Quality in Primary Pediatric Care How can we improve?

Quality in Primary Pediatric Care How can we improve?

Tolerate all the diversity, variability and errors? Who is the best provider? But we do not know what he does We do not know what GPs / nurses do because we cannot be everywhere What is best for children? Clear concept? Gap between desired performance and reality We all want to compare and improve

can be defined as the degree to which health services for infants and adolescents increase the likelihood of improved health outcomes and are consistent with current professional knowledge (adapted from Donabedian 1987)

They describe the best and consistent performance and processes delivered by of the pediatric team for children and adolescents under the given circumstances ( adopted with minor changes from Jan Mainz 2003) Examples?

indicator subject indicator statement indicator explanation indicator numerator indicator denominator asthma Children with the indicator states how asthma who many asthma patients have a have received an asthma written education and a clear asthmamanagement do if their gets worse written concept what to plan Written asthmamanagement plan is handed out and available all children of the facility with diagnosed asthma (ICD 10: J45)

indicator explanation indicator numerator indicator denominator Developmental Screening by 2 Years of Age. The percentage of children who turned 2 years old during the measurement year who had a developmental screening performed between 12 and 24 months of age. Children who had documentation in the medical record of a developmental screening (screening for risk of developmental, behavioral and social delays) between 12 and 24 months of age. Screening must be conducted using a standardized tool. Children with a visit who turned 2 years of age between January 1 and December 31 of the measurement year.

Evidence based Validity -> should measure what it is intended to measure Reliable -> repeated measurements should show stable results

COSI EAP Development of a core set of indicators for the medical care of children and adolescents in Europe A Where do we come from? B What do we have in our hands? C Where do we go? D How can you participate?

Aims Set up of a indicators databank after systematic literature review for existing indicators and public sources as knowledge base Selection of a small number of performance indicators for ambulatory primary child care with broad consensus by European pediatricians and other experts ( panel workshops )

Initial findings EMBASE 77 MEDLINE 466 Two reviewers independently analyzed the abstracts 88 MEDLINE Y 44 EMBASE selected Readings done by 6 colleagues Input to the Public Health Institute Witten / Herdecke University

Agency for Healthcare Research and Quality (AHRQ) [USA] National Quality Measures Clearinghouse (NQMC) National Advisory Council on Healthcare Research and Quality Subcommittee (SNAC)-recommended Initial Core Set on Children's Healthcare Quality Measures for Medicaid and Children's Health Insurance Program (CHIP) (voluntary use) The Ambulatory Care Quality Alliance (AQA) RAND [USA] National Quality Forum [USA] Center for quality assessment and improvement in mental health (CQAIMH) [USA] National Health Service (NHS) Quality and Outcomes Framework (QOF) [UK] District Health Board New Zealand (DHBNZ) [NZ] National Association of Statutory Health Insurance Physicians (NASHIP) Ambulatory Quality Indicators and Key Measures (AQUIK ) [GER] The National Association of Statutory Health Insurance Funds Quality Indicator Thesaurus (QUINTH) [GER]

Pediatric office Acute care Management of chronic patients Prevention Screening Early detection Adolescent health Integration of services Child and friendly health care

146 Office preparedness emergencies 106 Asthma 92 Immunization 83 Preventive and Developmental Services 67 ADHD 67 Emergency Department Care for Children 64 Examination 64 Patient s Satisfaction 47 Diarrhea and gastroenteritis 47 Fever in children under 3 years of age 44 Diabetes 43 respiratory infection 34 Screening 32 Epilepsy 31 Education and Training 31 HIV 31 paediatric prescriptions 30 Parents Perceptions 28 major depressive disorder 24 Vaginitis/ sexually transmitted diseases 22 urinary tract infection 19 Pelvic Inflammatory Disease 18 Otitis media 16 Tuberculosis 14 Equipment 14 patient records 14 Speech and language function 13 Practice Management 13 Service provided 12 patient safety 11 continuity of care 11 History 10 Acne 10 maternal and child care 10 Racial and Ethnic Disparities 9 Mental Health Impairment 8 Formation 8 Malaria 8 Medicines Management 8 Protocols and Guidelines 8 Quality and Productivity 7 Domestic violence 7 Nutrition 6 Accessibility 6 Acute otitis externa 6 Chronic Illness 5 Allergic Rhinitis 5 melanoma 5 Preoperative evaluation 5 Well-child care 4 Access 4 Family Planning/ Contraception 3 End stage renal disease (ESRD) 3 Cerebral Palsy 3 Laboratory 3 Migraine/ Headache 3 Rheumatoid arthritis 2 Alcohol and other drug (AOD) 2 Classification 2 Dehydration 2 Follow up 2 Information for Patients 2 Obesity 2 radionuclide bone imaging 1 Acute Phase Response 1 Adolescent preventive services 1 Anaemia 1 Antibiotic untilization 1 Chronic Pain 1 Depression 1 medication patient safety 1 Pneumonia

Reduction of the number of indicators using criteria as feasability, evidence, relevance, appropriateness Deletion of clinical based indicators and duplicities Grouping the indicators in a frame of domains Final preselection in May 2012 131 QI out of 1516 Core group: J. Ruiz, B.Wettergren Elke Jäger- Roman, D. Ewald, I. Butienne, A. Carrazco, A. Tenore, I. Winnicki, Yona Amitai DGAAP: V. Fehr, K. Geitmann, N. Kniess, S. Nolte, Laub

Domains 131 Preselected QI May 2012 Pediatric Office Practice Management 17 677,678,680,681,679,1065,707,706,737,676,641,642,634,635,619,629,1066 Well Child Care 26 28,26,176,177,224,336,337,335,334,332,333,588,589,590,604,650,684,689,690,691,710,723,727,728,729 Prevention, Screening 8 Smoking prevention and cessation: 711,195,193,682,683,225,232 3 Injury prevention: 599,211,212 Youth 7 735,721,214,208,207,206,205, Immunization 12 24,448,673,687,732,194,459,464,467,674,685,686 Acute care- 3 Fever 1260,414,397 acute diseases 11 Diarrhea 356,357,358,360,367,87,368,89,371,370,369 5 Urinay tract infection 1262,549,537,548,551, 6 URI, Pharyngitis 8,70,7,519,527,531 Chronic 28 Asthma 248,238,237,1202,1257,1201,1208,1209,1210, 5 Migraine 58,57,431,430,429 1150,1148,1151,1127,1050,1040,743,742,741,697,698,699,694,257,256,250,240,85,

Domains t QI Topics comments Godfather expert Pediatric Office 17 Documentation, records 3 Practice Management Patient satisfaction survey 1 Diagnostic equipment - maintenance- hygiene missing Access, home visits for disabled 1 incomplete Recall management 1 Emergency training 1 incomplete Error prevention, complaints, event review 2 incomplete DE Drug management, prescriptions, interactions 6 incomplete DE Vaccination administration error prevention missing DE Safe paediatric office missing DE Child friendly office and procedures missing DE Well Child Care 26 Weight, length, head, BMI many good QI Prevention development, fine-gross motor, language, Screening hearing, vision, hip dysplasia Injury prevention 3 incomplete AN Smoking prevention, cessation 8 Newborn hearing screening missing Newborn metabolic screening missing EJR Youth 7 many missing topics Immunization 12 adaptation Acute care- 3 Fever 3 incomplete Acute diseases 11 Diarrhea 11 complete 5 Urinay tract infection 5 incomplete 6 URI, Pharyngitis 6 incomplete Otitis missing Pneumoni a missing Chronic 28 Asthma 28 rather complete GH 5 Migraine 5 incomplete Diabetes none selected AT Epilepsy none selected ADHD none selected Integration Team- work missing LS

Diagnostic equipment - maintenance- hygiene Error prevention, complaints, event review Drug management, prescriptions, interactions Vaccination administration error prevention Safe paediatric office Child friendly office and procedures

Screenings: Hip dysplasia Newborn hearing screening Newborn metabolic screening Other screenings Adolescent medicine Youth-friendly services

Acute Chronic Otitis Pneumonia Migraine Diabetes Epilepsy ADHD Integration Team- work

Write your name and corresponding chapter of interest in the list Search the literature and/ or international guidelines and find suitable performance indicators - not health indicators Fill in the form possibly with all necessary items until end of summer 2012 bibliographic source author indicator subject indicator statement indicator numerator indicator denominator indicator evidence

A 2010 Project Planning Consultancy on AQUIK methodology 2011 Writing of EU grant proposal Literature review 2011 Consultancy indicator database University Witten financed by EAP 2012 Workshop Presentation of database and literature Brussels Confirmation of active COSI Core group, pre- selection Reduction of the number of indicators to 131 Clustering of QIs Identification of areas missing Recruitment of experts finding and generating missing Qis Refining format and formulation of Qis 2012 Pilot formal rating of QIs among EAP and ECPCP delegates B 2013 To scale : Implementation of panel expert consensus workshops 2013 Definition of core set of indicators and standards C Public Publication National adaptation for training, CME, peer review, benchmarking