Over the past 15 years, with alarming and illustrative reports released from the Institute of Medicine, quality improvement and patient safety have come to the forefront of medical care. This article reviews quality improvement frameworks and methodology and the use of evidence-based guidelines for pediatric emergency medicine. Top performance measures in pediatric emergency care are described, with examples of ongoing process and quality improvement work in our pediatric emergency department.
Key points
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During the 15 years since the Institute of Medicine report on errors in medical care, quality improvement and patient safety have become priorities in health care.
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Process and quality improvement should guide safe, effective, efficient, timely, patient-centered, and equitable care to patients.
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The framework of the Institute of Medicine’s domains of healthcare quality, the Donabedian categories, and the Acute Care Model all provide blueprints for change.
The Institute of Medicine’s call for improvement
During the last 15 years, quality improvement (QI) moved to the forefront of medical care in the United States. This focus started with the Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System . The IOM report described the many lives affected, and dollars lost, by flaws in health care systems.
A subsequent publication from the IOM defined quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. The IOM described 6 aims of quality to pursue in all health care settings:
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Effective: provide services based on scientific knowledge to all who can benefit and refrain from providing services to those not likely to benefit (avoiding underuse and overuse)
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Safe: avoid injuries to patients from the care that is intended to help them
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Efficient: avoid waste, in particular waste of equipment, supplies, ideas, and energy
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Timely: reduce sometimes harmful delays for both those who receive and those who give care
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Equitable: provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
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Patient-centered: provide care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions
In response to the call by the IOM for improvement in health care, the American College of Graduate Medical Education and the American Board of Pediatrics now require training and participation in QI work. It is important to recognize that, in the short term, many of those charged with teaching quality and safety science do not have formal training. Therefore, rapid acquisition of such science is required of all who answer the call of the IOM.
The Institute of Medicine’s call for improvement
During the last 15 years, quality improvement (QI) moved to the forefront of medical care in the United States. This focus started with the Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System . The IOM report described the many lives affected, and dollars lost, by flaws in health care systems.
A subsequent publication from the IOM defined quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. The IOM described 6 aims of quality to pursue in all health care settings:
- •
Effective: provide services based on scientific knowledge to all who can benefit and refrain from providing services to those not likely to benefit (avoiding underuse and overuse)
- •
Safe: avoid injuries to patients from the care that is intended to help them
- •
Efficient: avoid waste, in particular waste of equipment, supplies, ideas, and energy
- •
Timely: reduce sometimes harmful delays for both those who receive and those who give care
- •
Equitable: provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
- •
Patient-centered: provide care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions
In response to the call by the IOM for improvement in health care, the American College of Graduate Medical Education and the American Board of Pediatrics now require training and participation in QI work. It is important to recognize that, in the short term, many of those charged with teaching quality and safety science do not have formal training. Therefore, rapid acquisition of such science is required of all who answer the call of the IOM.
Quality improvement frameworks
At present, taking on the challenge of improving health care quality in a pediatric emergency department (ED) presents unique hurdles inherent to emergency care. Mahajan, from Children’s Hospital of Michigan, summarized the complexity of the chaotic ED setting, including the occurrence of multiple distractions (competing patient care priorities), incomplete information (some children present without family members to provide histories), and increasing ED patient volumes in many institutions in the United States. The IOM recognizes and draws attention to EDs being at a breaking point in these regards.
In an attempt to help bridge the gap between pediatric emergency medicine providers’ general lack of formal training in QI methodology and the expectation that pediatric emergency medicine providers be responsible for improving the quality of care in pediatric EDs, Dr Mahajan reviewed QI frameworks, terms, and tools inherent to QI methodology.
Three frameworks enable clinicians to understand, address, and evaluate QI efforts:
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The IOM’s 6 domains of health care quality
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Donabedian’s quality framework
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The Acute Care Model
The 6 domains of health care quality, as developed and described by the IOM, and listed earlier are effective, safe, efficient, timely, equitable, and patient-centered care. Categorizing QI endeavors into these domains is widely accepted and understood in the QI medical community. Many QI efforts cross categories. For example, improving the process to reduce pain in children with acute fractures addresses effective care, timely care, and patient-centered care.
The Donabedian quality framework categorizes QI work into 3 groups:
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Structure: the setting of care, including physical layout of the ED and available resources
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Process: the patient experience in the ED, such as pathway-guided care
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Outcomes: includes morbidity and mortality but also includes many other measures, such as frequency of antibiotic use or time metrics
The Donabedian categories are interrelated. Resources in play and the processes experienced by the patient may determine the outcome for a specific episode of care. The example of improving process to reduce pain in children with acute fractures is within the Process Donabedian framework, but affects the Outcome category as well.
The Acute Care Model was developed by Iyer and colleagues to address the complexity of a pediatric ED and to focus QI efforts. The model facilitates a detailed understanding of existing systems and helps to uncover areas of improvement, especially for ED flow. The Acute Care Model calls for adoption of a common language and an effort to improve 4 integrated components of acute care:
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Segmentation: patient triage based on severity of illness or injury. Several triage scores are used widely. For example, a common system is the 5-level tool called the Emergency Severity Index (ESI). The ESI is a validated ED triage score based on predicted resource consumption and length of stay in the department. In addition, several trauma scores are used to anticipate staffing and resources needed for patients with traumatic injuries.
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Therapeutic reliability: safe and effective treatment is provided in a timely manner and in a way that prevents deterioration. For example, an ED may have processes in place that prioritize a rapid response and provision of evidence-based therapies that optimize outcome for patients with asthma, anaphylaxis, or hyperbilirubinemia.
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Diagnostic accuracy: a correct diagnosis is made in a safe, effective, and efficient manner, particularly when a patient presents with undifferentiated illness.
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Disposition: correct disposition to home, hospital, or intensive care unit (ICU), or transfer to other facility is made with accuracy, minimizing return visits.
The Acute Care Model tracks each patient through the ED visit, from initial segmentation to disposition, with consideration of diagnostic accuracy and therapeutic reliability as often as needed. The model helps to frame and organize QI work in pediatric emergency medicine beyond the level of process mapping (examples of Acute Care Model organization are given in Ref. ). In brief, the model can be used to create pathways for clinically apparent illnesses with high illness severity, low variability in treatment, and high probability of admission, such as neonates with fever, children with severe asthma exacerbations, and febrile children with short gut syndrome or cancer.
Iyer and colleagues also describe core competencies required for the Acute Care Model to be successfully applied in emergency medicine QI:
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Appropriate segmentation of patients
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Appropriate and rigorous use of evidence for diagnostic accuracy and for therapeutic reliability
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Care systems with an emphasis on high reliability: preoccupation with failure, sensitivity to operations, resiliency, reluctance to simplify, and deference to expertise
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Organizational leadership that supports and sustains a culture of improvement by:
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Clearly communicating goals
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Sharing data transparently
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Providing system support that helps ED staff accomplish the stated goals
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Imposing clear consequences when goals are not achieved
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Quality improvement methods and tools
Methods used for QI vary based on the setting and desired outcomes. For pediatric emergency medicine, the Model for Improvement reference is the book by Langley and colleagues. This model asks 3 fundamental questions, followed by tests of change with plan-do-study-act (PDSA) cycles.
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What needs to be accomplished? That is, what is the purpose, goal, or aim of the project?
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How can it be determined that a change is an improvement? That is, what will be measured to show improvement (or lack of improvement)? There are 3 categories of measurement to be considered:
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Outcome measures: for example, reduction in pain score after early provision of a pain medication
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Process measures: for example, time from patient arrival to the provision of a pain medication
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Balance measures: an unexpected outcome, such as prolonged ED length of stay
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What change can be made that will result in an improvement? That is, what is the change idea to be tested?
The Model for Improvement can incorporate lessons learned from the process improvement approaches taken by high reliability organizations such as Six-sigma and Lean.
Briefly, Six-sigma process improvement methods organize the development of process improvement strategies into the DMAIC (define, measure, analyze, improve, and control) methodology to reduce variation :
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Define the problem
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Measure by collecting data
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Analyze the data and brainstorm solutions
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Improve the process by applying ideas
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Control performance by monitoring improvement
Lean process improvement methods focus on:
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Improved workflow
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Reducing waste
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Maximizing value-added processes
Again, once these sorts of methods are used, tests of change are then made by incorporating the PDSA cycle (discussed later).
Specific tools for quality improvement
Tools used in QI pursuits include process maps, failure modes and effects analyses (FMEAs), Pareto charts, key driver diagrams, PDSA cycles, run charts, and control charts. These tools help to identify specific areas for improvement, keep the plan focused, and track changes over time.
Process mapping is a process by which a problem is identified and a multidisciplinary group convenes to map the process around that problem. This can also be done by direct observation of the process, not only from the perspective of the patient, but also from the perspectives of involved health care providers. Typically, mapping of an entire process reveals elements of the process that may be enhanced or eliminated to improve overall performance.
An FMEA provides annotation to a process map by identifying elements of process that are at risk of failure (what could go wrong), identifying potential causes of a failure (why this could go wrong), and the consequences of the failure (what may happen if this goes wrong). Members of a multidisciplinary team ask themselves these 3 questions for each step in the process, and then identify possible interventions to reduce the occurrence of the failure. This tool helps the team plan a process improvement project by choosing 1 or a few possible interventions on which to act, and recording the outcomes as the project moves forward.
Pareto charts help QI teams prioritize possible interventions that may improve a process. Using baseline data, frequencies of failure are charted in order to provide a visual representation of the elements of the process to prioritize for change. Mahajan identified elements of a patient hand-off process that were often missing or not well communicated and found that although patient identifiers and history were most often included in the hand-offs, the information about consultants and special clinical equipment needs were not as frequently included. Using a Pareto chart to show the higher frequency of these two elements of failure, focused education could then be used to improve the patient hand-off process.
Key driver diagrams are another commonly used tool to help focus quality and process improvement efforts ( Fig. 1 ). A key driver diagram states the aim of the project and then lists all of the key drivers of the process. Key drivers are the factors that need to be in place in order for the aim to be achieved. Possible interventions are then identified to ensure that the key drivers are used in the process.
