Homer C J, Kleinman L C, Goldman D A
Children's Hospital, Boston, MA 02115, USA.
Health Serv Res. 1998 Oct;33(4 Pt 2):1091-109.
To summarize the state of the art in quality improvement, review its application to care for children, and define the information that will be needed so that care for children can be further improved.
Health services for children exhibit numerous deficiencies in quality of care. The deficiencies cross all major domains of pediatric care--preventive services, acute care, and chronic care--and provide the opportunity for creative application of improvement strategies with a potential to benefit the health and well-being of children. Approaches to quality improvement have changed over the past two decades from those emphasizing the inspection of structural aspects of care and the imposition of sanctions to more dynamic strategies that emphasize measurement and comparison to motivate change; the use of evidence to specify aims for improvement; and the adoption of a variety of management strategies adapted from business and the social sciences to achieve these aims. These modern approaches to quality improvement have rarely been subjected to rigorous testing of their effectiveness. Moreover, their application in pediatrics has been less widespread than in adult healthcare. For children, several aspects about health services, 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 approaches or meaningful modifications.
Research to understand better the general process of improvement will benefit improvement efforts 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 children's health. Quality of care for children would be enhanced by targeted research examining ways both to foster improvement across segments of society, and to make recommendations for care more sensitive to children's development and environmental context. Research that supports incorporating the child's perspective into care is both uniquely challenging to perform and central to improving pediatric care.
总结质量改进的最新状况，回顾其在儿童护理中的应用，并确定进一步改善儿童护理所需的信息。
儿童保健服务在护理质量方面存在诸多不足。这些不足贯穿儿科护理的所有主要领域——预防服务、急性护理和慢性护理——为创造性地应用改进策略提供了机会，这些策略有可能惠及儿童的健康和福祉。在过去二十年中，质量改进方法已从强调检查护理的结构方面和实施制裁转变为更具动态性的策略，这些策略强调测量和比较以推动变革；利用证据确定改进目标；以及采用从商业和社会科学借鉴的各种管理策略来实现这些目标。这些现代质量改进方法很少经过对其有效性的严格测试。此外，它们在儿科的应用不如在成人医疗保健中广泛。对于儿童而言，健康服务的几个方面，如慢性病相对罕见、社会因素对健康的重要影响以及成本有限，使得其中一些方法更具挑战性，可能需要新方法或有意义的调整。
开展研究以更好地理解改进的一般过程将有益于儿童的改进工作。建立关于儿童最佳实践知识基础的研究——有效性研究——也将增强改善儿童健康护理系统的能力。通过有针对性的研究可以提高儿童护理质量，这些研究既要考察促进社会各阶层改进的方法，又要提出使护理建议更能适应儿童发育和环境背景的建议。支持将儿童观点纳入护理的研究在执行上极具挑战性，但对于改善儿科护理至关重要。
