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BACKGROUND: The ability to measure and improve the quality of children's health care is of national importance. Despite the existence of numerous health care quality measures, the collective ability of measures to assess children's health care quality is unclear. A review of existing health care quality measures for children is timely for both assessing the current state of quality measures for children and identifying areas requiring additional research and development. OBJECTIVES: To identify and collect current health care quality measures for child health and then to systematically categorize and classify measures and identify gaps in child health care quality measures requiring additional development. DESIGN/METHODS: We first identified child health care quality instruments with assistance from staff at the Agency for Healthcare Research and Quality, experts in the field, the Computerized Needs-oriented Quality Measurement Evaluation System, the Child and Adolescent Health Measurement Initiative, and a medical literature review. From these instruments, we then selected clinical performance measures applicable to children (aged 0-18 years). We categorized the individual measures into the Institute of Medicine's framework for the National Health Care Quality Report. The framework includes health care quality domains (patient safety, effectiveness, patient-centeredness, and timeliness) and patient-perspective domains (staying healthy, getting better, living with illness, and end-of-life care). We then determined the balance of the measures (how well they assess care for all children versus children with special health care needs) and their comprehensiveness (how well the measures apply to the developmental range of children). Finally, we analyzed the ability of the measures to assess equity in care. RESULTS: We identified 19 measure sets, and 396 individual measures were used to assess children's health care quality. The distribution of measures in the health care quality domains was: safety, 14.4%; effectiveness, 59.1%; patient-centeredness, 32.1%; and timeliness, 33.3%. The distribution of measures in the patient-perspective domains was: staying healthy, 24%; getting better, 40.2%; living with illness, 17.4%; end of life, 0%; and multidimensional, 23.5% (measures were multidimensional if they applied to >1 domain). Most of the measures were meant for use in the general pediatric population (81.1%), with a significant proportion designed for children with special health care needs (18.9%). The majority (>or=79%) of the measures could be applied to children across all age groups. However, there were relatively few measures designed specifically for each developmental stage. Regarding the use of measures to study equity in health care, 6 of the measure sets have been used in previous studies of equity. All the survey measure sets contain items that identify patients at risk for poor outcomes, and 4 are available in languages other than English. However, only 1 survey (Consumer Assessment of Health Plans) has undergone studies of cross-cultural validation. Among the measure sets based on administrative data, 3 included infant mortality, a well-known measure of health disparity. CONCLUSIONS: There are several instruments designed to measure health care quality for children. Despite this, we found relatively few measures for assessing patient safety and living with illness and none for end-of-life care. Few measures are designed for specific age categories among children. Although equity is an overarching concern in health care quality, the application of current measures to assess disparities has been limited. These areas need additional research and development for a more complete assessment of health care quality for children. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Patient assessments of care are increasingly being considered an important dimension of quality of care. Few studies have examined the types and extent of problems identified by parents in the care of hospitalized children and whether hospital characteristics are associated with some of these problems. The objective of this study was to describe the quality of pediatric inpatient care as perceived by parents of hospitalized children and test whether hospital characteristics (academic status, market competition, freestanding children's hospital) are associated with variations in quality. METHODS: We performed a cross-sectional analysis of surveys from 6030 parents of children who were discharged for a medical condition from 38 hospitals that used the Picker Institute's Pediatric Inpatient Survey. The Pediatric Inpatient Survey measures 7 dimensions of inpatient care quality: partnership, coordination, information to parent, information to child, physical comfort, confidence and trust, and continuity and transition. Our main outcome measures included an overall quality of care rating (1 = poor, 5 = excellent), as well as overall and dimension-specific problem scores (0 = no problems, 100 = problems with 100% of processes asked about in the survey). We used Pearson correlation to determine the strength of association between the overall quality of care rating and dimension problem scores. We tested for associations between hospital characteristics and problem scores using linear regression models, controlling for patient health status and other socioeconomic status variables. RESULTS: Parents on average rated their child's care as very good (mean: 4.2) but reported problems with 27% of the survey's hospital process measures. Information to the child (33%) and coordination of care (30%) had the highest problem rates. Parent communication problems correlated most strongly with overall quality of care ratings (r = -0.49). Parents of children who were hospitalized at academic health centers (AHCs) reported 4% more problems overall (29.8% vs 25.5%) and almost 9% more problems with coordination of care (34.1% vs 25.6%) compared with those at non-AHCs. Parents in more competitive markets reported almost 3% more problems than those in the less competitive ones (28.9% vs 26.3%). The freestanding children's hospital classification was not associated with overall problem scores. We found wide variation in problem scores by hospital, even among AHCs. Hospital and patient characteristics explained only 6% of the variance in problem scores. CONCLUSIONS: Despite high subjective ratings of quality of care, measures of specific processes of care reveal significant variations among hospitals and identify areas with opportunities for improvement. Improving the quality of communication with the parent of a hospitalized child may have the most positive impact on a hospital's overall quality of care rating. AHCs and hospitals in more competitive markets may be more prone to problems. With wide variation in parental perceptions of hospital quality of care, a systems analysis of individual hospitals may provide strategies for hospitals to deliver higher quality care. [ABSTRACT FROM AUTHOR]

Abstract: Labor unions represent an increasing number of graduate medical education (GME) trainees in the United States. Most GME and other leaders at academic medical centers lack familiarity with resident/fellow unions, including what to expect, what decisions need to be made, and the processes involved in a unionization effort. It is important for designated institutional officials (DIOs), GME program directors, teaching faculty, and other institutional leaders to understand the drivers of resident/fellow unionization, the union organizing campaign and election process, and what follows a vote to unionize, including collective bargaining. Careful consideration of the role of educational and other institutional leaders during the unionization process is important to prevent any loss of trust between residents/fellows and those they view as their advocates. In this Commentary, the authors describe these considerations from their perspective as DIOs and GME leaders., (Copyright © 2024 the Association of American Medical Colleges.)

The relationship between lifestyle behaviors and common chronic conditions is well established. Lifestyle medicine (LM) interventions to modify health behaviors can dramatically improve the health of individuals and populations. There is an urgent need to meaningfully integrate LM into medical curricula horizontally across the medical domains and vertically in each year of school and training. Including LM content in medical and health professional curricula and training programs has been challenging. Barriers to LM integration include lack of awareness and prioritization of LM, limited time in the curricula, and too few LM-trained faculty to teach and role model the practice of LM. This limits the ability of health care professionals to provide effective LM and precludes the wide-reaching benefits of LM from being fully realized. Early innovators developed novel tools and resources aligned with current evidence for introducing LM into didactic and experiential learning. This review aimed to examine the educational efforts in each LM pillar for undergraduate and graduate medical education. A PubMed-based literature review was undertaken using the following search terms:  lifestyle medicine, education, medical school, residency, and healthcare professionals . We map the LM competencies to the core competency domains of the Accreditation Council for Graduate Medical Education. We highlight opportunities to train faculty, residents, and students. Moreover, we identify available evidence-based resources. This article serves as a "call to action" to incorporate LM across the spectrum of medical education curricula and training., Competing Interests: Dr Frates has served as a consultant for Jenny Craig Scientific Advisory Board, obVus Solutions, and Clearing.com. Dr Freeman is the Director of Workforce Development at the American College of Lifestyle Medicine and President of the Indiana Lifestyle Medicine Network; receives grant funding through the Ardmore Institute of Health. Dr Co is one of the Board of Directors, ACGME. Dr Bernstein receives royalties as a Nutrition Textbook Author for Jones and Bartlett Learning. The other author reports no competing interests., (© 2024 The Authors.)

Problem: Competency-based medical education is increasingly regarded as a preferred framework for physician training, but implementation is limited. U.S. residency programs remain largely time based, with variable assessments and limited opportunities for individualization. Gaps in graduates' readiness for unsupervised care have been noted across specialties. Logistical barriers and regulatory requirements constrain movement toward competency-based, time-variable (CBTV) graduate medical education (GME), despite its theoretical benefits., Approach: The authors describe a vision for CBTV-GME and an implementation model that can be applied across specialties. Termed "Promotion in Place" (PIP), the model relies on enhanced assessment, clear criteria for advancement, and flexibility to adjust individuals' responsibilities and time in training based on demonstrated competence. PIP allows a resident's graduation to be advanced or delayed accordingly. Residents deemed competent for early graduation can transition to attending physician status within their training institution and benefit from a period of "sheltered independence" until the standard graduation date. Residents who need extended time to achieve competency have graduation delayed to incorporate additional targeted education., Outcomes: A proposal to pilot the PIP model of CBTV-GME received funding through the American Medical Association's "Reimagining Residency" initiative in 2019. Ten of 46 residency programs in a multihospital system expressed interest and pursued initial planning. Seven programs withdrew for reasons including program director transitions, uncertainty about resident reactions, and the COVID-19 pandemic. Three programs petitioned their specialty boards for exemptions from time-based training. One program was granted the needed exemption and launched a PIP pilot, now in year 4, demonstrating the feasibility of implementing this model. Implementation tools and templates are described., Next Steps: Larger-scale implementation with longer-term assessment is needed to evaluate the impact and generalizability of this CBTV-GME model., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Objective: To address gaps in routine recommended care for children with Down syndrome, through quality improvement during the coronavirus disease 2019 (COVID-19) pandemic., Study Design: A retrospective chart review of patients with Down syndrome was conducted. Records of visits to the Massachusetts General Hospital Down Syndrome Program were assessed for adherence to 5 components of the 2011 American Academy of Pediatrics (AAP) Clinical Report, "Health Supervision for Children with Down Syndrome." The impact of 2 major changes was analyzed using statistical process control charts: a planned intervention of integrations to the electronic health record for routine health maintenance with age-based logic based on a diagnosis of Down syndrome, created and implemented in July 2020; and a natural disruption in care due to the COVID-19 pandemic, starting in March 2020., Results: From December 2018 to March 2022, 433 patients with Down syndrome had 940 visits. During the COVID-19 pandemic, adherence to the audiology component decreased (from 58% to 45%, P < .001); composite adherence decreased but later improved. Ophthalmology evaluation remained stable. Improvement in adherence to 3 components (thyroid-stimulating hormone, hemoglobin, sleep study ever) in July 2020 coincided with electronic health record integrations. Total adherence to the 5 AAP guideline components was greater for follow-up visits compared with new patient visits (69% and 61%, respectively; P < .01)., Conclusions: The COVID-19 pandemic influenced adherence to components of the AAP Health supervision for children with Down syndrome, but improvements in adherence coincided with implementation of our intervention and reopening after the COVID-19 pandemic., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Down syndrome (DS) has a unique medical and psychological profile that could impact how health is defined on three dimensions: physical, social and mental well-being., Methods: In 2021, we presented our proposed conceptual model to three expert panels, four focus groups of parents of individuals with DS age 0-21 years and four focus groups of individuals with DS age 13-21 years through videoconferencing technology. Participants gave feedback and discussed the concept of health in DS., Results: Feedback from participants resulted in iterative refinement of our model, retaining the three dimensions of health, and modifying constructs within those dimensions. Experts and parents agreed that individuals with DS have unique health concerns that necessitate the creation and validation of a syndrome-specific health model. We present key themes that we identified and a final conceptual model of health for individuals with DS., Conclusion: Health in DS is a multi-dimensional, multi-construct model focused on relevant constructs of causal and effect indicators. This conceptual model can be used in future research to develop a syndrome-specific measure of health status., (© 2023 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.)

Assessing residents and clinical fellows is a high-stakes activity. Effective assessment is important throughout training so that identified areas of strength and weakness can guide educational planning to optimize outcomes. Assessment has historically been underemphasized although medical education oversight organizations have strengthened requirements in recent years. Growing acceptance of competency-based medical education and its logical extension to competency-based time-variable (CB-TV) graduate medical education (GME) further highlights the importance of implementing effective evidence-based approaches to assessment. The Clinical Competency Committee (CCC) has emerged as a key programmatic structure in graduate medical education. In the context of launching a multi-specialty pilot of CB-TV GME in our health system, we have examined several program's CCC processes and reviewed the relevant literature to propose enhancements to CCCs. We recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident's developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability. We integrate the literature and observations from GME program CCCs in our institutions to evaluate how current CCC processes support or undermine these goals. Obstacles and key enablers are identified. Finally, we recommend ways to achieve the stated goals, including the following: (1) assess and promote the development of competency in all trainees, not just outliers, through a shared model of assessment and competency-based advancement; (2) strengthen CCC assessment processes to determine trainee readiness for independent practice; and (3) promote trainee reflection and informed self-assessment. The importance of coaching for competency, robust workplace-based assessments, feedback, and co-production of individualized learning plans are emphasized. Individual programs and their CCCs must strengthen assessment tools and frameworks to realize the potential of competency-oriented education., (© 2022. The Author(s).)

The February 2020 announcement that United States Medical Licensing Examination (USMLE) Step 1 results will be reported as pass/fail instead of numerical scores has been controversial. Step 1 scores have played a key role in residency selection, including screening for interviews. Although Step 1 scores are viewed as an objective criterion, they have been shown to disadvantage female and underrepresented minority applicants, cause student anxiety and financial burden, and affect student well-being. Furthermore, Step 1 scores incompletely predict applicants' overall residency performance. With this paradigm shift in Step 1 score reporting, residency programs will have fewer objective, standardized metrics for selection decisions, which may lead to greater emphasis on USMLE Step 2 Clinical Knowledge scores or yield unintended consequences, including shifting weight to metrics such as medical school reputation.Yet, greater breadth in residency selection metrics will better serve both applicants and programs. Some students excel in coursework, others in research or leadership. All factors should be recognized, and broader metrics should be implemented to promote and recognize diversity of excellence. Given the need for metrics for residency selection as well as for a more holistic approach to evaluating residency applicants, assessment during medical school should be revisited and made more meaningful. Another opportunity may involve use of situational judgment tests to predict professionalism and performance on other competencies. It will be important to evaluate the impact of the new Step 1 paradigm and related initiatives going forward. Residency application overload must also be addressed.

Objective: The Centers for Disease Control and Prevention recommend testing for Chlamydia trachomatis in sexually active female patients <25 years old using nucleic-acid amplification tests (NAAT) from a vaginal swab. Our providers were typically testing using the less sensitive urine NAATs. We aimed to increase the percentage of urogenital C trachomatis NAATs performed by using vaginal swabs in adolescent female patients ages 10 through 20 years from 1.4% to 25%., Methods: We implemented 3 interventions at 3 pediatric practices over 12 months including education, process standardization, and cross-training. We used statistical process control to analyze the effect of interventions on our primary outcome: the percentage of urogenital C trachomatis tests performed with a vaginal swab. Our balance measure was the total number of urogenital C trachomatis tests., Results: There were 818 urogenital C trachomatis tests performed: 289 before and 529 after the first intervention. Of urogenital C trachomatis tests in the preintervention time period, 1.4% were performed by using vaginal swabs. We surpassed our aim of 25% 6 weeks after the first intervention. We noted sustained improvement after the second intervention, with an average of 68.3% of tests performed by using vaginal swabs for the remaining postintervention period. There was no difference in the overall number of urogenital C trachomatis tests pre- and postintervention., Conclusions: Using quality improvement methodology and implementing easily replicable interventions, we significantly and sustainably increased use of vaginal swabs. The interventions standardizing processes were associated with a higher impact than the educational intervention., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Introduction: There is limited information about whether OSCE during GME orientation can identify trainee communication deficits before these become evident via clinical performance evaluations., Methods: Ninety-seven interns matriculating to eight residency programs in six specialties at four hospitals participated in a nine-station communication skills OSCE. Ratings were based on the "Kalamazoo, adapted" communication skills checklist. Possible association with intern performance evaluations was assessed by repeated-measures logistic regression and ROC curves were generated., Results: The mean OSCE score was 4.08 ± 0.27 with a range of 3.3-4.6. Baseline OSCE scores were associated with subsequent communication concerns recorded by faculty, based on 1591 evaluations. A 0.1-unit decrease in the OSCE communication score was associated with an 18% higher odds of being identified with a communication concern by faculty evaluation (odds ratio 1.18, 95% CI 1.01-1.36, p = 0.034). ROC curves did not demonstrate a "cut-off" score (AUC= 0.558). Non-faculty evaluators were 3-5 times more likely than faculty evaluators to identify communication deficits, based on 1900 evaluations., Conclusions: Lower OSCE performance was associated with faculty communication concerns on performance evaluations; however, a "cut-off" score was not demonstrated that could identify trainees for potential early intervention. Multi-source evaluation also identified trainees with communication skills deficits.