of Medicine

Performance Management “… a systematic process by which an organization involves its employees in improving the effectiveness of the organization and achieving the organization’s mission and strategic goals. By improving performance and quality, public health systems can save lives, cut costs, and get better results by managing performance.” Public Health Foundation

Process Improvement “… the systematic approach to closing of process or system performance gaps through streamlining and cycle time reduction, and identification and elimination of causes of below specifications quality, process variation, and non-value-adding activities.” BusinessDictionary.com

Model for Quality

Achieving quality improvement requires adoption of a 3-step model: “Data → Information → Improvement.” Quality needs to be measured. Quality data obtained from the measurement then need to be converted into meaningful information that can be compared and reported. This quality measurement must also be actionable to achieve improvements in clinical practice.

Measuring Quality

Robust quality indictors should have clinical and statistical relevance. Clinical relevance ensures that the indicators are meaningful in patient care from the standpoint of patients and clinicians. Statistical relevance ensures that the indicators have measurement properties to allow an acceptable level of accuracy and precision. These concepts are captured in the national recommendations that quality measures must meet the criteria of being valid, reliable, feasible, and usable (Table 2-2). Validity of quality measures relates to the notion that the measure is estimating the true concept of interest. Reliability relates to the notion that the measure is reproducible and provides the same result if retested. It is important that quality measures are feasible in practice. Quality measures must be useable, which means that they should be clinically meaningful. The Agency for Healthcare Research and Quality (AHRQ) has provided specific criteria to be considered when developing quality measures.

Table 2-2 PROPERTIES OF ROBUST QUALITY MEASURES

ATTRIBUTE RELEVANCE
Validity Indicator accurately captures the concept being measured.
Reliability Measure is reproducible.
Feasibility Data can be collected using paper or electronic records.
Usability Measure is useful in clinical practice.

Quality indicators can be aimed at measuring the performance within 3 components of health care delivery: structure, process, and outcome. Structure relates to the organizational characteristics in health care delivery. Examples of organizational characteristics are the number of physicians and nurses in an acute care setting and the availability and use of systems such as electronic health records. Process related measures estimate how services are provided. Examples of a process measures are the percent of families of children with asthma who receive an asthma action plan as part of their office visit or the percent of hospitalized children who have documentation of pain assessments as part of their care. Outcome measures relate to the final health status of the child. Examples of outcome measures are risk adjusted survival in an intensive care unit setting, birth weight adjusted survival in the neonatal intensive care unit setting, and functional status of children with chronic conditions such as cystic fibrosis.

Quality data can be quantitative and qualitative. Quantitative data includes numerical data, which can be continuous (patient satisfaction scores represented as a percentage with higher numbers indicating better satisfaction), or categorical (patient satisfaction scores obtained from a survey where a Likert scale is used indicating satisfactory, unsatisfactory, good, or superior care). Data can also be qualitative in nature, which includes non-numeric data. Examples of qualitative data can include results from open-ended surveys related to the satisfaction of care in a clinic or hospital setting. It is important to be sensitive to the source and quality of data being obtained to ensure data quality.

Data measuring quality of care can be obtained from a variety of sources, which include chart reviews, patient surveys, existing administrative data sources (billing data from hospitals), disease and specialty databases, and patient registries, which track individual patients over time.

It is important to distinguish between databases and data registries. Databases are data repositories that can be as simple as a Microsoft Excel spreadsheet or relational databases using sophisticated IT platforms. Databases can provide a rich source of aggregated data for both quality measurement and research. Data registries allow tracking individual patients over time; this dynamic and longitudinal characteristic is important for population health management and quality improvement.

Data quality can become a significant impediment when using data from secondary sources, which can adversely impact the overall quality evaluation. Once data on the quality indicator has been collected, quality measurement can occur at 3 levels: (1) measuring quality status at 1 point in time (e.g., percent of children seen in a primary care office setting who received the recommended 2 yr immunizations); (2) tracking performance over time (e.g., change in immunization rates in the primary care office setting for children 2 yr of age); and (3) comparing performance across clinical settings after accounting for epidemiologic confounders (e.g., immunization rates for children under 2 yr of age in a primary care office setting stratified by race and socioeconomic status as compared to the rates of other practices in community and rates at national levels).

Pediatric quality measures are being developed nationally. Table 2-3 provides a list of some of the important currently endorsed pediatric national quality indicators.

Table 2-3 NATIONAL PEDIATRIC QUALITY MEASURES

NQF PDIs (2008) NQF-ENDORSED INPATIENT MEASURES AMONG PICUs NQF-ENDORSED CHIPRA MEASURES (2009)
Accidental puncture or laceration PICU standardized mortality ratio Childhood immunization status
Decubitus ulcer PICU severity adjusted length of stay Appropriate testing for children with pharyngitis
Foreign body left after procedure, age under 18 yr Unplanned PICU readmission (readmissions within 24 hr after discharge/transfer from PICU) Chlamydia screening in women
Iatrogenic pneumothorax in non-neonates Review of unplanned PICU readmissions Follow-up/mental illness
Pediatric heart surgery mortality PICU pain assessment on admission Follow-up/ADHD medication
Pediatric heart surgery volume PICU periodic pain assessment (minimum of every 6 hr) HEDIS CAHPS/chronic conditions
Postoperative wound dehiscence, age under 18 yr Catheter-associated bloodstream infections Weight assessment and counseling
Transfusion reaction, age under 18 yr    

ADHD, attention-deficit/hyperactivity disorder; CAHPS, Consumer Assessment of Healthcare Providers and Systems; CHIPRA, Children’s Health Insurance Program Reauthorization Act; HEDIS, Healthcare Effectiveness Data and Information Set; NQF, National Quality Forum; PDIs, pediatric quality indicators; PICU, pediatric intensive care unit.

Comparing and Reporting Quality

There is an increasing emphasis on quality reporting in the USA. Many states have mandatory policies for reporting of quality data. This reporting may be tied to reimbursement using the policy of pay for performance (P4P). P4P implies that reimbursements by insurers to hospitals and physicians will be partially based on the quality metrics. P4P can include both incentives and disincentives. Incentives relate to additional payments for meeting certain quality thresholds. Disincentives relate to withholding certain payments for not meeting those quality thresholds. An extension of the P4P concept relates to the implementation of the policy of Never Events by the Centers for Medicare and Medicaid (CMS). CMS has identified a list of Never Events, which are specific quality events that will result in no payment for care provided to patients (e.g., wrong site surgery, catheter associated bloodstream infections, and decubitus ulcers acquired in the hospital).

Quality reporting is also being used in a voluntary manner as a business growth strategy. Leading children’s hospitals across the USA actively compete to have high ratings in national quality evaluations that are reported in publications such as Parents (formerly Child) magazine and US News & World Report. Many children’s hospitals have also developed their own websites for voluntarily reporting their quality information for greater transparency. Although greater transparency may provide a competitive advantage to institutions, the underlying goal of transparency is to improve the quality of care being delivered, and for families to be able to make informed choices in selecting hospitals and physicians for their children.

Quality measures may also be used for purposes of certifying individual physicians as part of the Maintenance of Certification (MOC) process. In the past, specialty and subspecialty certification in medicine, including pediatrics, was largely based on demonstrating a core fund of knowledge by being successful in an examination. No specific evidence of competency in actual practice needed to be demonstrated beyond successful completion of a training program. There continues to be significant variations in practice patterns even among physicians who are board certified, which highlighted the concept that medical knowledge is important but not sufficient for the delivery of high-quality care. Subsequently, the American Board of Medical Specialties (ABMS) including its member board, the ABP, implemented the MOC process in 2010. Within the MOC process, there is a specific requirement (Part IV of Maintenance of Certification) to demonstrate the assessment of quality of care and implementation of improvement strategies by the physician as part of recertification in pediatrics and subspecialties. Lifelong learning and the translation of learning into practice are the basis for the MOC process and for an essential competency for physicians—professionalism. There are also discussions to adopt a similar requirement for Maintenance of Licensure for physicians by state medical regulatory boards.

The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to incorporate quality improvement curriculum to ensure that systems-based practice and quality improvement are part of the overall competencies within accredited graduate medical training programs. One form of continuing medical education (CME), the Performance Improvement (PI) CME, is utilized for ongoing physician education. These initiatives require physicians to measure the quality of care they deliver to their patients, to compare their performance to peers or known benchmarks, and to work toward improving their care by leveraging quality improvement methods. This forms a feedback loop for continued learning and improvement in practice.

Prior to comparing quality measures data both within and across clinical settings, it is important to perform risk adjustment to the extent that is feasible. Risk adjustment

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