Physician professionalism and accountability: the role of collaborative improvement networks.

The medical profession is facing an imperative to deliver more patient-centered care, improve quality, and reduce unnecessary costs and waste. With significant unexplained variation in resource use and outcomes, even physicians and health care organizations with "the best" reputations cannot assume they always deliver the best care possible. Going forward, physicians will need to demonstrate professionalism and accountability in a different way: to their peers, to society in general, and to individual patients. The new accountability includes quality and clinical outcomes but also resource utilization, appropriateness and patient-centeredness of recommended care, and the responsibility to help improve systems of care. The pediatric collaborative improvement network model represents an important framework for helping transform health care. For individual physicians, participation in a multisite network offers the opportunity to demonstrate accountability by measuring and improving care as part of an approach that addresses the problems of small sample size, attribution, and unnecessary variation in care by pooling patients from individual practices and requiring standardization of care to participate. For patients and families, the model helps ensure that they are likely to receive the current best evidence-based recommendation. Finally, this model aligns with payers' goals of purchasing value-based care, rewarding quality and improvement, and reducing unnecessary variation around current best evidenced-based, effective, and efficient care. In addition, within the profession, the American Board of Pediatrics recognizes participation in a multisite quality improvement network as one of the most rigorous and meaningful approaches for a diplomate to meet practice performance maintenance of certification requirements.

A new framework for quality partnerships in Children's Hospitals.

Children's hospitals and their affiliated departments of pediatrics often pursue separate programs in quality and safety; by integrating these programs, they can accelerate progress. Hospital executives and pediatric department chairs from 14 children's hospitals have been exploring practical approaches for integrating quality programs. Three components provide focus: (1) alignment of quality priorities and resources across the organizations; (2) education and training for physicians in the science of improvement; and (3) professional development and career progression for physicians in recognition of quality-improvement activities. Process and resource requirements are identified for each component, and specific, actionable steps are identified. The action steps are arrayed on a continuum from basic to advanced integration. The resulting matrix serves as an "integration framework," useful to a hospital and its pediatric academic department at any stage of integration for assessing its current state, plotting a path toward further integration, tracking its progress, and identifying potential collaborators and models of advanced integration. The framework contributes to health care's quality-improvement movement in multiple ways: it addresses a basic impediment to quality and safety improvement; it is an implementable model for integrating quality programs; it offers career-advancement potential for physicians interested in quality; it helps optimize investments in quality and safety; and it can be applied both within a single children's hospital and across multiple children's hospitals. Widespread adoption of the integration framework could have a transformative effect on the children's hospital sector, not the least of which is improved quality and safety on a large scale.

Management patterns of childhood-onset nephrotic syndrome.

As an initial effort to identify opportunities to improve the management of children with nephrotic syndrome, the goal of this study was to assess the present-day management of children with primary nephrotic syndrome. A web-based survey was designed to assess the current management styles of all pediatric nephrology faculties at ten participating institutions. Ninety-one percent completed the initial survey. The duration of initial glucocorticoid therapy ranged from 4 to 24 weeks. Physicians reported that the recommendation for kidney biopsy was dependent on the response to initial corticosteroid therapy, with the minority always recommending a biopsy for frequently relapsing or steroid-dependent cases. All responding physicians recommended a kidney biopsy in steroid-resistant cases. Treatment strategies were reported to vary based upon the steroid response pattern and, where available, kidney histopathology. Striking variations in therapeutic preferences were described when alternatives to glucocorticoids were considered. The variability of management practices among pediatric nephrologists in the USA combined with the changing characteristics of our pediatric population raise concerns about our future strategies for improving healthcare for children coping with nephrotic syndrome. This variability is not unique to children's healthcare or to nephrology. However, a systematic approach to patient care and improvement in health outcomes has been shown to substantially improve morbidity and mortality outcomes in children with chronic health conditions.

Maintenance of Certification: the role of the American Board of Pediatrics in improving children's health care.

This article describes the evolution of board certification for pediatricians and the current ongoing assessment process called Maintenance of Certification (MOC). To be called a board-certified pediatrician under the MOC framework requires a level of training, competence, and knowledge that can only be achieved by completing a rigorous, defined, closely monitored training program approved by the Accreditation Council for Graduate Medical Education and then demonstrating a level of knowledge comparable to established standards by passing the initial certifying examination. Once this landmark baseline threshold is reached, the emphasis shifts to demonstrating lifelong professional development and the ability to deliver quality care and to continually improving that care through MOC.

Alliance for pediatric quality: creating a community of practice to improve health care for America's children.

On any given day, hundreds of physicians, nurses, informaticists, health information management directors, and other health care providers are collaborating on how to improve health information technology systems for use in child health care. Many work in small communities of practice to share ideas, to find solutions, and to build innovations that support the goal of making electronic health record systems accessible by 2014. Together, they are a formidable virtual community aligned around a common strategy, to ensure that health information technology works for children. Each member in the community represents a children's hospital or pediatric practice affiliated with one of the 4 major national pediatric organizations that constitute the Alliance for Pediatric Quality. The alliance works with the pediatric health information technology community to speed the adoption of pediatric data standards and to define data collection and reporting systems that would work for both quality improvement and electronic health record systems. With this foundation, hospitals and physicians should be better positioned to improve the quality of health care for US children by implementing technology equipped to care for children, actively participating in improvement initiatives, conducting meaningful measurement of care, and appropriately reporting for accountability.

A continuum of competency assessment: the potential for reciprocal use of the Accreditation Council for Graduate Medical Education toolbox and the components of the American Board of Pediatrics Maintenance-of-Certification Program.

Reduction of unexplained variation in medical practice and health outcomes is of paramount importance, which indicates a need for a continuum of medical learning that begins in medical school and continues until the end of a professional career. That, in turn, indicates need for continuing assessment of professional competence. The American Board of Pediatrics, the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education are working together to develop a common approach to documenting acquisition of competence during residency and maintenance of competence thereafter. A common approach will eliminate redundancy and make it possible to follow the evolution of professional competence over time.

Pediatric recertification and quality of care: the role of the American Board of Pediatrics in improving children's health care.

American health care is in the middle of a second revolution in quality as profound as the Flexner revolution occurring almost 100 years ago. Although systems issues are the basis for most of the concern, physician quality and professional development are also pertinent. Specialty board certification and maintenance of certification are key drivers of professional development and improvement of care.

Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies.

BACKGROUND: In 2001, the Institute of Medicine (IOM) recommended six Aims f or Improvement; the dimensions of quality describe a health care system that is safe, timely, effective, efficient, equitable, and patient centered. In 1999, the Accreditation Council of Graduate Medical Education (ACGME) adopted six core competencies that physicians in training must master if they are to provide quality care. A Healthcare Matrix was developed that links the IOM aims for improvement and the six ACGME Core Competencies. The matrix provides a blueprint to help residents to learn the core competencies in patient care, and to help faculty to link mastery of the competencies with improvement in quality of care. HEALTHCARE MATRIX: The Healthcare Matrix is a conceptual framework that projects an episode of care as an interaction between quality outcomes and the skills, knowledge, and attitudes (core competencies) necessary to affect those outcomes. For example, an anesthesiology resident used the Healthcare Matrix for a complex 18-hour episode of care with a life-threatening situation. ONGOING WORK AND RESEARCH AGENDA: Collecting and analyzing a series of matrices provides the foundation for systematic change in patient care and medical education and a rich source of data for operational and improvement research.

A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review.

PURPOSE: To create a framework for teaching the knowledge and skills of practice-based learning and improvement to medical students and residents based on proven, effective strategies. METHOD: The authors conducted a Medline search of English-language articles published between 1996 and May 2001, using the term "quality improvement" (QI), and cross-matched it with "medical education" and "health professions education." A thematic-synthesis method of review was used to compile the information from the articles. Based on the literature review, an expert panel recommended educational objectives for practice-based learning and improvement. RESULTS: Twenty-seven articles met the inclusion criteria. The majority of studies were conducted in academic medical centers and medical schools and 40% addressed experiential learning of QI. More than 75% were qualitative case reports capturing educational outcomes, and 7% included an experimental study design. The expert panel integrated data from the literature review with the Dreyfus model of professional skill acquisition, the Institute for Healthcare Improvement's (IHI) knowledge domains for improving health care, and the ACGME competencies and generated a framework of core educational objectives about teaching practice-based learning and improvement to medical students and residents. CONCLUSION: Teaching the knowledge and skills of practice-based learning and improvement to medical students and residents is a necessary and important foundation for improving patient care. The authors present a framework of learning objectives-informed by the literature and synthesized by the expert panel-to assist educational leaders when integrating these objectives into a curriculum. This framework serves as a blueprint to bridge the gap between current knowledge and future practice needs.