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Improving the Quality of Care Delivered to Children Served by State Agencies

Changing Care Delivery


Charles J. Homer, M.D., M.P.H., Executive Director, National Initiative for Children's Healthcare Quality, Institute for Healthcare Improvement, Boston, MA.

Components of each health care system include:

  • Policy and broad environmental context—e.g., patient bills of rights, Federal quality regulations, media attention, and election issues.
  • Organizational environment—e.g., leadership, financial incentives, and staffing models.
  • Micro-system—e.g., the core team of health care professionals, population served, information system, support staff, equipment, and work environment.
  • Patient and consumer.

Current efforts to improve health care tend to emphasize the policy and broad environmental context to the greatest extent, then organizational environments and patients and consumers. Rarely is the emphasis placed on the micro-system of the clinical practice.

A multi-faceted approach may have greatest success in changing the clinical practice micro-system. Many factors influence clinical practice, including society in general, the practice environment, beliefs of both providers and of patients and consumers, knowledge, and incentives. Physicians generally have the knowledge, skills, and desire to help their patients. Problems arise when the micro-system does not facilitate good care.

Data can motivate change by answering the question "How will we know that a change is an improvement?" A strategy for gathering and examining clinical data is "Next 10 Patients." This involves asking 10 patients or their parents specific questions related to the activities of their office visits, reviewing the chart information related to these 10 visits, and asking the clinician for his or her view of the specifics of these visits. Discrepancies in the reports of these three sources will highlight flaws in the system.

Provider teams can receive training on selected topics through programs such as "The Breakthrough Series" developed by the National Initiative for Children's Healthcare Quality. In "The Breakthrough Series", teams participate in three 1.5-hour sessions. Between these sessions, participants follow the Plan-Do-Study-Act cycle to change an aspect of their practice. Teams are encouraged to partner with community members.

Tools are both disease specific and overall quality improvement oriented. Providing tools without providing the necessary knowledge on why and how to use them results in non-use.

Supports include E-mail, visits, phone calls, conference calls, documents, and assessments.

The Lumberton Children's Clinic in North Carolina is an example of this approach. To improve severity classification of its asthmatic patients, the Clinic conducted several Plan-Do-Study-Act cycles.

Cycle One

  • Plan: Find and label charts of all asthmatic patients.
  • Act: Do a computer run of all asthmatics (n = 3500).
  • Learning: Too many patients to label.

Cycle Two

  • Plan: Start with the patients in the practice who have the most severe symptoms.
  • Act: Look at asthmatics seen in the emergency room and the office in the last two months, and at those identified as they come into the office.
  • Learning: Easy to accomplish.

Cycle Three

  • Plan: Is a management plan in each chart?
  • Act: Assess 10 charts weekly.
  • Learning: A plan is in 7 of 10 charts. Results are posted to help staff "see" the system for improvement.

Barriers to changing micro-systems include turmoil, time, and communication. Address the barriers by:

  • Engaging leadership, through such strategies as endorsement by a guiding coalition and regular reports about performance.
  • Planning for "spread" from the start, through such strategies as outlining leadership expectations, selecting the team, and making successes visible.

Actions that State agencies can take to facilitate health delivery system change include:

  • Forming guiding coalitions and engaging clinical leadership.
  • Using measurement for motivation and improvement.
  • Undertaking collaborative improvement, drawing on local leadership, and maintaining high expectations and support.
  • Building in strategies for "spread" by making changes visible, engaging opinion leaders, and removing obstacles.


Berwick DM. Sounding Board, Continuous Improvement as an Ideal in Health Care. N Engl J Med 1989; 320(1):53-6.

Berwick DM. Eleven Worthy Aims for Clinical Leadership of Health System Reform. JAMA 1994, Sep; 272(10):797-802.

Berwick DM, Nolan TW. Physicians as Leaders in Improving Health Care: A New Series in Annals of Internal Medicine. Ann Intern Med 1998, Feb; 128(4):289-92.

Heinrich P, Homer CJ. Improving the Care Children with Asthma in Pediatric Practice: the HIPPO Project. Ped Ann 1999, Jan; 28(1):64-72.

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