Implementing and using quality measures for children's health care: perspectives on the state of the practice.

PEDIATRICS (Impact Factor: 5.3). 02/2004; 113(1 Pt 2):217-27.
Source: PubMed

ABSTRACT The objective of this study was to identify issues, obstacles, and priorities related to implementing and using child health care quality measures from the perspectives of 4 groups: 1) funders of quality-measurement development and implementation; 2) developers of quality measures; 3) users of quality measures (including Medicaid and the State Children's Health Insurance Program, employer coalitions, and consumer groups); and 4) health plans and providers (in their role as both subjects and users of quality measures).
A series of semistructured interviews was conducted with approximately 40 opinion leaders drawn from these 4 groups. The interviews were conducted by telephone between September and December of 2001. Major topic areas covered in the interviews were similar across the groups. Topic areas included 1) strategic vision and/or objectives for funding, developing, or using quality measures for children's health care; 2) a brief summary of the specific quality measures funded, developed, or used; 3) issues and challenges facing funders and developers of measures; 4) major successes achieved; 5) obstacles to implementation and use of measures; and 6) priority needs for future funding.
Leaders from all 4 groups acknowledge the importance of developing a robust set of quality measures that can serve multiple objectives and multiple audiences. Standardization of measures is viewed as a critical feature related to all objectives. An assessment of specific quality measures funded, developed, or used by strategic objective shows a high correlation between the uses intended by funders and developers and the actual applications of the various users. The most commonly cited measures across all groups are the Consumer Assessment of Health Plans Survey and Health Plan Employer Data and Information Set, followed by the Child and Adolescent Health Measurement Initiative and special topic studies to support quality-improvement applications (eg, asthma, diabetes, etc). The major issues and challenges cited in common among funders and developers are 1) the lack of trained capacity in the field to conduct needed research and development, and 2) the difficulty in generating sustained interest and support among funders because of the complexity of quality-measurement issues, competing funding priorities in the face of limited funds available to allocate, and the lack of clear and compelling evidence that quality measurement and improvement actually result in better outcomes for children. The 3 most common successes cited across all 4 groups are 1) the growing consensus and collaboration among diverse stakeholder groups involved in measurement development and implementation; 2) the increasing collection and use of specific measures; and 3) early documentation of tangible results in terms of improved quality of care. Specific measurement tools cited as successes by funders and developers include the Medicaid Health Plan Employer Data and Information Set, Consumer Assessment of Health Plans Survey, the Child and Adolescent Health Measurement Initiative, and Rand QA Tools. The most important obstacle reported across all groups is the lack of a strong and compelling "business case" that clearly demonstrates the benefits of quality measurement relative to the costs of implementation. Strongly related to this barrier is the cost of implementing and using measures without a sustainable source of financing as well as the absence of strong public awareness and political support for children's health care quality measurement. Another major barrier cited is the lack of coordination among funders, which prevents the field from developing a unified approach to addressing the numerous technical, political, and administrative issues also cited at length by the leaders interviewed. The 5 top needs for future funding identified across all 4 groups follow directly from the major obstacles that they reported: 1) develop the business case for children's health care quality measurement and improvement based on rigorous cost-bigorous cost-benefit analysis and documentation of quantifiable successes; 2) develop new measures to fill the gaps in critical areas (including adolescent health care, behavioral health, and chronic conditions) that can be applied at the hospital and ambulatory care provider levels; 3) invest in building needed research capacity, a trained pool of users of quality measures, and the capacity among providers to understand and use quality-improvement methods and tools; 4) invest in developing an information infrastructure that will support the efficient collection and use of measures for multiple purposes, including clinical practice, quality measurement, and quality improvement; and 5) develop increased public awareness and support for quality measurement based on improved strategies for communicating with consumers, purchasers, providers, and policy makers.
Several implications are suggested by these perspectives for the future direction of quality measurement in children's health care. First, to meet the funding needs identified, many funders must improve coordination to reduce the noise and fragmentation generated by numerous competing or redundant activities. Improved coordination among funders will help assure maximum impact and the efficient use of scarce resources. Second, the importance attached to standardization of measures by both users and developers may conflict at times with the need for innovation and flexibility. Child health quality leaders will need to manage this tension between standardization and innovation to maintain an appropriate balance between the benefits of both. Finally, many of the obstacles identified are not unique to children's health care. Child health quality leaders will need to determine to what extent their efforts to overcome these obstacles can be successfully undertaken independently as opposed to in concert with groups concerned about other populations and sectors in the health care system.

1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: To query children about the perceptions of their inpatient healthcare experiences in order to improve care to make it more developmentally appropriate and responsive to children's needs and desires. Children (n = 120) were interviewed and their comments were recorded as they described the best and worst things about their hospitalization and made recommendations for change. They were approached at the time of discharge from a tertiary care unit. Content analysis was used to compare their responses within their developmental levels. Themes were developed, and data were co-coded for trustworthiness of findings. Quotes were extracted that illustrated the themes. Children provided insightful and specific data regarding the perceptions of their hospital experiences. Pain and discomfort were cited most frequently as the worst aspects of hospitalization and the areas most needing improvement. Play activities were valued by children of all ages. Their positive relationships with hospital staff were described frequently. The developmental stage of children determined the specificity and diversity of their comments. Children's unique perspectives should be sought regularly and their data included in ongoing programs of quality assessment. When only parents are queried, important and insightful perspectives of children are missed that could improve care quality.
    MCN The American Journal of Maternal/Child Nursing 09/2006; 31(5):290-5; quiz 296-7. DOI:10.1097/00005721-200609000-00005 · 0.84 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The development of the quality improvement programme of the Paediatric Association of the Netherlands is described within the setting of the national programme of the Dutch government. The programme is based on four pillars: site visits by peers (visitatie), continuous medical and professional education, development of clinical (evidence based) guidelines and patient safety with complication registration. The site visits by peers play a central role in assessing the quality improvement activities in hospital based paediatric care. The self assessment approach and the confidential character of the visits are well received by the surveyed specialists. Recent inclusion of quality criteria in the legally required 5 yearly medical specialist recertification process has boosted the care for quality, which could serve as example for other countries.
    Archives of Disease in Childhood 08/2007; 92(7):633-6. DOI:10.1136/adc.2006.104091 · 2.91 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Deficiencies in the quality of health care are major limiting factors to the achievement of the Millennium Development Goals for child and maternal health. Quality of patient care in hospitals is firmly on the agendas of Western countries but has been slower to gain traction in developing countries, despite evidence that there is substantial scope for improvement, that hospitals have a major role in child survival, and that inequities in quality may be as important as inequities in access. There is now substantial global experience of strategies and interventions that improve the quality of care for children in hospitals with limited resources. The World Health Organization has developed a toolkit that contains adaptable instruments, including a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocket Book of Hospital Care for Children, teaching material, assessment, and mortality audit tools. These tools have been field-tested by doctors, nurses, and other child health workers in many developing countries. This collective experience was brought together in a global World Health Organization meeting in Bali in 2007. This article describes how many countries are achieving improvements in quality of pediatric care, despite limited resources and other major obstacles, and how the evidence has progressed in recent years from documenting the nature and scope of the problems to describing the effectiveness of innovative interventions. The challenges remain to bring these and other strategies to scale and to support research into their use, impact, and sustainability in different environments.
    PEDIATRICS 05/2008; 121(4):e984-92. DOI:10.1542/peds.2007-1395 · 5.30 Impact Factor