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?

asthma Children with asthma who have a written asthma-management plan

the indicator states how many asthma patients have received an asthma education and a clear written concept what to do if their gets worse

Written asthma-management plan is handed out and available

all children of the facility with diagnosed asthma (ICD 10: J45)

indicator subject

indicator statement

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.

indicator explanation indicator numerator indicator denominator

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

88 MEDLINE Y 44 EMBASE selected Readings done by 6 colleagues

Input to the Public Health Institute Witten / Herdecke University

Two reviewers independently analyzed the abstracts

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 1 Prescriptions 1 Psychosis 1 Supervision 1 Thyroid Function

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 17 677,678,680,681,679,1065,707,706,737,676,641,642,634,635,619,629,1066

Practice Management

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,

1150,1148,1151,1127,1050,1040,743,742,741,697,698,699,694,257,256,250,240,85,

5 Migraine 58,57,431,430,429

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

Pneumonia 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 Otitis Pneumonia Chronic 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 Publication

Public National adaptation for training, CME, peer review, benchmarking