Improving Safety and Quality in the Outpatient Pediatric Setting
John W. Harrington, MD
Director, Division of General Academic Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
Harrington JW. Improving safety and quality in the outpatient pediatric setting. Consultant360. Published online February 22, 2021.
Common concerns about ambulatory care quality and safety have been identified nationally. Here are 5 areas that you and your colleagues can review at your next practice meeting to help address the concerns. I challenge everyone to try to find one area of their practice that can be improved each day.
1. Medication: Any deviation from optimal medication use
When someone in your practice or an affiliate uses the wrong dose of amoxicillin (40 mg/kg vs 80-100 mg/kg) for otitis media in a toddler, do you discuss this with them? Do any of your colleagues still give albuterol syrup for coughs or tout the benefit of cough medicines and decongestants for toddlers? Following evidence-based guidelines allows everyone to win, including the most important person of all: the patient.
One area of interest and measurement for some insurance and health systems is making sure a child with a sore throat is not assumed to have streptococcal pharyngitis and must have positive results from a strep test to qualify for antibiotics. This decreases the misuse and over-use of antibiotics for common colds and viral illnesses along with the common issue of developing a rash and falsely presuming the viral rash is an allergic reaction to a common antibiotic. This in turn places antibiotic pressure on the community, forcing the physician to use a broader spectrum of antibiotics than is necessary in the future.
2. Diagnosis: Delayed or missed diagnosis
This is obviously an extremely sensitive area for physicians and clinicians to tackle in a holistic and transparent fashion. Ever since the landmark book “To Err is Human: Building a Safer Health System” in 2000,1 health care providers have struggled to grapple with diagnostic insecurity and accuracy. Framing the conversation from a diagnostic “error” to a diagnostic “opportunity” has gained more traction in the more-recent literature.2-3 The specter of litigation and lawsuits clouds the real aspect of quality improvement in one’s own diagnostic abilities.
There are still areas of medicine that can be considered an art, but other areas have evidenced-based guidelines that should help direct decision-making. There are also areas of omission or timeliness that can affect final outcomes. The most familiar problem in the diagnostic process is the overuse of efficient first-level thinking when presented with a common symptom.
First-level thinking is quick and provides resolution to what appears to be a simple diagnosis. However, it negates the ability to formulate counter thinking that allows doubt and second-level thinking to help broaden one’s differential. A perfect example is an infant with a persistent fever that, at several office visits, gets treated as otitis media when the physical examination findings are fairly mild, and the child is ultimately found to have a chronic urinary tract infection instead.
One strategy to combat this problem is to consider at least 2 other diagnoses that would be more severe before landing on the most common one. Then, convince yourself with tangible evidence that the severe diagnoses are unlikely, and document why and what criteria would make you consider them in the future. This allows you to always be centered in both first-level and second-level thinking at all times.
3. Transitions: Among providers in ambulatory settings
It is interesting to consider where we were just 15 years ago and how the practice of pediatric care has changed. Expectations for outpatient pediatric care overall have been redesigned from the jack-of-all-trades—nursery, private practice, inpatient hospitalized care, and 24/7 clinical coverage—to reliance on advanced practice providers, pediatric hospitalists, overnight triage call systems, and now pediatric-specific urgent cares. The only way this new division of labor can be done efficiently, while maintaining quality and safety, is through a standardization of processes that allows the free flow of information to all providers for smooth transitions.
In the best-case scenario, all providers would be all on the same electronic medical record (EMR). Thus, providers would be able to review care decisions and transitions based on the same data. Unfortunately, this is not the case. Many health systems must rely on communication that can be fractured or obtained through systems that only can interface with each other and are not integrated. Creating more systems that can integrate will be the next new hurdle our EMRs will have to overcome in order to leverage the information to benefit patients.
4. Referrals: Reason for visit, completion of visit, timely information, and feedback
Providing a referral to a subspecialist is a 2-way street. Being very specific about the patient’s expectations and why you are sending a patient for the referral can be critical in creating a positive experience for everyone. Your office tracking system for referral completion is supported by 2 things: EMRs and using patient care coordinators in your practice.
Many of us have struggled with some services having extremely long waiting periods for a referral. Two services that come to mind are: 1. Psychiatry with patients requiring complex psychopharmacology and 2. Developmental Pediatric assessments to specifically test for autism spectrum disorders. The first step in the process is to assess your current method and get a real-time level of what the wait time is to the next appointment. This will essentially start your quality improvement process where you will need to gather the stakeholders—primary care provider, subspecialist, and parent representative—to develop your improvement plan.
5. Management of Test Results: Notification of, tracking of, and communication to parent/guardian/patient
An area that can cause significant stress and put a physician at risk is the failure to follow up on laboratory or radiological studies. The idea that “if the test result is abnormal, we will call you” may no longer be acceptable, especially with COVID-19 test results. Fortunately, many EMRs now have a portal system that allows the patient or parent/guardian to comanage the follow-up of results. If there are any abnormalities that the physician may consider insignificant, it will likely require a conversation to explain why that abnormality is insignificant.
Luckily, many of the insurance regulations now allow billing codes based on time for discussing laboratory results and providing reassurance to parents/guardians. Many physicians who get high marks on quality surveys, but also have strong patient care skills, will follow up with their patients’ laboratory and radiological test results. Calling a parent/guardian with the good and bad news is both a skill and a requirement for good communication. It also forever links the parent/guardian, patient, and physician together as a care team. Overcoming obstacles with our patients can be a reason why many of us do this thing we call “doctoring.”
I hope you found one pearl or helpful piece of information in these 5 areas I’ve outlined. Alternatively, you can email me at John.Harrington@chkd.org to share your thoughts on providing better quality care to your pediatric patients.
- Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.
- Bates DW, Singh H. Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37(11):1736-1743. https://doi.org/10.1377/hlthaff.2018.0738
- Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J Qual Patient Saf. 2021;47(2):120-126. https://doi.org/10.1016/j.jcjq.2020.08.014