How (and why) do quality improvement professionals measure performance?

The era of value-based care has engulfed healthcare delivery systems around the world. Pediatricians are especially challenged by constrained resources for providing care to our vulnerable population, and methods for achieving value for children through improved quality and reduced cost of care are crucial for success. This paper examines the use of measures to determine the two components of the value proposition: quality and cost. The implications for adopting Lean Six Sigma as an improvement paradigm are reviewed, and the case for using these concepts is detailed with examples of measures used in health systems in the United States and several other countries.

Patient engagement: Changing pediatric practice to improve patient care.

Twenty-first century health care has evolved into a patient-centred enterprise that has changed the relationship between doctors and patients. Society now sets a high expectation for clinicians not only to impart knowledge to people about their illnesses and prescribe treatments to improve their clinical conditions but also to work with patients to ensure that the treatments are acceptable to ensure the patients' adherence to the recommendations. Most physicians are not trained for this change, but the principles of patient engagement can help clinicians meet these new challenges and perform well on measures of patient satisfaction and compliance with care recommendations. This article presents the basics of patient engagement for clinical staff to aid the facilitation of new approaches to patient care.

Effect of a resident physician educational program on pediatric emergency department pharmacy interventions and medication errors.

PURPOSE: To determine the effects of a resident physician educational program in a pediatric emergency department (ED) on pharmacy interventions and medication errors, particularly dose adjustments, order clarifications, and adverse drug events (ADE). METHODS: The ED pharmacist recorded all interventions and medication errors on weekdays from 3 to 11 pm during a 9-month period, consisting of a preobservational (Quarter 1), observational (Quarter 2), and interventional (Quarter 3) phases. Program implementation occurred in Quarter 3, with an initial 3-hour lecture during the ED orientation, followed by daily patient case discussions. Weekly interventions and errors were analyzed using statistical process control u-chart analyses. Chi-square analyses of independence were also performed. Resident and ED staff feedback on the program was obtained through anonymous internet-based surveys. RESULTS: A total of 3507 interventions were recorded during the 9-month period. Chi-square approximation and interval estimation of odds ratio showed a statistically significant decrease between Quarters 1 and 3 in the number of dose adjustments (95% confidence interval [CI], 0.324-0.689) and order clarifications (95% CI, 0.137 to 0.382) after initiation of the program. The decline in ADE, while not as substantial (95% CI, 0.003 to 1.078), still achieved a level of significance (90% CI, 0.006 to 0.674). Survey results were positive toward the program. CONCLUSIONS: The implementation of a resident physician educational program in our pediatric ED significantly decreased the number of medication errors, increased resident physician awareness of the potential for errors, and increased ED pharmacist utilization.

Building communication between professionals at children's specialty hospitals and the medical home.

OBJECTIVE: Build a quality improvement (QI) intervention to improve communication between a children's specialty hospital and referring primary care providers (PCPs). METHODS: A network of charitable children's hospitals identified improving communication as a systemwide goal. At one model hospital, we used qualitative telephone interviewing of hospital specialists and staff, and referring PCPs, to characterize the communication system and identify potential improvements. We identified potential high-impact areas through content analysis and developed a QI change package with hospital leadership. RESULTS: Participants described inconsistent communication, with no systematic identification of PCPs. Families were the typical means of inter-physician communication. Multiple non-PCP referral sources were a major contributor to communication breakdowns. Respondents identified a system for identification and communication with PCPs as an essential first step. CONCLUSIONS: Systems for communication with PCPs are underdeveloped at a children's charitable specialty hospital. Straightforward changes could build an effective system that is generalizable to other hospitals.

Evidence-based analysis of removal of orthopaedic implants in the pediatric population.

BACKGROUND: Requested project of the Pediatric Orthopaedic Society of North America Evidenced-Based Medicine Committee. METHODS: The English literature was systematically reviewed for scientific evidence supporting or disputing the common practice of elective removal of implants in children. RESULTS: Several case series reported implant removal, but none contained a control group with retained implants. No articles reported long-term outcomes of retained implants in large numbers. Several small series describe complications associated with retained implants without evidence of causation. The existing literature was not amenable to a meta-analysis. By compiling data from the literature, it is possible to calculate a complication rate of 10% for implant removal surgery. The complication rate for removal of implants placed for slipped capital femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic science were also reviewed. CONCLUSIONS: There is no evidence in the current literature to support or refute the practice of routine implant removal in children.

A prospective evaluation of the WeeFIM in patients with cerebral palsy undergoing orthopaedic surgery.

PURPOSE: Although frequently used in pediatric rehabilitation settings, the WeeFIM has not been tested in surgical pediatric orthopaedic patients. METHODS: The WeeFIM was administered to patients with surgical cerebral palsy at defined intervals preoperatively and at both 6 and 12 months postoperatively. The age-adjusted change scores from baseline to follow-up were tested both parametrically and nonparametrically. RESULTS: Four hundred sixty-eight patients had baseline evaluations. There were 161 six-month follow-up assessments and 108 twelve-month follow-up assessments. The baseline WeeFIM was able to separate children with different patterns of cerebral palsy. Hemiplegic patients had higher scores than diplegic and tetraplegic patients. Overall age-adjusted scores were improved at both 6 (mean increase 2.0) and 12 months (mean increase 2.2). The instrument showed significant ceiling effects for diplegic and hemiplegic patients with lower or upper extremity surgery and limited responsiveness for lower extremity surgery in tetraplegic patients. Parametrically, it showed improvements in mobility for both rhizotomy and tetraplegic upper extremity surgery. Nonparametric tests were not significant for rhizotomy mobility improvement. CONCLUSIONS: Although the WeeFIM adequately reflects the severity of neurological involvement in pediatric orthopaedic patients with cerebral palsy, it has a significant ceiling effect in diplegic and hemiplegic patients limiting responsiveness and lacks content validity for tetraplegic patients. The instrument may have some use in tetraplegic patients with upper extremity surgery and in rhizotomy patients. We recommend against its general use for orthopaedic surgery in patients with cerebral palsy lower extremity or spine surgery and in hemiplegic patients with upper extremity surgery.

Computer equipment used in patient care within a multihospital system: recommendations for cleaning and disinfection.

Computer hardware has been implicated as a potential reservoir for infectious agents. Leaders of a 22-hospital system, which spans North America and serves pediatric patients with orthopedic or severe burns, sought to develop recommendations for the cleaning and disinfection of computer hardware within its myriad patient care venues. A task force comprising representatives from infection control, medical affairs, information services, and outcomes management departments was formed. Following a review of the literature and of procedures within the 22 hospitals, criteria for cleaning and disinfection were established and recommendations made. The recommendations are consistent with general environmental infection control cleaning and disinfection guidelines, yet flexible enough to be applicable to the different locales, different computer and cleaning products available, and different patient populations served within this large hospital system.

Case study: using control charts to track physician productivity.

Learn how control charts are being used to gauge physician productivity in a Shriners hospital in Kentucky. The charts provide a fair and accurate analysis that doctors appreciate.