In the fall of 1999, quality of care was raised to a new level of prominence at the American Academy of Pediatrics (AAP). At that time, Donald M. Berwick, Chief Executive Officer of the Institute for Healthcare Improvement, posed a challenge to the AAP in his keynote address at the AAP’s annual meeting. Steve Berman, then newly elected as AAP President, made quality one of the key initiatives in his presidency.1 How far has the Academy come since that time, and where does it need to go if this renewed focus is to make a difference for the children we serve?
Berwick challenged the Academy to build the credibility of our profession and of organized medicine by making a strong and visible commitment to enhancing the quality of care that our patients—children and their families—receive. Building on theories on leadership of change,2 he recommended the Academy take 5 steps:
Make a commitment to a bold aim, such as reducing inappropriate antibiotic use.
Choose public measures to track our progress.
Find the best ideas and generate a campaign.
Take action—learning from our successes and failures.
Collaborate with others—family physicians, nurses, and pharmacists.
When Berwick issued this challenge, few of us knew how other events would shape the environment in which the Academy would be responding to this challenge. In December 1999, the issue of patient safety broke onto public consciousness.3 Patient safety not only provoked public attention, but also political and policy reaction. Although some thought the issue might pass, it appears to have staying power and pediatrics is not immune. Indeed, the “poster child” case at national hearings hosted by the Agency for Healthcare Research and Quality was a 5-year-old with kernicterus.4
Changes have also taken place in requirements for both residency education and board certification and recertification. In residency education, the Accreditation Council for Graduate Medical Education now lists improvement science as one of the core areas for competency that residents must learn.5 In continuing certification, the American Board of Pediatrics proposes to require ongoing certification of competency based on practice, not merely knowledge based on a test.6
Both of these external pressures confirm that quality of care is the crucial issue for professional groups to focus on to ensure our future as trusted protectors of our patients’ health.
Many pediatric practices around the country are making quality of care their by-word and organizational priority. Many—intentionally or otherwise—are using the same framework of Aim, Measures, Ideas, Action, and Collaboration, which Don Berwick proposed the Academy adopt.
Hill Health Center, for example, is 1 of almost 30 federally qualified health centers that recently completed working for over a year to enhance the care it provides to children with asthma. Hill Health Center in New Haven—like Denver Community Health Alliance, run by Committee on Community Health chair Paul Melinkovich—has set lofty aims—to reduce symptoms and improve quality of life for children with asthma through the implementation of a comprehensive system of caring for children with chronic conditions. This site is tracking measures—symptom-free days, use of antiinflammatory medications, provision of written management plans—that are posted on a Web site and in their offices. They have reached out to others—national leaders in asthma care, in chronic illness, in improvement and change, and to other community health centers—to find out ideas about what is working elsewhere. They act, on a small scale first, observing to see if things work and then changing if they don’t. Finally, they collaborate—not only with other health centers, but with schools, home health agencies, hospitals, pharmacies, parent groups—anybody with whom they need to work to make care better for kids. They are also achieving results—major results that translate into better lives for the children they serve. The approach they are using mirrors that of neonatal intensive care units in the Vermont Oxford Network, and is as likely to achieve the kind of clinical and cost-saving improvements as that organization has demonstrated.7
Somerville Pediatrics is another practice that is not waiting. David Osler and his partners set an aim of improving patient satisfaction by reducing waiting time and delays. They are tracking the length of time until their next available appointment, and learned from the national leaders about a system of same day appointments called “Open Access,” where patients can call that day—whether for well or ill visit—and be seen. They have taken action, and reorganized all of the processes of their office. Their “no-show” rate has decreased from 40% to 18%.8 They, together with others, have shown courage in recognizing that their old systems were broken, and that change was required.
These commitments and innovations are not restricted to the “practice” level. Chapters of the AAP are also demonstrating how to make a difference in quality. In Vermont, the chapter has spoken loudly in committing itself to across the board improvement in Preventive Health Services. Building on the work of Peter Margolis and Carole Lannon in North Carolina, practices are measuring their current level of performance.9 Successful ideas for improvement are harvested from the literature, from the Centers for Disease Control and Prevention, and from experience of colleagues. The chapter—led by Wendy Davis—is partnering with the Medical School, the Agency of Human Services, the Department of Health, and the Vermont Program for Quality in Health Care to create the Vermont Child Health Improvement Program led by Judy Shaw.
Many more examples exist of commitment to quality at the chapter level, just as there are at the individual practice level. Pennsylvania, for example, with Susan Aronson and Alan Kohrt, has made similar commitments in improving care related to immunization, child abuse, and children with special health care needs. We at the AAP need better ways to “harvest” the knowledge that is being generated in the field, so that both practices and chapters could benefit from innovations, rather than recreate them.
Although innovation may take place mainly at local levels, national organizations can influence public policy, marshal diverse resources, and disseminate local successes. The AAP has taken a few real steps in this past year that—as with the infants we care for—presage more activity to come.
Specific commitments to enhanced quality can and should follow from the rigorous, evidence-based practice guidelines the AAP has developed. In the past year the AAP published—among others— guidelines on the diagnosis and treatment of attention-deficit/hyperactivity disorder, out of a subcommittee led by Jim Perrin and Marty Stein.10,11 This guideline included strong recommendations, including the need to include teacher perspectives before making the diagnosis and a careful assessment of comorbidity. Several leaders at the AAP are seeking to organize an initiative to ensure that children with this disorder are appropriately diagnosed and treated, and that children without this condition are not needlessly prescribed stimulants. As Jim Reinertson, Chief Executive Officer of CareGroup, an integrated delivery system in Boston, has stated, patients should get all the care and only the care that is appropriate (personal communication with Don Berwick, April 2000).
There will be no shortage of future topics for commitment, either. The AAP has new guidelines on developmental dysplasia of the hip, sinusitis, and will soon have guidelines on acute otitis media.
The AAP is not standing still with its measurements, either. The Ambulatory Quality Improvement Program—that has for 10 years had a program of practice self-assessment—is being expanded and brought into the Internet age with eQIPP—an electronic program of measurement and feedback linked to improvement.
For the past year, the AAP has also provided support to enable Carole Lannon, MD, MPH, FAAP, a national leader in quality improvement at the primary care level, to participate in a wide array of AAP committee activities, and bring a quality perspective across the organization.
Yet, while we have done a lot this year at the Academy, we could do much more. A number of barriers exist that inhibit our ability to move a quality agenda ahead. At the national level, the agenda of the Academy is crowded—each committee, each interest is clamoring for attention and each voice is caring and just. Nonetheless, quality needs to stay right at the top of the screen—along with access and reimbursement. Moreover, it needs to be embedded in each committee and section.
Again at the national level, quality does not fit in a neat organizational box. It affects practice, draws on measurement research, requires innovative education, pulls in subspecialist expertise, and bridges national and chapter work. Organizational structures that stay within these boundaries don’t enable a quality focus. For those of us engaged with the national Academy, we need design a structure that will enable cross-departmental collaboration. Several of us have recommended that such a structure be established to promote quality across the organization. The recently created steering committee on quality improvement and management may enable this bridging to take place.
Several barriers exist outside the Academy that inhibit real progress in improvement. Despite the belief of many of us in the field of quality measurement and improvement that the “marketplace” would reward high-quality performers, scant evidence exists that high-quality performers improve market share and garner better reimbursement. We must work at local, regional, and national levels to influence employers and government to make this strategy viable.
The primitive state of medical records and office data systems makes measurement even for self-assessment and improvement onerous. The development of more flexible databases, investment in measurement development for child health—such as by the Child and Adolescent Health Measurement Initiative-and the Web should make this barrier more amenable to solution. Enhancing the information infrastructure for clinical practice should accelerate improvement in care.
Committing to improvement requires a perspective of humility—that we as practitioners can be better, that our current modes of work and care are not as good as they might. It is hard to say we need to improve when we are on the defensive, with many questioning our performance and even our good will. Nonetheless, the commitment to improvement is the only perspective that over time can sustain us.
Actions by individual practitioners and practices can likely do more to accelerate improvement than structural changes at a national organization. If practitioners take the following steps, then pediatricians will be at the forefront of our profession in restoring public confidence in health care:
Make a commitment, yourself, to making the care you deliver tomorrow better than the care you gave today—and each day going forward. Choose an area you are passionate about—chronic illness, prevention, development, behavior, attention-deficit/hyperactivity disorder, medication safety.
Learn a little about improvement methods—read some of Don Berwick’s or Paul Batalden’s articles, go the Institute for Healthcare Improvement Web site, or go to a workshop at a national or chapter meeting.12
Examine your own practice—don’t just curse the managed care organizations for auditing your charts—you decide what you want to look at, and look at it. Post the data for your partners and staff, and then measure again.
Involve your patients—find out what they really think about care or what ideas they have to make care better.
Involve your colleagues—they can give you ideas, and keep the momentum up.
Try, try, and try—improvement requires change.
Why should Academy practitioners care about this issue of quality? Think back, if you will, to the essay you wrote when you applied to medical school, or to your pediatric residency. For most of you, the essay emphasized your wish to make a difference in people’s lives, to make the world a better place one person at a time. My residency essay starts off: “The outstanding experiences in my life to date [at all of 22] stem from my persistent activism in the realm of social welfare,” and ends, “… my aspirations in medicine are a continuation of these earlier trends.”
The way we influence children’s lives as doctors is through the health care we provide. The federal Bureau of Primary Health Care places their focus on quality improvement administratively within their initiatives to reduce racial and economic disparities in health. It is through enhancing quality that we better fulfill our mission for being in medicine—and pediatrics.
- Received July 24, 2001.
- Accepted July 24, 2001.
- Address correspondence to Charles J. Homer, MD, MPH, National Initiative for Children’s Healthcare Quality, 375 Longwood Ave, Fourth Floor, Boston, MA 02215. E-mail: email@example.com
Delivered as a presentation at the AAP National Conference and Exhibition, Fall 2000.
- ↵Berman S. Are we ready to provide leadership to ensure all children’s health? AAP News.2000 ;17:192
- ↵Berwick DM. Taking the Lead—Keynote Address. Presented at: Annual Meeting of the AAP; October 12, 1999; Washington, DC
- ↵Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press; 1999
- ↵Appleby J. Jaundice-caused brain damage is on the rise. USA Today. October 11, 2000:81–86
- ↵ACGME General Competencies 1.3. Available at: http://www.acgme.org
- ↵Stockman JA III. Diplomate newsletter. Chapel Hill, NC: American Board of Pediatrics; 2000
- ↵Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal intensive care. Pediatrics.2001 ;107:14–22
- ↵Robertson T. More doctors now offer same-day service. Boston Globe. October 15, 2000
- ↵Margolis PA, Lannon CM, Stuart J, Fried B, Moore D, Keyes-Elstein L. Improving delivery systems for prevention in primary care practices: a randomized trial. Paper presented at: APA Presidential Plenary; Pediatric Academic Society Meeting; April 30, 2001
- ↵American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics.2000 ;105:1158–1170
- ↵American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics.2001 ;108:1033–1044
- ↵Berwick DM. Eleven worthy aims for clinical leadership of health system reform. JAMA.1994 ;272:10
- American Academy of Pediatrics