With the current focus in hospital medicine on quality and reporting quality measures, you don’t hear much about pediatric patients. What’s happening with quality and children?
In “Pediatric Hospitalist Quality Forum: Standards, Reporting and Improvement,” Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego, Calif., and Lakshmi Halasyamani, MD, assistant chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich., provided an overview of what’s happening in pediatric quality of care and strategies for organizational and clinical improvement.
“The pediatric quality landscape is emerging, and you have a tremendous opportunity to help shape that landscape,” Dr. Stucky told the audience of hospitalist-pediatricians.
Dr. Halasyamani provided an overview of national organizations that are implementing quality indicators for hospitalized adult patients, from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to the Hospital Quality Alliance to the Institute for Healthcare Improvement. These groups and others have shown some interest in pediatric-specific quality initiatives, but “organizations are trying to coordinate things,” explained Dr. Stucky. “We can’t let the local efforts die while we’re focusing on the national level.”
QI at the Local Level
There are steps a hospitalist can take to improve quality and safety at his or her hospital.
“What can you do?” asked Dr. Halasyamani. The most obvious thing is to continue your education by pursuing CMEs, classes, and workshops in relevant areas. You can improve physician awareness, which forces everyone to look at the bigger picture. But this alone may not change behaviors. At a process and systems level, implementing a multidisciplinary team is a good step. “And you must dispel the myth that to be more effective, it has to be more difficult,” added Dr. Halasyamani.
Elements of success, or sustainability, for a quality improvement (QI) effort include establishing absolute team clarity and unity on goals, ensuring you have the organizational support to eliminate any barriers, and a built-in measurement system for what you’re trying to demonstrate. You’ll need organizational structures for your project to recruit your team, as well as a clear reporting structure. “Make sure the stakeholders are at the table,” advised Dr. Halasyamani.
—Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego
A Case Study
The presenters supplied a local example of a QI initiative hospitalists can follow. Dr. Stucky outlined an asthma QI project her hospitalist-led team had undertaken.
Her team reviews their algorithms every six to 12 months. “Even if review says what we’re doing is good, we still need to look at it and make sure we’re making that decision personally,” explained Dr. Stucky. In looking at the asthma data, the team noticed some pediatric patients were receiving a lot of chest X-rays.
“We looked at our first- and second-quarter data, and compared it to the [Pediatric Health Information System] data,” said Dr. Stucky. “We saw that we ordered chest X-rays at about the national average [on 61% and 62% of eligible patients versus an average of 66%], but is that average a good number?” The team decided to break down the data to see where X-rays were ordered—in the ED and on the ward—and why.
The team mapped a new asthma pathway for the ED based on the end of first-hour events, asthma scores, and medical history. “We decided to involve a respiratory therapist more with decisions on hospital placement” in the ED, said Dr. Stucky. The therapist then drove the protocols for mild, moderate, and severe cases.
The team changed the chest X-ray order set on the ward to read, “Consider ordering CRX if it will affect your treatment plan, and you must check or write the indication if ordering one.”
The result: The percentage of patients with chest X-rays in hospital beds dropped to 55%.
“Performance improvement is here to stay,” pronounced Dr. Stucky. “Leadership in pediatric QI is in our hands.” TH