The Children's Hospital of the Future: A Vision That Meets All Needs.

OBJECTIVES: The objective of this article is twofold. First, to present a comprehensive internal assessment of the hospital by different groups of stakeholders and, second, to determine whether there are common needs and wishes that, if incorporated in the hospital vision, will enable future development. BACKGROUND: The Children's Memorial Health Center is the largest children's hospital in Poland. The hospital began operations in 1977 with a vision to be a modern healthcare facility that provides comprehensive care for children. That vision has not changed over time but everything else did. METHODS: Six design thinking sessions were conducted with 83 employees and 40 respondents who used health services in the hospital in the past, along with in-depth interviews with 25 representatives of management to gather data for the hospital assessment. RESULTS: Sixty-three features influencing future development were identified. Seven groups of features were classified to be either transformation drivers (four groups) or enablers (three groups). We focused on features that were indicated by all groups of respondents to define a common vision for future development. CONCLUSIONS: Depending on the respondent's role in the healthcare ecosystem, the list of variables within each of seven groups defining the "hospital of the future" was different while evaluating the healthcare services. Therefore, all stakeholders must be engaged in the ideation process to create a strategy for a future care model driven by innovation.

Variation Between and Within Hospitals in Single Injection Caudal Local Anesthetic Dose: A Report From the Pediatric Regional Anesthesia Network.

BACKGROUND: Given that variation exists in health care utilization, expenditure, and medical practice, there is a paucity of data on variation within the practice of anesthesia. The Pediatric Regional Anesthesia Network (PRAN) data lend itself to explore whether different medical practice patterns exist and if there are nerve blocks with more local anesthetic dosing variation than others. The primary aim of this study was to quantify variation in single injection caudal block dosing, and the secondary aim was to explore possible causes for variation (eg, number of blocks performed versus geographic location). METHODS: We queried the PRAN database for single injection caudal blocks in children <1 year of age. Data were analyzed for local anesthetic dose, variation within and across institutions, and possible causes. RESULTS: Mean dose of bupivacaine equivalents per kilogram (BE·kg) among sites ranged from 1.39 to 2.22 with an interdecile range (IDR) containing the mid 80% of all doses ranging from 0.21 to 1.48. Mean dose (BE·kg) was associated with site, age, weight, and local anesthetic used (all P < .0001). Cohen's F effect size estimate was 10 times higher for site (0.65) than for age (0.05) or weight (0.02). Variation (IDR) was not related to number of blocks done at each site (P = .23). Mean volume per kilogram was 0.9± ± 0.2 (mean ± ±standard deviation) and was more strongly associated with site (Cohen's F 0.3) than age (0.04) or weight (0.07). CONCLUSIONS: Wide variation in caudal local anesthetic dosing and administered volume exists. This variation is independent of the number of cases performed at each center but rather is determined by study site (ie, variation between centers) with considerable additional variation within study centers, suggesting additional variability dependent on individual practitioners. While there are legitimate reasons to vary dosing, the current approach is inconsistent and not supported by strong evidence over giving a standardized dose.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Neonatal Jaundice: Improved Quality and Cost Savings After Implementation of a Standard Pathway.

OBJECTIVES: Seattle Children's Hospital sought to optimize the value equation for neonatal jaundice patients by creating a standard care pathway. METHODS: An evidence-based pathway for management of neonatal jaundice was created. This included multidisciplinary team assembly, comprehensive literature review, creation of a treatment algorithm and computer order sets, formulation of goals and metrics, roll-out of an education program for end users, and ongoing pathway improvement. The pathway was implemented on May 31, 2012. Quality metrics before and after implementation were compared. External data were used to analyze cost impacts. RESULTS: Significant improvements were achieved across multiple quality dimensions. Time to recovery decreased: mean length of stay was 1.30 days for 117 prepathway patients compared with 0.87 days for 69 postpathway patients (P < .001). Efficiency was enhanced: mean time to phototherapy initiation was 101.26 minutes for 14 prepathway patients compared with 54.67 minutes for 67 postpathway patients (P = .03). Care was less invasive: intravenous fluid orders were reduced from 80% to 44% (P < .001). Inpatient use was reduced: 66% of prepathway patients were admitted from the emergency department to inpatient care, compared with 50% of postpathway patients (P = .01). There was no increase in the readmission rate. These achievements translated to statistically significant cost reductions in total charges, as well as in the following categories: intravenous fluids, laboratory, room cost, and emergency department charges. CONCLUSIONS: An evidence-based standard care pathway for neonatal jaundice can significantly improve multiple dimensions of value, including reductions in cost and length of stay.

Student nurses experience of a "fairy garden" healing haven garden for sick children.

BACKGROUND: The concept and philosophy of healing environments in health care is not new and there has been recent research into the experience of nurses and families experience of healing environments producing positive outcomes in relieving stress and improving quality of life. However, there is little in-depth information about student nurse's experience of healing environments in support of patients. AIM: To report on the stories of student nurses who participated in formal and informal activities in a healing haven environment called a Fairy Garden (FG) within a hospital in northern Thailand. Their beliefs about the care of sick children in an environment designed to provide educational and recreational activity during hospital care are explored. METHODS: Narrative inquiry, a qualitative methodology was selected to capture the main threads of the participants' experience. Clandinin's narrative inquiry framework involving the three commonality dimensions of sociality, temporality and place were used in analysing the data. Sixty-two student nurses from a Thai College of Nursing and from an Australian university were interviewed. RESULTS: In this study the place of a FG has been investigated as a non-clinical environment providing sick children with exposure to nature, play activities and spaces to explore. Findings include three main threads: freedom to be a child not a sick child, engaging in care and professionalism, a moment in time of living fantasy. CONCLUSIONS: Student nurses in this study had a broader understanding of health care other than the biomedical model. It transformed their learning and opened their eyes to a more holistic approach to humanising care of sick children.

Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation.

BACKGROUND AND OBJECTIVE: Constipation is a common pediatric condition with a prevalence of 3% to 5% in children aged 4 to 17 years. Currently, there are no evidence-based guidelines for the management of pediatric patients hospitalized with constipation. The primary objective was to evaluate practice patterns and patient outcomes for the hospital management of functional constipation in US children's hospitals. METHODS: We conducted a multicenter, retrospective cohort study of children aged 0 to 18 years hospitalized for functional constipation from 2012 to 2014 by using the Pediatric Health Information System. Patients were included by using constipation and other related diagnoses as classified by International Classification of Diseases, Ninth Revision. Patients with complex chronic conditions were excluded. Outcome measures included percentage of hospitalizations due to functional constipation, therapies used, length of stay, and 90-day readmission rates. Statistical analysis included means with 95% confidence intervals for individual hospital outcomes. RESULTS: A total of 14 243 hospitalizations were included, representing 12 804 unique patients. The overall percentage of hospitalizations due to functional constipation was 0.65% (range: 0.19%-1.41%, P < .0001). The percentage of patients receiving the following treatment during their hospitalization included: electrolyte laxatives: 40% to 96%; sodium phosphate enema: 0% to 64%; mineral oil enema: 0% to 61%; glycerin suppository: 0% to 37%; bisacodyl 0% to 47%; senna: 0% to 23%; and docusate 0% to 11%. Mean length of stay was 1.97 days (range: 1.31-2.73 days, P < .0001). Mean 90-day readmission rate was 3.78% (range: 0.95%-7.53%, P < .0001). CONCLUSIONS: There is significant variation in practice patterns and clinical outcomes for pediatric patients hospitalized with functional constipation across US children's hospitals. Collaborative initiatives to adopt evidence-based best practices guidelines could help standardize the hospital management of pediatric functional constipation.

Instituto Pediátrico del Corazón / Pediatric Health Institute

En el año 2001, se constituye el Instituto Pediátrico del Corazón (IPC) con el fin de integrar a cardiólogos pediátricos y cirujanos cardiacos en una unidad multidisciplinar dedicada a la atención integral del paciente con cardiopatía congénita. Esto incluye la atención a pacientes desde el periodo fetal hasta la edad adulta y requiere de una estrecha colaboración con intensivistas pediátricos, anestesiólogos, obstetras y cardiólogos de adultos. El crecimiento y la calidad de la actividad asistencial, investigadora y docente de esta unidad en los últimos años, la ha llevado a ser designada como unidad de referencia a nivel nacional (CSUR) para el tratamiento de neonatos y niños con cardiopatías congénitas así como para el tratamiento de la hipertensión pulmonar compleja (AU)

In the year 2001, the Pediatric Heart Institute (PHI) was formed in order to integrate pediatric cardiologists and heart surgeons into a multidisciplinary unit dedicated to the comprehensive care of the patient with congenital heart disease. This includes patient care from the fetal period up to the adult age and requires close collaboration by the pediatric intensive care physicians, anesthesiologists, adult cardiologist and obstetricians. The growth and quality of the care, investigator and teaching activity of this unit in recent years has led it to being designated as Reference Centers, Services and Units (CSUR by its acronym in Spanish) on the national level for the treatment of newborn and children with congenital heart disease and for the treatment of complex pulmonary hypertension (AU)

La Sección de Hospitalaización de Pediatría del Hospital Materno Infantil Gregorio Marañón en 2016 / Pediatric Hospitalization Section of the Hospital Materno Infantil Gregorio Marañón in 2016

Entre los objetivos principales de la hospitalización pediátrica en un hospital terciario se incluyen el cuidado integral de los pacientes pediátricos ingresados incluyendo aspectos diagnósticos, curativos, preventivos y de rehabilitación. La Academia Americana de Pediatría reconoció hace más de 20 años la importancia y el papel crucial de los programas de hospitalización pediátrica. Así, la Pediatría General en un hospital terciario juega un papel muy importante en el cuidado agudo de pacientes pediátricos con patologías prevalentes, pero también como coordinador e integrador del cuidado de pacientes crónicos y de alta complejidad. También creemos que la Pediatría General en un hospital terciario tiene la responsabilidad de desarrollar los programas de calidad, implantar una cultura de seguridad en Pediatría, promover protocolos y guías clínicas en patologías prevalentes, ser referentes en la educación de los familiares de nuestros pacientes así como desarrollar los programas de e-health y cooperación internacional (AU)

The main objectives of the Pediatric Hospitalist Programs within a Tertiary Hospital include comprehensive care to hospitalized pediatric patients in diagnostic, curative, preventive, and rehabilitation aspects. The American Academy of Pediatrics recognized about 20 years ago, the importance and the key role of Pediatrics Hospitalist programs. General Pediatrics plays an important role not only for the care in acute prevalent pathologies, but also as a coordinator and integrator in chronic and highly complex patients. We also believe that General Pediatrics at a Third level hospital, has the responsibility to develop quality programs, implement safety culture in hospitalized patients, promote protocols and clinical guidelines in prevalent pathologies, health education in our population, and developing e-health and international cooperation programs (AU)

A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures.

BACKGROUND AND OBJECTIVE: Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures. METHODS: We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database. RESULTS: We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%. CONCLUSIONS: We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.

Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference.

BACKGROUND/PURPOSE: The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care. METHODS: A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items. RESULTS: Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training. CONCLUSIONS: Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.

Child- and family-centered care in the treatment of children - knowledge, attitudes, practice.

Despite the advances in medical technology, health care improvements have not always been accompanied by commensurate attention to the child's well-being. Psychological and emotional status of children during hospital treatment is often underestimated. Namely, certain kind of institutional negligence is frequently present in everyday practice in children's institutions. Many hospitals in Bosnia and Herzegovina (B&H) have become child-friendly during the implementation of the Project on Child-Friendly Hospitals supported by UNICEF and WHO. Apart from the introduction of child friendly environment, staff in hospitals was trained to provide a holistic approach. The program was closely linked to the Baby Friendly Hospital Initiative that supported breastfeeding. A few years thereafter, our focus is still on the physical treatment of sick children, whereas the attention to their anxieties, fears and suffering has failed. A more serious approach to this problem is needed and should begin at an educational level in medical school programs. Accordingly, our philosophy (mission) should change from a mechanical (techno-) medicine to holistic medicine.

Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes.

BACKGROUND: Pediatric hospitalist systems are increasing in popularity, but data regarding the effects of hospitalist systems on the quality of care has been sparse, in part because rigorous metrics for analysis have not yet been established. We conducted a literature review of studies comparing the performance of pediatric hospitalists and traditional attendings. OBJECTIVE: To determine the effect of pediatric hospitalists on quality and outcome metrics such as length of stay, cost, patient satisfaction, mortality, readmission rates, and use of evidence-based medicine during care. RESULTS: A Medline literature search identified 11 studies that met criteria for inclusion. Five previously reviewed studies reported lengths of stay between 6% and 14% shorter for hospitalists. Five of the new studies evaluated lengths of stay, with 1 showing significantly lower length of stay and cost for a faculty model, 1 showing lower length of stay for hospitalists for all conditions, 1 for certain conditions only, and 2 showing no statistical difference. Six studies reported on readmission rate, with 4 showing no difference, 1 showing decreased readmissions for hospitalists, and 1 showing decreased readmissions for a traditional faculty service. Hospitalists self-report higher use of evidence-based guidelines. Few differences in patient satisfaction were reported. Mortality on the pediatrics wards is rare, and no studies were adequately powered to evaluate mortality rate. CONCLUSION: Hospitalists can improve the quality and efficiency of inpatient care in the pediatric population, but the effect is not universal, and mechanisms underlying demonstrated improvements are poorly understood. We propose 4 components to improve quality and value in hospital medicine systems: investment in comparative effectiveness research involving delivery system interventions, development and implementation of pediatric quality measures, better understanding of improvement mechanisms for hospital medicine systems, and increased focus on quality and value delivered by hospital medicine groups and individuals.

Provider attitudes toward Standardized Clinical Assessment and Management Plans (SCAMPs).

INTRODUCTION: Despite the growing importance of clinical guidelines, their adoption has encountered significant resistance among clinicians. We developed Standardized Clinical Assessment and Management Plans (SCAMPs) as an innovative, clinician-led approach to building, implementing, and constantly improving flexible guidelines. We hypothesized that SCAMPs would fit well within the culture of medicine and that clinicians would therefore prefer SCAMPs over other guidelines. METHODS: We implemented an anonymous, computer-based survey to analyze provider attitudes toward SCAMPs at our institution. RESULTS: Sixty-nine providers completed the questionnaire (73% response rate). Most providers reported a positive opinion about SCAMPs along axes of overall familiarity (83%), trust (91-94%), utility (75-87%), and overall attitude (64%). Fewer providers felt familiar with the SCAMP improvement process (60% neutral to unfamiliar) or knew that they played a role in this process (62% said no or unsure). Sixty-five percent reported experiencing an erosion in their autonomy with SCAMPs; when comparing this to other guidelines, 38% said other guidelines erode more, 26% felt SCAMPs erode more, and 36% were neutral. The plurality of providers chose SCAMPs as their preferred means to incorporate evidence-based medicine into their practice (46% vs 29% for clinical practice guidelines, 25% for other guidelines). CONCLUSION: Providers look upon SCAMPs favorably and believe that SCAMPs successfully address numerous barriers to guideline adoption. Furthermore, SCAMPs are the preferred means to incorporate evidence-based medicine into practice among providers surveyed. SCAMPs may represent an important step in building guidelines that fit into the culture of medicine, obtain clinician "buy-in," and better influence clinical decision making.

A novel approach to gathering and acting on relevant clinical information: SCAMPs.

The current tools to adequately inform the process of improving health-care delivery consist primarily of retrospective studies, prospective trials, and clinical practice guidelines. We propose a novel and systematic approach that bridges the gap of our current tools to affect change, provides an infrastructure to improve health-care delivery, and identifies unnecessary resource utilization. The objective of this special article is to introduce the rationale and methods for this endeavor entitled "Standardized Clinical Assessment and Management Plans" (SCAMPs). SCAMPs take a relatively heterogeneous patient population and through a process of iterative analysis and modification of standardized assessment and management algorithms, SCAMPs allow the intrinsic biologic variability in a patient population to emerge and be understood. SCAMPs can be used to complement our currently available tools in order to result in incremental and sustained improvement in health-care delivery.

Complementary and alternative therapies: survey of knowledge and attitudes of health professionals at a tertiary pediatric/women's care facility.

Nurses, physicians, and allied health professionals at the IWK Health Centre, Halifax, NS, Canada, a tertiary care, regional center for a population of 2.5 million were surveyed. We examined personal attitudes and professional practice in addressing the use of complementary and alternative medicine (CAM) use by patients. We also examined the availability of CAM-related information to health professionals. The findings suggest that health professionals: (1) are supportive of the use of selected CAM therapies by patients; (2) have almost no personal experience of CAM; (3) have limited knowledge about CAM and acquire that information mainly from the Internet, friends or family rather than professional journals; (4) are uncomfortable discussing CAM with patients and; (5) rarely or never ask patients about CAM use. We have identified barriers for health professionals to effective communication about CAM use by their patients and families. Improved access to existing policies and scientific publications, and specific continuing professional development opportunities focused on speaking openly and non-judgmentally with patients are likely to enhance accurate guidance of patients in the highly prevalent use of CAM.

Cincinnati Children's Hospital Medical Center: transforming care for children and families.

BACKGROUND: Cincinnati Children's Hospital Medical Center pursues its vision to be the leader in improving child health through the creation of new knowledge, education of professionals and the community, and transformation of our health care delivery system. OVERALL APPROACH TO QUALITY AND SAFETY: The strategic plan focuses on achieving the best medical and quality of life outcomes, patient and family experience of care, and value through horizontal integration of research and delivery system design, thereby accelerating the transfer of new knowledge to the bedside. CREATING QUALITY FROM THE FAMILY PERSPECTIVE: Family members and patients participate at all levels of the organization, from the organizationwide family advisory council, to unit-based inpatient teams, to serving as family faculty who teach pediatric residents and orient new employees. Family members ensure that children's and parents' voices are heard. DISCUSSION: Key factors contributing to ongoing transformation include senior leaders' drive for change, focus on perfection or near-perfection goals, vertical alignment in measures, accountability, improvement capability, commitment to internal and external transparency, and focus on measurement and constancy of purpose.

Integration of complementary and alternative medicine in a major pediatric teaching hospital: an initial overview.

OBJECTIVE: To describe the establishment of a multidisciplinary team of complementary and alternative medicine (CAM) providers and educators in an urban pediatric hospital and affiliated medical school. BACKGROUND: Pediatric CAM use is increasing. Physicians are interested in CAM-related education but few programs had been developed in pediatrics. In 1998, Children's Hospital Boston established the Center for Holistic Pediatric Education and Research (CHPER), a CAM multidisciplinary team providing clinical services, education, and research. METHOD: A retrospective review describing data from patient consultation notes, CAM lectures, clinical practice guidelines, curriculum materials, team meeting minutes, and team member manuscripts and publications. RESULTS: Over 5.5 years, CHPER staff provided over 2100 consults: acupuncture, massage, holistic pediatrician, relaxation therapies, biofeedback, hypnosis, and bio-pharmaceutics. Acupuncture and massage therapies were incorporated into a Clinical Practice Guideline. Formal education was delivered through didactic sessions, workshops, self-learning modules, clinical observation, and clinical practice. CHPER faculty published 1 book and 64 articles on CAM-related topics. CONCLUSION: An interdisciplinary team of CAM clinicians and educators can be integrated into an urban pediatric teaching hospital to provide CAM medical education and clinical services.

Pediatric hematology and oncology in Iran.

UNLABELLED: Pediatric hematology and oncology (PHO) is a rapidly expandingfield. It has been our goal to meet the needs and increasing demands for comprehensive medical care of children suffering from chronic blood diseases and malignancies. In the past decade we have been able expand and optimize the PHO services throughout Iran, in general and in respect to their prevalence and clinical importance, by trained pediatric hematologist-oncologists, pediatric surgeons and improved para clinical facilities. Major beta-thalassemics receive blood transfusion and chelation therapy according to the current standards mostly at regional blood banks centers. To curb major beta-thalassemia a premarital screening program has been enacted and abortion has been legitimized if major thalassemia is diagnosed by CVS. Hemophiliacs are supervised and treated as indicated by Iranian Hemophilia Comprehensive Care Centers (IHCCC). Screening for transfusion related complications and transmitted viral diseases (HBV, HCV and HIV) in both cohorts are carried out in regular intervals and necessary management will be then carried out as indicated at respective specialized units. Childhood malignancies are treated according to protocols adopted from accredited institutions in the USA and Europe, with almost comparable results. BMT is available for selected patients with beta-thalassemia or malignancies. By going to public we have been able to rise general awareness about chronic blood diseases and childhood malignancies and have initiated establishment of parents groups and formation of NGOs to support these children and their families. Foundation of Iranian Society of Pediatric Hamatology and Oncology (ISPHO) in the year 2000 has been another step forward to consolidate and coordinate the available manpower and facilities. CONCLUSION: By evaluation of the country's main problems and shortcomings and conduction of collaborative studies and operation planning one will succeed to get the expected feedback and scientifically based approach to provide medical services to far reaching underdeveloped regions.