Quality in Pediatric Subspecialty Care (QPSC): Case Analysis

Introduction

Assessing the quality of care for children, compared to the adult population, is challenging as children and adolescents differ clinically from adults. Pediatrics subspecialties that include all medical and surgical subspecialties are viewed as isolated disciplines that differ significantly from each other, as well as from adult medicine subspecialties The American Board of Pediatrics (ABP), based on evidence, perceive that there is significant variation in medical care, even among board-certified physicians, signifying that medical knowledge alone is not sufficient to ensure high quality of care.

It prompted the creation of a more continuous process of recertification and launching the Quality in Pediatric Subspecialty Care (QPSC) initiative by the American Board of Medical Specialties (ABMS) in 2003. A recertification program is envisaged to assess physicians’ competency in performance, practice, and system-based thinking, in addition to the current requirements for medical knowledge, communication skills, and professional behavior. Considering the increasing interest in ensuring quality in medical care it is essential to assess whether the QPSC initiative is relevant and the intervention of professional societies and certifying authorities crucial.

Challenges to quality Pediatric care

Children’s normal developmental trajectory is characterized by change and they have differential morbidity, which limits the development of measures to assess the quality of care for children. “The term “Pediatric Medical Subspecialist” denotes a pediatrician who has obtained sub-bard certification in 1 of the 16 American Board of Pediatrics (ABP designated subspecialties.” (Jewett, et al, 2005, p. 1192-1202).

Mangione-Smith & McGlynn (2000) opine that although several practice guidelines and indicators of quality have been constructed, a conceptual framework to guide the development of such tools for quality assessment in the pediatric population is lacking, Experience of Children’s Oncology Group in the U.S that studied the performance of children with cancer shows that were robust systems have been defined and implemented, the results have been dramatic, as there was increased survival rate in children who participated in a robust system incorporating new therapies. In order to change the mode of pediatric sub-specialists’ practice, QPSC uses a unique process that integrates three components, such as national database, quality improvement collaborative, and Web-based education.

Three components are:

  1. national databases/registries of key childhood illnesses developed and coordinated through a national data coordinating center;
  2. subspecialty-wide multicenter collaborative improvement activities among pediatric sub-specialists; and
  3. web-based improvement/educational modules (e.g. eQIPP module with AAP).

Since overall aim of QPSC system is to improve the health of children by improving the quality of pediatric subspecialty care, the leadership role of the QPSC council is clearly identified, and the system is divided into leadership process and program support processes.

Introduction to QPSC

The QPSC initiative aims to ‘improve the health care delivery system for children with complex medical conditions’ through a mass customization approach that help share existing knowledge and experiences among peers to achieve mutually agreed-upon improvement goal. The three-part QPSC model includes shared data across sites of care; multi-center quality improvement collaborative and collaborative research; and education in quality improvement methods. (McCandless & DeWolf, 2006). The inspiration for the initiation of QPSC was derived from the success of Cystic Fibrosis Collaborative that applied quality improvement processes to improve children’s health outcomes.

The Cystic Fibrosis collaborative, based on data comparisons between centers, noted that by improving nutritional counseling and reducing exposure to tobacco smoke children’s life expectancy could be improved as much as 50% above the national average. The Cystic Fibrosis Collaborative model is adopted on a larger scale in QPSC. The organizational structure of QPSC includes the American Board of Pediatrics (ABP), the American Academy of Pediatrics (AAP), and UNC School of Public Health (UNC-SPH). American Board of Pediatrics (ABP) is one of 24 certifying boards that awards certificates in 13 pediatric subspecialties, which assures the public and the profession that a pediatrician possesses ‘the knowledge, skills, and experience requisite to the provision of high-quality care in pediatrics’ (Sollecito et al).

The American Academy of Pediatrics (AAP) supports some 60,000 member health professionals in pediatrics and allied specialties in their effort to ensure quality health care of children, adolescents, and young adults. Its online system Education in Quality Improvement for Pediatric Practices (eQIPP) is used to disseminate knowledge and assist subspecialty pediatricians in implementing practice improvements, as well as enabling them to meet recertification requirements.

The UNC School of Public Health (UNC-SPH) contributes expertise in epidemiology, health behavior, biostatistics, child health at the population level, and public health leadership to QPSC. The UNC SPH, having experience in collaborative improvement activities and multifaceted software designing provides infrastructure support to QPSC through its Instructional and Information Systems (IIS) group. Expertise in large-scale organizational design, project management, and continuous improvement is facilitated by Public Health Leadership Program. The North Carolina Centre for Children’s Health Care Improvement (NCCHI), with a proven track record since 1992 in practice-based improvement, is the national program office for QPSC

Collaborative program for continuous quality improvement

The key CQI component of Deming’s ‘System of Profound Knowledge,’ posited on the belief that ‘each improvement effort within a subspecialty is framed within a generic model for managing improvement,’ is applied in QPSC. It is hypothesized that this approach provides a framework for the use of Shewhart (PDSA) cycles to determine how to implement improvements in care with the network of collaborating provider centers. A traditional CQI transitional model of incremental change for gaining knowledge from a subspecialty ‘pilot group’ and expanding to all 13 pediatric subspecialties was adopted by the QPSC.

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) were selected to be the pilot subspecialty to develop, implement, and evaluate the QSPC model. The QPSC implementation team comprises a coordination team headed by a program director; five specialized teams in the field of collaborative learning and improvement, educational module development and implementation, data management and statistics, software system development and support, and research; a set of subcommittees that coordinate design, governance, and fund-raising activities; and an advisory board that provides guidance and insurance input from all constituencies, including patients and their families.

The first NASPGHAN initiative of Pediatric Inflammatory Bowel Disease Network for Research and Improvement (PIBDNet), with entire 800 pediatric gastroenterologists in North America, conducted collaborative improvement and research on the quality and safety of care delivered by member subspecialists to children with inflammatory bowl disease (IBD). Main reason for selecting this subspecialty for pilot study was that over 45,000 children and adolescents in North America suffer from IBD, and yet there was lack of evidence for its optimal management and the safety and effectiveness of available treatment.

Project objective for PIBDNet, among other things, was to determine the extent of variation in care of children with IBD, who are initiating specific medication and identify the predictors of a successful outcome treatment, by engaging 200 pediatric gastroenterologists in network activities. Involving 10-15 GI practices in a collaborative ‘innovation community’ to identify, test, and develop changes that can improve IBD care. In addition, spreading the successful strategy among members, developing eQIPP module, and measuring the measuring the effectiveness of the program under specified benchmark were also included under the project objective.

By the summer of 2004, NASPGHAN was able to create PIBDNet, enroll 40% of its members in the network, and implement all the individual components of QPSC by partner organizations. An evaluation of NASPGHAN pilot program had been initiated to assess ways to improve the efficiency of the implementation steps, and planning to expand the model to next subspecialties was underway. However, financial constraint is found to be the main barrier for implementing each of the components of QPSC in all subspecialties by 2010 and meet ABP’s aggressive timeline.

Relevance of Pediatric Subspecialists’ recertification

Dramatic changes in health care and the perceived need to contain rising costs, including shift to managed care system, encourages federal and state agencies, health care providers, and health care consumers to seek better information and methods on quality assurance. Every stakeholder will have their own set of priorities and reasons that urge measuring clinical standards, performance, and quality of care delivered. Shortell et al (1995, p.377-401). hypothesized that “hospitals using an overall CQI/TQM approach to improvement will experience a greater degree of quality implementation; greater perceived impact of CQI/TQM on human resources development, patient outcomes, and financial outcomes; and greater clinical efficiency in terms of lower charges and length of stay for selected clinical conditions.

Organizations adopt CQI for a variety of reasons, including accreditation requirements, cost control, competition for customers, and pressure from employers and payers. Quoting recent investigations, Lee et al (2002, 383-391). point out that though approximately 98% of the U.S hospitals employ TQM/CQI concepts and tools, there are many barriers to its effective implementation, such as: insufficient CQI skills, poor planning, placing a low strategic priority on CQI, and lack of employee participation. Under these circumstances recertification of pediatric subspecialists as envisaged under QPSC is crucial for improving skills and competence of pediatric professionals.

Conclusions and recommendations

Literature reviews reveal that health plans are not concentrating to ensure credentialing of pediatric subspecialty force. “Credentialing is the systematic approach to the collection, review, and verification of a practitioner’s professional qualifications,” According to ABP “the intent of certification is to provide assurance to the public and the medical profession that a certified pediatrician has successfully complete an accredited educational program and various evaluations, including an examination, and that the individual possesses the knowledge, skills, and experience requisite to the provision of high quality care in pediatrics.” (Freed, et al, 2006, 913-918).

The study by Freed et al (2006) found that 174 (90%) of the 193 health plans do not require general pediatricians to be board certified at the time of initial contract in order to be credentialed, and only 29(15%) of 190 plans indicated that they require subspecialty certification for initial credentialing as pediatric subspecialist. In addition, seventy-seven percent of plans allow physicians bill as subspecialist with expired certificates, which raise questions regarding the ability of plans to ensure initial or continued competence of their credentialed physicians.

Another survey by Freed et al (2008) on characteristics of General and Subspecialty Pediatricians whose board certification had expired and who had not recertified in 2004 or 2005 found that most common reason for not maintaining certification were the expense, the time required to complete maintenance of certification, and the perceived lack of relevance to their current practice, or change in career path making recertification unnecessary. Overall, most commonly cited reason was expenses. These studies show that there is dearth of professionalism, and strong initiative, even at highest cost, is crucial to bridge the knowledge gap among pediatric subspecialties.

At this juncture it will be worth noting that service providers are assumed to have exclusive access to knowledge and competence, and professionalism warrant individual professional development, to take full responsibility for self-regulation and for quality. McLaughlin & Kaluzny (2005, p.5) opine that “We cannot ignore the role of professional development as a potential engine of quality improvement, despite the popular emphasis on institutional improvement and societal learning.”

Since the basic tenet of QPSC is professional development through collaborative learning it is essential to involve professional societies and certifying authorities to engage in professional development of its registered incumbents. Evidence suggests that collaborative movement for continuous quality improvement is need of the hour. The example of ‘Alliance for Pediatric Quality, among other initiatives, that included ‘Trailblazer Improvement Collaborative for Pediatric Inflammatory Bowel Disease’ in its ‘Improve First Implementation’ program in 2008 is a remarkable move in collaborative quality improvement measure.

Since credentialing of medical practitioners is paramount from the ‘public interest vantage’, and significant ‘legal risk to the health plans for exposing an injured subscriber to an unqualified physician,’ concerted effort should be made by health care providers to ensure continued competence of their physicians. The Quality in Pediatric Subspecialty Care (QPSC) model initiative should be implemented in all other medical specialties, and recertification should be made compulsory to ensure total quality in medical care.

Reference

Freed, Gary. L. et al. (2008). Characteristics of general and subspecialty pediatricians who choose not to recertify. Official Journal of the American Academy of Pediatrics, 121 (4), 711-717. Web.

Freed Gary. L., et al. (2006). Use of board certification and recertification of pediatricians in health plan credentialing policies: Introduction. The Journal of American Medical Association, 295 (8), 913-918. Web.

Jewett, Ethan Alexander., Anderson, Michael. R., & Gilchrist, Gerald. S. (2005). The pediatric subspecialty workforce: Public Policy and Forces of Change. Official Journal of the American Academy of Pediatrics, 116 (5), 1192-1202. Web.

Lee, Sunhee., et al. (2002). Assessing the factors influencing continuous quality improvement implementation: Experience in Korean hospitals. International Journal for Quality in Health Care, 14 (5), 383-391. Web.

McCandless, Keith., & DeWolf, Linda. (2006). Mastering the art of innovating. Web.

McLaughlin, Curtis. P., & Kaluzny, Arnold. D. (2005). Professional responsibility. Continuous Quality Improvement in Health Care. 5. Web.

Miles, Paul. V., et al. (2009). Alliance for pediatric quality: Creating a community of practice to improve health care for America’s children. Supplement article. Official Journal of the American Academy of Pediatrics, 123, S64-S66. Web.

Shortell, S. M, et al. (1995). Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Service Research, 30 (2), 377-401. Web.

Smith, Rita Mangione., & McGlynn, Elizabeth. A. (2000). Assessing the quality of Healthcare provided to children. Health Services Research. Web.