- RWJF —
- Robert Wood Johnson Foundation
- UCLA —
- University of California, Los Angeles
This issue links together a broad construct (quality) in a defined population (children) with alumni from a specific training program. In so doing, it is both a celebration and a challenge. The supplement celebrates the contributions of Robert Wood Johnson Foundation (RWJF) Clinical Scholars to the national discourse regarding the measurement and improvement of quality; it acknowledges the increasing prominence of child health work as part of the national quality agenda and the hope for filling the many gaps regarding our understanding of how to measure and improve children’s health care. Children’s health care quality has become a major part on the research agenda of pediatric participants in the RWJF Clinical Scholars Program. Alumni of this program have in turn nurtured additional health services research and quality fellowships at other institutions and have helped build this area of inquiry in pediatrics.
The Clinical Scholars Program marks its 40th anniversary this year. This is a remarkable milestone of sustained support for any US philanthropy but even more so when the outlines of the history of the RWJF are filled in. As the story goes, in the late 1960s, physicians from a handful of prominent institutions were gathered (whether it was in a bar was not recorded) after a national meeting and chatting with leaders of The Commonwealth Fund and the Carnegie Corporation about the need for advanced training in the nonbiological sciences to create a career development path for clinicians who were intellectually inclined and humanistic but not inclined to laboratory training. Out of this conversation came an invitation to submit a proposal; that proposal evolved into a postresidency academic fellowship in the nonbiological sciences that would be national in scope and local in character. It was first funded in 1969 and built on institutional strengths (at Johns Hopkins University, University of California, Los Angeles [UCLA], Case Western University, McGill University, and Duke University) while developing a national vision. In 1972, as the RWJF was reborn as a national health care philanthropy, it took on supporting the program. Under the initial leadership of David Rogers, Annie Lea Shuster, and Leighton Cluff, the RWJF Clinical Scholars Program flourished and grew. Through recompetition and the funding of new institutions, the defunding of old institutions, and emerging priorities, a total of 13 institutions have served as training sites at various times. A 3-decade-long partnership with the Veterans Administration funds VA-affiliated scholars who train in the program. Program leadership transitioned from Annie Lea Shuster at the foundation headquarters to Iris Litt at Stanford University, and then to Desmond Runyan, one of this article’s authors who is a University of North Carolina Clinical Scholars Program alumnus now of the University of Colorado. Although the specifics of its mission have evolved, the governing principles have been close to its founding mission: to provide nonbiological training that would serve to enhance access to ambulatory health care services, improve the quality of that care, and to develop better data and information to inform national health care policy.1–3
The Clinical Scholars Program was birthed by 2 other philanthropies, predates the emergence of the RWJF as a national foundation, and still flourishes after 40 years. Rigorous evaluations of the program have identified a number of critical contributions. The program truly was the pioneer in providing a structured training for health services research and legitimizing it as a field of scholarly inquiry for medical school faculty. Indeed, it helped to launch the field and to define its breadth. Specialty-specific training programs in pediatrics, internal medicine, and generalist academics followed at the RWJF. Clinical Scholars have risen to head federal agencies, state health departments, and academic departments and institutions.3–5 One of the earliest Clinical Scholars played a particularly critical role in the development of quality of health care as a scientific and an academic endeavor. Robert Brook led the Rand Health Insurance Experiment while his pioneering work on appropriateness of care stimulated the field. He continues to stimulate policy and policy debates 3 or 4 decades after his initial work.6,7 In the early 1990s, the first author of this article was fortunate, as a UCLA Clinical Scholar, to work with Robert Brook and Rand colleagues to publish the first study of the appropriateness of a pediatric surgical procedure.8 That research stimulated a presentation with Clinical Scholar alumnus Charlie Homer, at which they asserted that the study of pediatric quality of care was a worthwhile academic pursuit and postulated a vision for a flourishing field. With the added leadership of a number of other Clinical Scholars, the reality has far exceeded our vision.
Many professionals in medicine, nursing, and other health professions have committed their careers to improving the quality of care and the advancement of safety in hospitals, and the impact on patient safety and quality has been measureable. The RWJF, and the cadre of the physician–leaders that they have trained, maintain a record of sustained attention to these fields that is disproportionate. In 2009, the Children’s Health Insurance Program Reauthorization Act called for the establishment of the Pediatric Quality Measures Program (http://www.ahrq.gov/chipra/pqmpfact.htm). This act represented unprecedented federal attention to, and investment in, assessment of the quality of children’s health care. Of the 7 national centers of excellence established under this program, 5 are headed by Clinical Scholar alumni (Jeffrey Silber [University of Pennsylvania]; Lawrence Kleinman, Rita Mangione-Smith, Mark Schuster [UCLA]; and Gary Freed [University of North Carolina]). Three Clinical Scholars (Kleinman, Mangione-Smith, and Michael Cabana [University of Michigan]) were among the leaders organizing 2 well-attended Agency for Healthcare Research and Quality–funded conferences on the science of quality improvement associated with the annual Pediatric Academic Societies Meetings (another is planned for 2013). The attention and energy stimulated by the Pediatric Quality Measures Program assure that pediatric quality is an active and rapidly evolving field which far exceeds the vision that Homer and Kleinman first articulated. It seems particularly appropriate that the RWJF Clinical Scholars Program is sponsoring this supplement to Pediatrics for the purpose of highlighting some of the fresh and bright work that current and past Clinical Scholars are producing today.
It was a privilege to work with wonderful colleagues to help put together this supplement: Beth Tarini, Alex Fiks, Paul Chung, and Marjorie Rosenthal. Each are experts and leaders in their own right; they also provide programmatic leadership and mentorship to past and current Clinical Scholars and served as an editorial team in developing the call for papers and reviewing the submissions that now comprise this issue. Kristin Siebenhaler and Kathy Donnald are the heart of the Clinical Scholars national administrative team; their contributions pulse through every article and the very existence of this supplement. The National Program Director of the RWJF provides leadership and vision that makes everything, including this supplement, happen.
This issue spans territory new and old. Controversies arose in 1988, when Clinical Scholars Program alumnus Charlie Homer wrote a report for what was then called the Office of Technology Assessment. This report set off a series of unintended consequences when his noting of the lack of evidence base for well-child care was interpreted to suggest that perhaps it was not necessary, rather than as a call to develop an evidence base, which is what he had intended. Drs Coker and colleagues show how far we have come in their review of a variety of potential improvements to the organization and delivery of well-child care.
Disparities and care for vulnerable children have remained a constant theme in assessments of children’s health and health care. The Agency for Healthcare Research and Quality now publishes an annual report on disparities, and children's health is featured prominently. Dr Lara and her colleagues provide a sensitive and important case study describing community health and health care improvement in a Puerto Rican housing project with particularly high needs.
Dr Zima and her colleagues offer up 2 servings related to prominent themes in children’s health: behavioral and developmental concerns. Her first article, written in conjunction with colleagues in the Pediatric Quality Measures Program, offers a thoughtful conceptual framework that brings important critical thinking both to the issue of mental health care for children and to its measurement. Her focus on partnership and engagement is likely to represent the future for the development of meaningful and useful pediatric quality measures. Her second article brings a family-centered approach to considerations of the continuity of care for Medicaid-insured children with attention-deficit/hyperactivity disorder.
Dr Leu returns us to the case history format, telling the fascinating and cautionary story regarding the Seattle Children’s Hospital experience studying and improving prespecified packages of orders (known as order sets) that are used with the computer order entry system at the hospital.
Dr Patrick also led 2 studies. In the first article, he and his colleagues provide an analytical review of risk adjustment methods for the NICU; they share with us a narrative that is informative, with themes both historical and topical. Regardless of whether you share their perspective, you will be far better informed on the topic having read this article. With a second set of colleagues, Dr Patrick assesses the accuracy of critical information required for a quality measure important to the Centers for Medicare & Medicaid Services; they find it seriously lacking at their institution, raising critical concerns with broad implications.
Dr Jan and colleagues provide us with a thoughtful secondary data analysis examining surgical care for older adolescents and young adults with inflammatory bowel disease. This article reminds us how structural attributes are often associated with substantive outcomes.
Dr. Walter and her colleagues present an article regarding the end of life for critically ill children, an important and understudied topic. Their research found meaningful variations in performance and indicate that looking more systematically at these issues is a valuable component in assessing overall quality of care.
Dr Parker and her colleagues provide a nice example of a quality improvement research project. By identifying key success factors, their article represents a case study that suggests generalizable knowledge and can be used as a foundation for additional study at other institutions or with other conditions.
Dr Johnson and colleagues demonstrate how large national data sets can be used to look at trends in practices over time that do or do not result from changes in policies. The National Ambulatory Care Survey and National Hospital Medical Care Surveys are 2 of several important secondary data sources made available by the Center for Disease Statistics of the Centers for Disease Control and Prevention. These and other data sets, including the Agency for Healthcare Research and Quality’s Healthcare Cost Utilization Project and the Medical Expenditure Panel Survey, as well as the Centers for Disease Control and Prevention surveys found at the Data Resource Center (childhealthdata.org), are critical resources for those interested in studying children’s health and health quality.
We conclude this supplement with an article the first author has written with Denise Dougherty, Senior Advisor for Child Health and Quality Improvement and leader of the Pediatric Quality Measures Program at the Agency for Healthcare Research and Quality. This article suggests the possibility of evolving a model of quality to inform research and development specifically regarding quality improvement or action research, rather than Donabedian’s stated initial purpose of quality measurement. We suggest that such a model should focus on operations; in other words, what health care providers and systems do, rather than the Donabedian tripartite model of structure, process, and outcomes. To stimulate that conversation, we posit a conceptual model built on such constructs that may serve as a straw person, stimulating future conversation and deeper understanding.
As this supplement clearly demonstrates, RWJF Clinical Scholars are among the thought leaders of a group of investigators sharing an explicit imperative to improve the quality of health care delivered to US children. We hope that this work will contribute to that goal.
- Accepted December 20, 2012.
- Address correspondence to Lawrence C. Kleinman, MD, MPH, Department of Health Evidence and Policy, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1077, New York, NY 10029. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- Showstack J, Rothman AA, Leviton LC, Sandy LG. The Robert Wood Johnson Clinical Scholars Program. In: Isaacs SL, Knickman JR. To Improve Health and Health Care, Volume VII. Robert Wood Johnson Foundation Anthology. San Francisco, CA: Jossey-Bass; 2004
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- Copyright © 2013 by the American Academy of Pediatrics