A practical guide to measuring, improving care in your practice
Joel S.Tieder, M.D., M.P.H., FAAP
All pediatricians should be well on their way to incorporating quality measurement
into their practice. Increasingly, colleagues, patients, payers and certifying agencies
expect such measurement to achieve the Triple Aim of better health, better care and
lower cost. In addition, new payment models increasingly pay providers for demonstrated
value rather than volume, and they expect participation in continuous improvement.
The American Board of Pediatrics (ABP) Maintenance of Certification (MOC) Part 4 requires
most pediatricians to participate in two data-driven quality improvement (QI) projects
every five years. Measurement is a critical component of these projects. Pediatricians
select quality measures to evaluate whether patient outcomes and experience improve,
and if not, identify and overcome barriers.
Precious time and resources are needed to identify measures, implement interventions,
use data to monitor improvements, and identify and mitigate barriers. How does one
meet these expectations while addressing factors like poverty, access to care and
a rapidly changing health care environment — without burning out? Here are some practical
Step 1: Learn the basics of QI
Learning about QI is easier than one might think and can have amazing effects on patient
outcomes, efficiency and job satisfaction. You can find numerous books, websites,
and in-person and distance learning courses based on your learning style, budget and
time. A popular one is the Institute for Healthcare Improvement (IHI) Open School
(see resources), which also offers MOC Part 2 credit.
Step 2: Identify and prioritize potential opportunities to improve care
The changing health care environment provides numerous improvement opportunities.
Practices should prioritize areas for improvement, which may include family experience,
safety, access, medical partnerships/team communication, new technology use and evidence-based
practice. More opportunities exist than time, so identify a problem easy to measure
and important to the practice and patients. For example, a practice may be ready to
adopt telehealth to improve access or text messaging to improve adherence. Patients
and staff also can identify ideas for change.
Research existing measures. Much progress has occurred in developing quality measures
to address gaps in pediatric health care delivery (e.g., National Quality Forum and
Children’s Health Insurance Program Reauthorization Act Pediatric Quality Measures
Program). The AAP Quality Measurement webpage lists quality measures and implementation
tools for clinical practice guidelines. (See resources.)
The ABP now permits pediatricians under the AAP MOC Portfolio Program to receive MOC
Part 4 credit for small “home-grown” QI projects, tailored to the practice.
Step 3: Identify a solution for data collection, management and display
The burden of collecting, managing and displaying data creates a huge barrier to meaningful
engagement in QI. Practical solutions include abstracting data from the medical record
onto an electronic spreadsheet. However, this can be resource intensive. So, always
consider scoping the project to available data. Some practices can use data from electronic
health record or project registries (e.g., immunization database). Involving nonclinical
staff with data experience also helps. Information technology staff can determine
current data collection, data quality and access.
Simple data display is critical to assess interventions and to identify and mitigate
barriers. Data should be displayed over time (e.g., run chart or statistical process
control chart), indicating where interventions occurred.
Step 4: Improve quality
Quality improvement is a continuous process that usually begins on a small scale.
First, define the problem as clearly and narrowly as possible. Second, establish a
measurable aim for improvement. Third, develop and implement an intervention to meet
the aim. Finally, repeat assessments to see if improvements occurred and what changes
to the intervention are needed.
Many methods exist to set goals and monitor improvements, including the IHI (Plan,
Do, Study, Act) and Lean-Six Sigma (Define, Measure, Analysis, Improvement, Control).
Step 5: Don’t give up
Make sure accomplishments don’t fade away once you reach your goal. Health care systems
are complex social constructs and will always change quickly. Continue to measure
and reassess your interventions and assess new opportunities for improvement.
Step 6: Lead change
A way to have a lasting effect on improving the health care of children is to lead,
teach and mentor others. Greater attention to population health and changes in the
health care environment leads to greater reliance on teams. A pediatrician equipped
with QI experience is well-poised to lead these efforts.
Dr. Tieder is vice chair of the AAP Council on Quality Improvement and Patient Safety