Commentary
Why Quality Matters in the Journal of Developmental & Behavioral Pediatrics Eugenia Chan, MD, MPH
I
n 2001, the Institute of Medicine (IOM) released its call to action to improve the quality of American health care. Crossing the Quality Chasm proposed redesigning the health care system to achieve 6 primary aims: delivering care that is safe, timely, effective, efficient, equitable, and patient-centered.1 Central to the IOM report was the idea that quality is a system property. Improving health care quality therefore can occur only by changing systems, not simply by trying harder or working within current systems of care. In pediatrics, the imperative to improve health care quality is now embodied in the requirement that pediatricians engage in meaningful quality improvement (QI) activities as part of maintaining board certification. Increasing movement toward payment based on high-quality clinical performance only adds to the critical and immediate need to be able to demonstrate the value of developmental-behavioral care and assure the viability of our field. Recognizing that developmental-behavioral clinicians may be unfamiliar with concepts of quality measurement and the methods of QI, we introduce the new Quality Matters section in this issue of the Journal of Developmental & Behavioral Pediatrics. Under the direction of section editor Eugenia Chan, Quality Matters will serve a dual purpose for our readers. Our first goal is to illustrate key principles of quality measurement, improvement methods, and implications for policy and the practice of developmental-behavioral pediatrics through reviews, case studies, and commentaries from thought leaders in the field. The second goal is to provide an avenue for reporting the implementation and results of QI projects in developmentalbehavioral pediatrics. We especially encourage reports of “real-world” improvement projects, both successful and unsuccessful, that illustrate rigorous improvement meth-
(J Dev Behav Pediatr 35:458–459, 2014) Index terms: quality, quality improvement. From the Division of Developmental Medicine, Boston Children’s Hospital, Boston, MA. Received July 2014; accepted July 2014. Disclosure: The authors declare no conflict of interest. Address for reprints: Eugenia Chan, MD, MPH, Division of Developmental Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins
458 | www.jdbp.org
ods and draw from the traditions of both classic biomedical research as well as the social sciences. Reports should describe the local context in which the project is situated, the problem being addressed and the specific aims of the improvement project, the process of implementing the project, and the measures used to demonstrate change. We suggest that authors include examples of the tools used during the planning and implementation, and hope that authors will share their “lessons learned” from the project, for example, insights as to why something did or did not work, unexpected results, and unanticipated barriers and facilitators. Submissions reporting the results of a QI project are expected to follow the Standard for Quality Improvement Reporting Excellence (available at www.squirestatement.org).2 Although not all elements in the SQUIRE guidelines may be applicable to all submissions, attention to the relevant elements will enhance the rigor of reporting QI projects. For example, if the study design involves use of iterative QI methods (such as Plan-DoStudy-Act [PDSA] cycles), these should be described and relevant data from the cycles should be displayed in a time-line diagram such as an annotated run chart or statistical process control chart. Classical biostatistical methods can still be used (and often will enhance the report of a QI intervention) but typically are not the sole analytic strategy for QI. To launch this new section, we are pleased to feature a 2-part educational series to introduce the basics of QI to our readers. Chung et al3 present a case illustrating the key tools and iterative process involved in conducting QI projects in developmental-behavioral pediatric practice. Part 1 is focused on the importance of thoughtful planning and design; Part 2 will focus on learning from consecutive small tests of change to effect lasting improvement. While not intended to be a comprehensive overview of improvement methods, the series hopes to demystify QI and inspire readers to begin to engage in the process. Future articles will focus on topics such as practice variation and the role of clinical practice guidelines, the landscape of quality measures relevant for developmental-behavioral pediatrics, and the concept of value and its implications for reimbursement. We eagerly anticipate your submissions to Quality Matters. In a cognitive specialty such as developmentalbehavioral pediatrics, where patient-relevant outcomes Journal of Developmental & Behavioral Pediatrics
can be challenging not only to define but also to measure in a reliable, valid, and efficient manner, our best source of knowledge is the shared experiences of all. REFERENCES 1. Committee on Quality Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System
for the 21st Century. Washington, DC: National Academy Press; 2001. 2. Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care. 2008;17:i13–i32. 3. Chung P, Baum R, Soares N, et al. Introduction to quality improvement, part one: defining the problem, making a plan. J Dev Behav Pediatr. 2014;35:460–466.
Book Review Pediatric Neuropsychology: Medical Advances and Lifespan Outcomes Ida S. Baron, Celiane Rey-Casserly, eds, New York, NY, Oxford University Press, 2013, 446 pp, Hardcover, $89.98. In Pediatric Neuropsychology: Medical Advances and Lifespan Outcomes, editors Ida Sue Baron and Celiane ReyCasserly bring together experts to address the complex issue of pediatric diseases and their effects on the life course. With continuing improvements in pediatric care, mortality rates have improved for many once-fatal disorders, resulting in a growing and aging survivor population. The lifelong morbidity of this cohort has become a vital issue, which the editors hope to address. This text is a thorough overview on the neuropsychological outcomes for pediatric disease survivors; however, this complex and nascent field is only as good as the science behind it, and there is still more research needed before meaningful conclusions could be drawn. The authors make a heroic effort to discuss this complex issue, resulting in a resource that is informative but not always helpful. The first section of the text, Medical Disorders, constitutes its bulk. Each chapter focuses on a medical condition, providing a historic overview, a summary of pathophysiologic processes, and a review of neuropsychological outcomes. The medical content presupposes the reader’s familiarity with jargon, but the flow in each chapter allows the appreciation of the diseases in their historical context. This disease-centric approach makes structural sense but results in a lack of uniformity in content depth and quality. Disorders with multisite databases and research consortiums, for example, chronic kidney disease, have tremendous banks of research to draw on, both in mortality and morbidity; other diseases are significantly limited in prevalence and/or research with great variability in
Vol. 35, No. 7, September 2014
the content and quality of contributing studies. Some authors are tasked with discussing disorders that have a significant body of neuropsychological literature to summarize (e.g., autism), and the space allotted is far too limited to do them justice. More importantly, only a few chapters provide clinical suggestions drawn from the literature. The lack of practical application related to neuropsychological outcome for some diagnoses leaves the reader with more questions than answers, particularly if one hopes to apply this research in clinical settings. Section 2, Impact on Educational Systems, covers special educational services and higher education. These chapters provide a targeted overview of the history and science behind educational policies, providing perspectives not typically covered in medical training. This information is covered in a systematic way that provides a helpful knowledge base, especially for clinicians who are unfamiliar with the science and legislation behind educational supports. Specific prompts that are immediately applicable to clinical scenarios are included. However, there is surprisingly little mentioned about contextual factors (e.g., family structure, socioeconomic status, mental health) that play a vital role in the outcome of the child, and an expansion of this section would be a welcome addition to the book’s diversity of perspectives. Section 3, Methodological and Lifespan Developmental Considerations, is the most eclectic section. The most helpful chapters address the role of the neuropsychologist and the process of transitioning between pediatrics and
adult medicine. A chapter on statistics is well written but poorly contextualized, and the section on cognitive reserve and the Flynn effect (i.e., the increase of intelligence scores in the population over time) is written at a theoretical level that lacks immediate relevance to the intended audience. Sections 2 and 3 overall provide an excellent scaffold to understand the topic and might have been more helpful had they come at the book’s beginning. This text is an excellent reference for clinicians who care for children with chronic medical diseases across the lifespan. Primary physicians who struggle with this population’s developmental and educational needs will gain an appreciation for the myriad of challenges; this population has overcome and will continue to face. Future editions are a necessity; the literature will expand as medical knowledge advances and disease cohorts’ age. A greater emphasis on social, behavioral, and mental health would be a welcome perspective on life course outcomes. Finally, one hopes that future editions will emphasize “take-away” messages to bridge the gap between research and clinical settings. Disclosure: The authors declare no conflict of interest. Peter J. Chung, MD* Douglas L. Vanderbilt, MD† *Developmental-Behavioral Pediatrics, University of California, Los Angeles, Los Angeles, CA †Developmental-Behavioral Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
© 2014 Lippincott Williams & Wilkins
459
Why Quality Matters in the Journal of Developmental & Behavioral Pediatrics Eugenia Chan, MD, MPH
I
n 2001, the Institute of Medicine (IOM) released its call to action to improve the quality of American health care. Crossing the Quality Chasm proposed redesigning the health care system to achieve 6 primary aims: delivering care that is safe, timely, effective, efficient, equitable, and patient-centered.1 Central to the IOM report was the idea that quality is a system property. Improving health care quality therefore can occur only by changing systems, not simply by trying harder or working within current systems of care. In pediatrics, the imperative to improve health care quality is now embodied in the requirement that pediatricians engage in meaningful quality improvement (QI) activities as part of maintaining board certification. Increasing movement toward payment based on high-quality clinical performance only adds to the critical and immediate need to be able to demonstrate the value of developmental-behavioral care and assure the viability of our field. Recognizing that developmental-behavioral clinicians may be unfamiliar with concepts of quality measurement and the methods of QI, we introduce the new Quality Matters section in this issue of the Journal of Developmental & Behavioral Pediatrics. Under the direction of section editor Eugenia Chan, Quality Matters will serve a dual purpose for our readers. Our first goal is to illustrate key principles of quality measurement, improvement methods, and implications for policy and the practice of developmental-behavioral pediatrics through reviews, case studies, and commentaries from thought leaders in the field. The second goal is to provide an avenue for reporting the implementation and results of QI projects in developmentalbehavioral pediatrics. We especially encourage reports of “real-world” improvement projects, both successful and unsuccessful, that illustrate rigorous improvement meth-
(J Dev Behav Pediatr 35:458–459, 2014) Index terms: quality, quality improvement. From the Division of Developmental Medicine, Boston Children’s Hospital, Boston, MA. Received July 2014; accepted July 2014. Disclosure: The authors declare no conflict of interest. Address for reprints: Eugenia Chan, MD, MPH, Division of Developmental Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins
458 | www.jdbp.org
ods and draw from the traditions of both classic biomedical research as well as the social sciences. Reports should describe the local context in which the project is situated, the problem being addressed and the specific aims of the improvement project, the process of implementing the project, and the measures used to demonstrate change. We suggest that authors include examples of the tools used during the planning and implementation, and hope that authors will share their “lessons learned” from the project, for example, insights as to why something did or did not work, unexpected results, and unanticipated barriers and facilitators. Submissions reporting the results of a QI project are expected to follow the Standard for Quality Improvement Reporting Excellence (available at www.squirestatement.org).2 Although not all elements in the SQUIRE guidelines may be applicable to all submissions, attention to the relevant elements will enhance the rigor of reporting QI projects. For example, if the study design involves use of iterative QI methods (such as Plan-DoStudy-Act [PDSA] cycles), these should be described and relevant data from the cycles should be displayed in a time-line diagram such as an annotated run chart or statistical process control chart. Classical biostatistical methods can still be used (and often will enhance the report of a QI intervention) but typically are not the sole analytic strategy for QI. To launch this new section, we are pleased to feature a 2-part educational series to introduce the basics of QI to our readers. Chung et al3 present a case illustrating the key tools and iterative process involved in conducting QI projects in developmental-behavioral pediatric practice. Part 1 is focused on the importance of thoughtful planning and design; Part 2 will focus on learning from consecutive small tests of change to effect lasting improvement. While not intended to be a comprehensive overview of improvement methods, the series hopes to demystify QI and inspire readers to begin to engage in the process. Future articles will focus on topics such as practice variation and the role of clinical practice guidelines, the landscape of quality measures relevant for developmental-behavioral pediatrics, and the concept of value and its implications for reimbursement. We eagerly anticipate your submissions to Quality Matters. In a cognitive specialty such as developmentalbehavioral pediatrics, where patient-relevant outcomes Journal of Developmental & Behavioral Pediatrics
can be challenging not only to define but also to measure in a reliable, valid, and efficient manner, our best source of knowledge is the shared experiences of all. REFERENCES 1. Committee on Quality Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System
for the 21st Century. Washington, DC: National Academy Press; 2001. 2. Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care. 2008;17:i13–i32. 3. Chung P, Baum R, Soares N, et al. Introduction to quality improvement, part one: defining the problem, making a plan. J Dev Behav Pediatr. 2014;35:460–466.
Book Review Pediatric Neuropsychology: Medical Advances and Lifespan Outcomes Ida S. Baron, Celiane Rey-Casserly, eds, New York, NY, Oxford University Press, 2013, 446 pp, Hardcover, $89.98. In Pediatric Neuropsychology: Medical Advances and Lifespan Outcomes, editors Ida Sue Baron and Celiane ReyCasserly bring together experts to address the complex issue of pediatric diseases and their effects on the life course. With continuing improvements in pediatric care, mortality rates have improved for many once-fatal disorders, resulting in a growing and aging survivor population. The lifelong morbidity of this cohort has become a vital issue, which the editors hope to address. This text is a thorough overview on the neuropsychological outcomes for pediatric disease survivors; however, this complex and nascent field is only as good as the science behind it, and there is still more research needed before meaningful conclusions could be drawn. The authors make a heroic effort to discuss this complex issue, resulting in a resource that is informative but not always helpful. The first section of the text, Medical Disorders, constitutes its bulk. Each chapter focuses on a medical condition, providing a historic overview, a summary of pathophysiologic processes, and a review of neuropsychological outcomes. The medical content presupposes the reader’s familiarity with jargon, but the flow in each chapter allows the appreciation of the diseases in their historical context. This disease-centric approach makes structural sense but results in a lack of uniformity in content depth and quality. Disorders with multisite databases and research consortiums, for example, chronic kidney disease, have tremendous banks of research to draw on, both in mortality and morbidity; other diseases are significantly limited in prevalence and/or research with great variability in
Vol. 35, No. 7, September 2014
the content and quality of contributing studies. Some authors are tasked with discussing disorders that have a significant body of neuropsychological literature to summarize (e.g., autism), and the space allotted is far too limited to do them justice. More importantly, only a few chapters provide clinical suggestions drawn from the literature. The lack of practical application related to neuropsychological outcome for some diagnoses leaves the reader with more questions than answers, particularly if one hopes to apply this research in clinical settings. Section 2, Impact on Educational Systems, covers special educational services and higher education. These chapters provide a targeted overview of the history and science behind educational policies, providing perspectives not typically covered in medical training. This information is covered in a systematic way that provides a helpful knowledge base, especially for clinicians who are unfamiliar with the science and legislation behind educational supports. Specific prompts that are immediately applicable to clinical scenarios are included. However, there is surprisingly little mentioned about contextual factors (e.g., family structure, socioeconomic status, mental health) that play a vital role in the outcome of the child, and an expansion of this section would be a welcome addition to the book’s diversity of perspectives. Section 3, Methodological and Lifespan Developmental Considerations, is the most eclectic section. The most helpful chapters address the role of the neuropsychologist and the process of transitioning between pediatrics and
adult medicine. A chapter on statistics is well written but poorly contextualized, and the section on cognitive reserve and the Flynn effect (i.e., the increase of intelligence scores in the population over time) is written at a theoretical level that lacks immediate relevance to the intended audience. Sections 2 and 3 overall provide an excellent scaffold to understand the topic and might have been more helpful had they come at the book’s beginning. This text is an excellent reference for clinicians who care for children with chronic medical diseases across the lifespan. Primary physicians who struggle with this population’s developmental and educational needs will gain an appreciation for the myriad of challenges; this population has overcome and will continue to face. Future editions are a necessity; the literature will expand as medical knowledge advances and disease cohorts’ age. A greater emphasis on social, behavioral, and mental health would be a welcome perspective on life course outcomes. Finally, one hopes that future editions will emphasize “take-away” messages to bridge the gap between research and clinical settings. Disclosure: The authors declare no conflict of interest. Peter J. Chung, MD* Douglas L. Vanderbilt, MD† *Developmental-Behavioral Pediatrics, University of California, Los Angeles, Los Angeles, CA †Developmental-Behavioral Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
© 2014 Lippincott Williams & Wilkins
459
