IMPROVING THE QUALITY OF CARE FOR CHILDREN IN HEALTH SYSTEMS

Objective. To summarize the state of the art in quality improvement, r eview its application to care for children, and define the information that will be needed so that care for children can be further improved . Principal Findings. Health services for children exhibit numerous de ficiencies in quality of care. The deficiencies cross all major domain s of pediatric care-preventive services, acute care, and chronic care- and provide the opportunity for creative application of improvement st rategies with a potential to benefit the health and well-being of chil dren. Approaches to quality improvement have changed over the past two decades from those emphasizing the inspection of structural aspects o f care and the imposition of sanctions to more dynamic strategies that emphasize measurement and comparison to motivate change; the use of e vidence to specify aims for improvement; and the adoption of a variety of management strategies adapted from business and the social science s to achieve these aims. These modern approaches to quality improvemen t have rarely been subjected to rigorous testing of their effectivenes s. Moreover, their application in pediatrics has been less widespread than in adult healthcare. For children, several aspects about health s ervices, such as the relative rarity of chronic illness, the important effects of social factors on health, and the limited cost, make some of these approaches even more challenging and may require new approach es or meaningful modifications. Recommendations. Research to understan d better the general process of improvement will benefit improvement e fforts for children. Research that builds the base of knowledge about best practices for children-effectiveness research-will also result in an enhanced capacity for improvement of those systems that care for c hildren's health. Quality of care for children would be enhanced by ta rgeted research examining ways both to foster improvement across segme nts of society, and to make recommendations for care more sensitive to children's development and environmental context. Research that suppo rts incorporating the child's perspective into care is both uniquely c hallenging to perform and central to improving pediatric care.