High-Quality Health Care for Children: What Can We Do?
Article Outline
HIGH-QUALITY HEALTH CARE is synonymous with safe and effective health care. Although high-quality health care is important to all of us, children are special. Their unique growth and development needs make them (particularly special-needs children and children in poverty) especially vulnerable to poor health care outcomes (Chung & Schuster, 2004).
The quality and safety movement in North America gained momentum in 1999 with the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999). This report turned the spotlight on the U.S. health care system. Although the report focused predominantly on adult acute care settings, it generated health services research that emphasized the increased risks associated with being a child. One research study, for instance, demonstrated that medication errors were more common with children than with adults, perhaps due to differences in how medications are dosed for children versus adults. In two institutions, there were three times as many medication errors for children as for adults (Kaushal et al., 2001).
As pediatric nurses, what can we do to ensure high-quality care for our patients and their families? This editorial will focus on some easily accessible resources associated with the provision of high-quality care for children. One of these resources is the IOM. This branch of the National Academies of Sciences was established in 1970 to provide objective evidence-based information to improve the nation's health. Its website (www.iom.edu) provides child health links to current reports and research on a range of topics, such as nutrition, immunizations, and palliative care.
Another valuable resource for pediatric nurses is the Agency for HealthCare Research and Quality (AHRQ). Housed within the U.S. Department of Health and Human Services, the AHRQ is the federal agency responsible for “improving the quality, safety, efficiency, and effectiveness of health care for all Americans” (http://www.ahrq.gov/about/ataglance.htm). The AHRQ website is a repository of evidence-based fact sheets on many health-related topics, including children's health. One fact sheet of interest is the Child Health Care Quality Toolbox. A toolbox is typically an online resource with information, helpful tips, and tools related to a particular topic. The Child Health Care Quality Toolbox (http://www.ahrq.gov/chtoolbox) is intended to help users, including pediatric nurses, determine whether specific health care programs are functioning effectively and providing quality health care to children. Toolbox content includes information on quality measurement (e.g., What is quality measurement and why is it relevant to children's health?).
Quality is defined 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” (http://www.ahrq.gov/chtoolbox/understn.htm).
The AHRQ, in collaboration with the University of California and Stanford Evidence-Based Practice Center, developed a series of quality indicators (QIs) or measures where there is evidence linking care delivery with patient outcomes. This collaborative used a rigorous process, including expert opinion, statistical analyses of databases, benchmarking across institutions, and literature review, to develop these QIs. There are three general types of AHRQ QIs: prevention, inpatient, and patient safety. Within the last few years, these three sets of QIs have been adapted for pediatric populations. Pediatric experts consulted with the AHRQ to produce pediatric QIs (PDIs) that reflect the unique characteristics of children's health, such as developmental status, dependence on adults, and differential epidemiology. In the latter instance, children suffer fewer chronic ailments than adults, but their basic anatomy and physiology predispose them to other ailments, such as otitis media and bronchiolitis. PDIs, therefore, provide scientifically sound and systematic ways to assess whether children are receiving the care they require. They can be used by hospitals, managed care organizations, health care plans or programs, or practitioners. Here are some examples of how PDIs can be used: Standardized immunization schedules exist for infants and children. Immunization rates can be easily compared to ideal standards at many different levels, including national, regional, and statewide levels. Another PDI concerns emergency room visits for children with asthma. Lower visit rates are obviously preferable to higher visit rates. PDI rates can be used for comparing one's own performance over time, for benchmarking with other similar institutions, and for comparing with scientific standards, recommendations, or goals, such as Healthy People 2010 (http://www.healthypeople.gov/default.htm) and Bright Futures (http://www.brightfutures.org/).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the accrediting body for hospitals and other health care facilities in the United States. In 1997, the JCAHO made quality measurement tracking and evaluation requirements of the accreditation process (http://www.jcaho.org). AHRQ QIs, therefore, are government-supported quality measurement tools available to health care organizations for them to meet JCAHO mandates. There are other child health care quality measures that are used by public and private sectors caring for children, such as the Child and Adolescent Health Measurement Initiative, which includes two measurement sets used to assess how well children and young adults receive recommended preventive and developmental health services (http://www.ahrq.gov/chtoolbox/measure6.htm). There are more than 70 child health measures that focus on different aspects of pediatric health care delivery. The AHRQ has a web-based collection of these quality measures (http://www.qualitymeasures.ahrq.gov/).
What do these resources have to do with us? If we focus on quality of care and strive to meet particular standards or goals of care based on scientific and expert evidence available to us, we will be providing safe and effective care. Safety is only one piece of the quality equation. In many health care organizations, quality (quality assurance) and patient safety (risk management) programs go hand in hand. The IOM linked the two in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century (Richardson & Biere, 2001) and, of particular interest to nurses, in its 2004 report Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004). As pediatric nurses, we play a role in contributing to the quality (and the safety) of health care delivery for children. Although many of these quality measurement initiatives may seem to apply at a higher level of accountability, it is the direct care providers (bedside nurses) who are often called upon to help monitor and evaluate “how we are doing” and, consequently, direct providers are often in the best position to know what works well and on which part of care delivery there are actual or potential gaps that need to be rectified. Direct care providers, therefore, should know about and be involved in their institution's quality and safety programs.
This is a two-way issue. Direct care providers need to be informed, and health care institutions need to provide “real-time” feedback to them. In addition to the quality measurements being collected by health care organizations to meet JCAHO mandates, some organizations are additionally experimenting with other ways to involve staff in quality and safety monitoring processes. In a recent article by Ursprung et al. (2005), real-time safety audits with frontline staff were able to promptly identify safety problems and resulted in efficient and effective changes in practice and policies.
The article featured in this issue's Clinical Practice Column provides an in-depth look at how health care professionals within one children's hospital were able to implement successful interprofessional programs to safeguard children's health. Of note is that this article is from a province in Canada. Although Canadian and U.S. health care systems are different, the importance of patient quality and safety is universal. Canada and the United States have been collaborating on North American patient quality and safety initiatives, and Canada's patient safety agencies, laws, and policies parallel those in the United States. This article also illustrates that the depth and breadth of quality and patient issues require many different levels and approaches to monitoring and intervention. At higher levels (national, state/provincial, and organizational levels), it is important to use systematic and standardized quality measurement sets (such as AHRQ QIs) to effectively compare and contrast performance at these different levels. At the front line, creative and time-efficient strategies are being piloted by organizations to engage more staff and to identify potential/actual problems not captured by existing quality measurement methods. No matter where we are within the health care system, we need to know about these monitoring procedures and to stay involved and informed.
References
- . Access and quality in child health services: Voltage drops. Health Affairs. 2004;23:77–87
- . Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;185:2114–2120
- In: Kohn L, Corrigan J, Donaldson M editor. To err is human: Building a safer health system. Washington, DC: National Academy Press; 1999;
- In: Page A editors. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press; 2004;
- In: Richardson W, Biere R editor. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001;
- Real time patient safety audits: Improving safety every day. Quality and Safety Health Care. 2005;14:284–289
PII: S0882-5963(06)00358-7
doi:10.1016/j.pedn.2006.08.011
© 2007 Elsevier Inc. All rights reserved.
