Quality Metrics

Quality improvement practitioners have traditionally used 3 types of measures or metrics to help track what type of change a quality improvement project produces. The 3 traditional measure types are: process measure, outcome measure, and balancing measure. An equity measure is a new type of measure that is designed to identify and address existing inequities and barriers to attaining health equity for all people, and should be utilized going forward for all quality improvement projects including implementation of this guideline.

Quality Improvement Metrics Defined

Process Measure

Indicated by what a provider is doing to improve whatever condition they are trying to improve. Process measures are generally based on accepted clinical practice standards or recommendations. For example, what percentage of newborns had a transcutaneous bilirubin measured between 24 and 48 hours after birth or before discharge?

Outcome Measure

Indicated by how the things that a provider has done or how the system the patient is in impacts the patient with the condition they are trying to improve. For example, what percentage of well-appearing infants age 29 to 60 days old with fever who were discharged home from the ED without an LP were later diagnosed with meningitis?

Balancing Measure

Indicated by whether or not changes we make to try to improve a process or change an outcome result in new or unanticipated problems. Balancing measures are a way for us to ensure that our changes don’t result in unforeseen consequences. Changes to hospital lengths of stay are frequently used as a balancing measure. For example, what percentage of newborns with bronchiolitis not requiring oxygen or other respiratory support had a delay in discharge due to continuous pulse oximetry monitoring?

Equity Measure

Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people”. The best ways to measure equity are still being evaluated. For this CPG, we are defining an equity measure as any process, outcome or balancing measure that incorporates an equity lens. It is essential to think about health equity at the start of the QI process, and to utilize information about pre-existing disparities. A diverse and multi-disciplinary team that seeks input from all stakeholders is also necessary. Equity measure example: use the outcome measure example above, stratify the data by race to identify existing inequities and barriers to improvement, and then direct improvement measures to reduce these inequities.

We are aware that smaller practices may not have enough patients to make equity measure stratifications statements that are statistically significant or actionable. However, we recommend, where possible, to still perform these analyses in an effort to reduce inequities in our health systems and practices.

Quality Improvement Metrics

The following are examples of quality metrics that could be used by individual providers, health care systems, or multi-center quality improvement collaboratives to monitor adherence to the American Academy of Pediatrics Guideline for Faltering Weight.

Equity Note: Each of the measures should be evaluated with an equity lens by stratifying the data by race, ethnicity, preferred language, sex, gender, and insurance type. Additional stratifications can be done as indicated based on identified inequities.

Measure Name	Type of Measure	Definition	Calculation
Example: Bili Discharge	Example: process, balancing, outcome; equity	Example: Routine bilirubin testing for newborns discharged before 24 hours	Example Numerator: At least one total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measure before discharge Example Denominator: Newborns discharged at or before 24h after birth
Faltering Weight Evaluation (KAS 2)	Process	Patients evaluated for faltering weight should have an initial evaluation that includes: detailed medical history, family history, social history, feeding history, growth history, growth assessment and detailed physical exam	Numerator: Number of patients with all aspects of history and physical exam Denominator: Total number of patients evaluated for faltering weight
Equity in Faltering Weight Evaluation (KAS 1)	Process Equity	All patients undergoing evaluation for faltering weight should be evaluated with the same criteria regardless of race or socioeconomic status	Numerators: 1) Number of white patients with all aspects of history and physical exam 2) Number of Black patients with all aspects of history and physical exam 3) Number of Hispanic patients with all aspects of history and physical exam 4) Number of Asian/Pacific Islander patients with all aspects of history and physical exam 5) Number of Native American patients with all aspects of history and physical exam Denominator: Total number of (white, Black, Hispanic or Asian/Pacific Islander, Native American etc.) patients evaluated for faltering weight
Faltering Weight Diagnostic Testing (KAS 2)	Process	Patients undergoing initial evaluation for faltering weight did not undergo diagnostic testing	Numerator: Number of patients evaluated for faltering weight that had NO diagnostic tests performed Denominator: Total number of patients evaluated for faltering weight
Faltering Weight Treatment (KAS 4)	Process	Increased calories should be the first treatment recommendation for all patients with faltering weight	Numerator: Number of patients who were given the recommendation to increase calories Denominator: Total number of patients diagnosed with faltering weight
Faltering Weight Patient Growth (KAS 1 – 6)	Outcome	Patients with faltering weight who have been appropriately diagnosed and treated will no longer meet the criteria for faltering weight 6 months after initial diagnosis	Numerator: Number of patients diagnosed with faltering weight who no longer met the criteria after 6 months of treatment Denominator: Total number of patients diagnosed with faltering weight
Feeding Therapy (KAS 6)	Outcome	Patients with documented feeding issues should be referred for feeding therapy	Numerator: Number of patients with feeding issues referred for feeding therapy Denominator: Total number of patients with faltering weight who were identified as having feeding issues
Faltering Weight Diagnosis Delayed (KAS 1 - 6)	Balancing	Patients with faltering weight who had a delay in diagnosis	Numerator: Number of patients who were not diagnosed during the initial evaluation but were subsequently diagnosed with faltering weight Denominator: Total number of patients diagnosed with faltering weight
Patients Needing Diagnostic Testing (KAS 2)	Balancing	Patients with faltering weight who did not meet the criteria for lab evaluation at the initial evaluation (based on algorithm), but who had lab tests performed on follow-up evaluation.	Numerator: Number of patients who had lab testing performed on any follow-up evaluation. Denominator: Total number of patients evaluated for faltering weight

Acknowledgement

Nicole Anania, DO, MS, FAAP, served as the Implementation Scientist on the recently published American Academy of Pediatrics Faltering Weight Clinical Practice Guideline. Most recently, she was a Professor of Pediatrics at the University of Kentucky and Medical Director for Inpatient Pediatrics at Med Center Health in Bowling Green, KY. Prior to that, she served as a Master Clinician and Director of Quality Improvement for the Outreach Division of Ann & Robert H. Lurie Children's Hospital of Chicago and has extensive experience working with children with medical complexity and faltering weight.

Last Updated

03/11/2026

Source

American Academy of Pediatrics