Transforming Children's Health Never Ends, and for Good Reason

Posted March 27, 2015 by Charles Homer, MD, MPH

Thoughts from NICHQ Founder, Charlie Homer, MD, MPH, as he prepares to move on to the next chapter of his professional life

Hear Charlie Homer's perspective on children’s health trends, quality improvement strategies and his hopes for the future in our new video.
My personal tendency at times of transition is to look forward to my new challenges and environment, and not dwell or reflect on what has come before. It is an odd tendency for a former history major, somebody who teaches about the critical importance of reflection for learning (a key component of the Plan-Do-Study-Act cycle). So, I will go against type and offer my reflections on over 20 years of engagement in and leadership of activities to improve children’s health and healthcare, and almost 16 years of doing this from the vantage point of leading NICHQ.

On the Field of Children’s Health and Healthcare Quality

Twenty years ago, very few people considered quality of care to be a matter of serious concern. Americans considered their healthcare system the best in the world, their doctors as not only compassionate and professional, but also knowledgeable and acting in a manner consistent with science. Hospitals were considered modern miracles, and the idea of avoiding medical or hospital care out of fear of harm was considered a curiosity only seen in primitive societies. Poor performance was viewed as an aberration, best corrected through remedial education or removal from practice. And when quality was considered at all, children’s healthcare was scarcely on the radar screen—after all, kids are healthy, and pediatricians and family doctors nice.

In 1999, when “To Err is Human” was published, Americans became broadly aware of defects in the delivery of healthcare. Now, scarcely a day goes by without a media article highlighting an area of system shortcomings—whether it is under-immunization, overuse of psychotropic drugs in children, too frequent induction of labor, disparities in use of effective cardiac procedures, or end-of-life care inconsistent with patient preferences. Atul Gawande’s artful prose and Don Berwick’s impassioned speeches communicated in ways that previous generations of health services researchers could not the stark deficiencies in quality experienced by patients and methods that might address them. NICHQ’s voice contributed to the burgeoning awareness of these challenges and in particular that they affected children as well as adults.

Has quality of care improved as a consequence of this awareness? Absolutely! Fewer children get antibiotics when they don’t need them. Fewer infants and children develop infections from intravenous catheters. Many more practices create registries of their patients and manage from the denominator. More mothers are breastfeeding their infants. The healthcare system’s approach to obesity prevention is far more proactive. Collaborative improvement networks exist for several of the chronic conditions affecting children with demonstrable improvements in processes and outcomes of care. Primary care clinicians serving more than half of America’s children can now get telephone access to mental health professionals when they need guidance. Quality improvement is the dominant approach being used by the US Maternal and Child Health Bureau to achieve its objectives, unlike when we stated our work there on the medical home a dozen years ago. Patients and families are far more engaged in driving improvement than they were a decade ago. Quality improvement is a recognized field for academic research and a legitimate career path for healthcare professionals.

What we don’t yet have is consistent, nationwide progress. We still cannot guarantee every parent that their child will receive the right care, delivered in the most appropriate setting on a timely basis, sensitive to that child and family’s preferences and needs, attentive to resource use and in a manner that promotes equity in outcomes. We still don’t have a system that is continuously learning and “getting better at getting better.” Children’s health insurance coverage remains both inadequate and fragmented; data about children’s care and child health remain scattered across insurance companies, states, surveys and medical records. Healthcare, education and social care remain in their own silos. Disparities and gross inequity in health outcomes remain omnipresent and unless addressed damn us to a dismal future. We do have bright spots and we must celebrate and learn from them, but we do not yet have the brilliant daylight from horizon to horizon that we must promise and deliver to our children.

I truly believe we are on the path to get there. When I see states from Texas to Minnesota and Washington to Florida voluntarily committing their resources and working together with other states to reduce infant mortality and promote equity, when I hear how the CMS Innovation Center is seeking ways to apply its resources to improve the health of populations, when I witness the IT infrastructure already in place to monitor the health of Boston’s poorest residents, I am optimistic. When I attend conferences and meet young health and healthcare leaders from diverse backgrounds with not only passion but also new skills and ideas and a commitment to work together, I smile with hope. When I meet parents who are activated to design and drive change and use social media to get there, I know we are headed in the right direction.

The improvement journey is hard work and it never ends, but I know we’re in a better place and have the knowledge, people and tools we need to continue improving the lives of children and families in the months and years ahead.

On NICHQ’s Contribution

From its founding, NICHQ was the leading voice articulating the need for improvement in children’s healthcare. Speaking credibly to the academic, professional and policy communities, we emphasized that quality of care was important to child health, and that it needed focused attention. Our national conference for 10 years was the only place that diverse professionals—ranging from community leaders to hospital executives, from parents to pediatricians—could come together for the common purpose of improving children’s healthcare. Countless individuals now in the field have approached me to let me know that this conference, as well as participating in other NICHQ programs, transformed their careers and their lives.

Relatively unique among organizations focused on quality, NICHQ focused its quality efforts on ambulatory and specifically primary care. We helped frame quality concerns in primary care—be they outcomes for children with asthma or ADHD or more general preventive services—as the consequence of system failures, viewing community practices as small systems amenable to improvement. We adopted the “chronic care model,” and customized it to the child health context primarily by greatly strengthening the emphasis on the role of the community. We always grounded our “big ideas” about healthcare system change in our project work, seeking to show we could improve care and outcomes for real children and families in real care settings.

We have been unafraid to tackle big challenges throughout our history. In focusing our early work on ADHD, we were willing to address the most common mental health condition affecting children and one whose management is still steeped in controversy. When we decided to address childhood obesity, many argued that clinicians don’t have a meaningful role in the efforts to tackle this epidemic, a perspective that has changed 180 degrees. Our focus on primary care and especially the medical home as early as 2002 was substantially in advance of the current national movement to strengthen America’s primary care base. Our work linking state Title V programs to support transformation of primary care to medical homes, as well as our work linking local public health with primary care and community to address childhood obesity, anticipated today’s focus on public health/primary care linkages and population health. We were willing to completely challenge and revamp the approach to improving care for people with sickle cell disease by transforming a traditional grant program to a system for continuous improvement. Our embrace of parents as key partners in improvement work changed the face of the improvement field and is perhaps the contribution to our field that gives me the most satisfaction.

While our courage may have enabled us to enter various fields, our ability to demonstrably produce results has enabled us to remain vibrant and grow. For example, our track record with improving maternity practices for New York State positioned us well to apply our knowledge at a national level for the CDC in our Best Fed Beginnings initiative. Our success there enabled us to engage with Texas on a similar program and to continue to grow our efforts.

Since our founding in 1999, we have recognized the critical importance of the world beyond the clinical walls as a strong determinant of child health and well-being. In our initial work on asthma and ADHD, we emphasized the role of schools and after school programs. We applied our improvement methods to address health of children in child welfare system. As we focused on childhood obesity, we knew that we had to extend our attention to broader community settings. We now consider this issue a “both/and” rather than an “either/or.” That is, we are now addressing not only improvement in clinical care, but also improvement in public health and community systems. What is different is that we are applying improvement, innovation and human centered design methods to these challenges, and not dropping our tools (although we are adding new ones) when we move into these new environments.

This is only a sampling of how NICHQ has helped improve the world for children in the past 15 plus years. I have full confidence that NICHQ will continue to achieve unprecedented success in making the world a better place for children to grow for many years to come.

All the best,
Charlie

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