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Quality Improvement in the Pediatric Practice

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Quality Improvement (QI) is a science of process management that focuses on using a systematic approach to improve care outcomes, system performance, as well as professional development. In a pediatric practice setting, the focus is on improving patient care by measuring and analyzing processes, and then identifying ways to make them better. QI is not a "one and done" type of effort; rather, it is an ongoing commitment to ensure that the best possible care is provided to patients and their families.

An increasing number of payers are using quality of care as a variable in calculating payment rates for pediatric practices. For example, with Pay for Performance (P4P), a practice receives enhanced payment or a bonus payment for attaining certain quality targets. Additionally, participation in quality improvement activities is one requirement in Maintenance of Certification as a pediatrician. 

Quality Improvement in the Pediatric Practice: Implementation Steps

    1. Understand the Basics of Quality Improvement

    ​The AAP offers free online QI modules to its members through a program called EQIPP. A pre-requisite of participating in an EQIPP module is completion of the EQIPP QI Basics course. This online course is free to all AAP members and can be found at: http://eqipp.aap.org/qi-basics/clinical-guide/units/introduction.  ​

    2. Establish a Quality Improvement Team

    Building a team to oversee a practice's QI efforts is important, as practice-wide changes cannot be made through the efforts of a single person. The team should be led by a QI champion, who will provide committed leadership to ongoing practice improvement. Ideally, the QI champion is an individual experienced with change concepts and comfortable in collecting and analyzing data to know when change has resulted in improvement. An effective QI team is made up of a small group of individuals with varied levels of experience and insights who represent all areas of the practice that will be affected by the proposed improvement. At minimum, the team should include a physician leader, a family representative, and one or two key staff members who know the practice well.

    When recruiting members for the QI team, one strategy is to consider selecting individuals with the following attributes:

    • Respected by a broad range of staff
    • Team players
    • Excellent listeners
    • Good communicators
    • Proven problem solvers
    • Open to and ready for change
    • Creative and able to offer solutions
    • Flexible - demonstrated by their willingness to change and accept new technology
    • Proficient in the areas and systems focused for improvement
    • Willing to dedicate time to drive improvement efforts​


    The Team should also be encouraged to look for improvement opportunities with all duties and responsibilities of their job role. One strategy would be to add the following to every employee's job description: "Continue to identify opportunities for improvement in the practice and work with team members to take steps to continuously improve". 

    3. “Plan” the Improvement

    ​The Model for Improvement is an approach for process improvement, which helps teams accelerate the adoption of proven and effective changes. This method can also be used to test measures, strategies, and tools; and to ultimately make improvements in practice.

    The planning phase consists of three components/questions:

    • What are we trying to accomplish?
    • How will we know the change is an improvement?
    • What changes can we make that will result in an improvement?


    As a first project, a practice might want to select a topic that is "low hanging fruit" for a greater likelihood of measureable improvement and to generate enthusiasm among staff. Topics might also include areas where the practice is performing less than optimally, or where payers are asking the practice to submit data to calculate incentive payments. As staff become more​​ experienced with quality improvement, topics that are more challenging to measure could be selected. ​

    One easy way of selecting a topic for improvement is through AAP EQIPP modules. EQIPP will help your practice with regular review of performance data and evaluation of performance against goals or benchmarks.

    3a. Develop an Aim Statement
    An aim statement is the practice's written, measurable, and time-sensitive statement of the expected results of the improvement process. Review the AIM Statement for the components of a SMAART objective (Specific, Measureable, Actionable, Achievable, Realistic and Timely).

    Sample Aim Statement
    By September 2013, Pediatric Practice, Inc. will improve the assessment and identification of genetic conditions for all of our patients aged 0‐21 years old, as part of the health supervision visit by:

    • Creating or updating/maintaining multi‐generational family histories at health supervision visits, using the family history components defined by the project, for 90% of our patients
    • Discussing current family histories with 90% of our patients/families​


    Utilize the AIM worksheet to develop practice's goals for quality improvement measures.

    Reso​​u​​rce:

    3b. Determine the Measures
    Have the practice set goals and benchmarks for expected achievement that the practice has set themselves. Create measures that are "just enough" instead of "just in case", which can increase data collection burden.  Keep it simple with 4-8 measures, a combination of the types of measures listed below:

    • Process Measures: Measures how services are provided
    • Outcome Measures: Measures the results of health care.   This could include whether the patient's health improved or whether the patient was satisfied with the services received.​
    • Balancing Measures: Ensures that if changes are made to one part of the system, it doesn't cause problems in another part of the system.

    Characteristics of a Good Measure:

    • Relates to the aim and key changes
    • Simple
    • Shows improvement quickly
    • Easy to collect
    • Meaningful and understandable to participants
    • Creates a tension for change
    • Can be graphically displayed over time

    3c. Select your Ideas for Change to Address the Quality Gap
    Specify the steps that it will take and identify who will be responsible for what, when, where and how. The current state of the practice will be the benchmark for your QI initiatives. Benchmarks can also be generated from similar practices in the same area or by comparing them to a larger group of practices from across the country. Change ideas can be determined through brainstorming, reviewing the literature, speaking with colleagues, and process mapping. Key questions to ask include: What specific change concepts will achieve the aim? What theories and predictions can you make about how these change concepts will cause improvement?

    4. “Do”: Implement Your Action Plan

    ​Once the benchmarks are set and the team has been organized, it is now time to launch the ​QI plan. "Do" is when the practice implements the improvement. When conducting the tests of change think on a small scale such as one patient, one change, one day, and note what happens. If change becomes an improvement then test it on a wider group or under new conditions. Document the challenges and benefits.​

    5. The practice should implement the improvement, father specified data, analyze results, and produce a report. “Study” the Measured Results

    ​The "Study" aspect is when the ​practice collects and regularly reviews performance data and compares results to goals and benchmarks. The QI team should meet on a regular basis to determine which element(s) can be further improved upon to reach benchmarked goals, and to determine next steps for moving forward. Further, the team should evaluate what worked and what did not.  ​

    6. “Act”: Identify and Integrate What You’ve Learned

    ​The final component, "Act", is when the ​practice uses the results to identify inconsistencies, barriers and potential areas to improve. Adopt, reject, or modify the change so the next cycle can begin. Will you increase the scope if the results were positive, or plan another test if the results were less than desirable? Decide what you will do differently in the next cycle.​

    7. Repeat Steps 3-6

    ​Repeat Steps 3-6 before proceding to step 8. 

    8. Identify Other Areas for Improvement

    Consider using an EQIPP module to make decisions about other areas for improvement.

    ​Resourc​​es:

    9. Consider Joining an AAP QI Community

    The Quality Improvement Innovation Networks (QuIIN) is an AAP national program that is home to multiple pediatric improvement networks focused on improving the quality and value of care and outcomes for children and families. Membership is free and can be found here.

    Reso​​ur​​ces: 

We need your help to keep our practice transformation strategies up-to-date amid today's unprecedented changes in health care. Please share your "best practices," innovations, implementation tools, and resources to help other AAP members keep pace as the health care environment rapidly evolves. Simply complete and submit the form below. Thank you for keeping pediatric practice strong. ​​​​

 

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