Introduction to the Special Issue: Quality Improvement in Pediatric Psychology

The Quality Improvement movement grew out of two reports from the Institute of Medicine (IOM) on the quality and safety of healthcare in the United States, ‘‘To Err is Human: Building a Safer Health System’’ (Kohn, Corrigan, & Donaldson, 1999) and ‘‘Crossing the Quality Chasm: A new Health System for the 21st Century’’ (Institute of Medicine, 2001). In the 2001 Crossing the Quality Chasm report the IOM bluntly stated, ‘‘Between the healthcare we have and the care we could have lies not just a gap, but a chasm.’’ The United States has one of the most expensive and technologically advanced systems of care, with the most highly trained, technically proficient and bestmotivated providers; yet millions of Americans do not receive proven, effective treatments that can save lives, millions suffer because they are exposed to unnecessary health services, and a large number are injured because of preventable complications of medical treatment that could be averted (Chassin & Galvin, 1998). Since these reports, healthcare reform has moved to the forefront of important concerns facing our nation and is the number one priority for President Obama and his administration. The central goals of the healthcare reform effort are to contain costs, currently estimated to hit 17.6% of the gross domestic product in 2009 (Henry J. Kaiser Family Foundation, 2009), and to do so by delivering care that works (Obama, 2009). Indeed, the Obama administration is carefully studying the data from the Dartmouth Atlas Project which generates comprehensive analysis of healthcare trends based on Medicare data, demonstrating that higher expenditures and more procedures are not related to better outcomes (Fisher, Goodman, Skinner, & Bronner, 2009). ‘‘At the core of both the stimulus bill and Obama’s budget is Orszag’s [the White House Budget Director] belief that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient health care providers, thus saving billions of dollars.’’ (Lizza, 2009). Notably, one of the six aims for improving healthcare that came out of the IOM’s Quality Chasm Report is increasing effectiveness of healthcare, defined as matching care to science, thereby avoiding overuse of ineffective care (i.e., use of healthcare resources and procedures in the absence of evidence they can help patients) and underuse of effective care (i.e., the failure to provide healthcare services or practices that are of proven benefit) (Berwick, 2002). Evidence based treatments are those that have produced therapeutic change in controlled trials (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996), Similar to clinical effectiveness research, QI seeks to apply proven treatments to ‘‘real world’’ patients. Clinical effectiveness research typically applies an intervention shown to be efficacious in a randomized clinical trial to a broader clinical population, often in a clinical setting. The clinical effectiveness model is most often implemented in the context of a randomized design in which the emphasis is on treatment fidelity and examining the effectiveness of treatment for a group of patients who are more typical of how patients present in the clinical setting and not those carefully screened for an efficacy trial. While similar in intent with clinical effectiveness, QI science does not follow the typical research paradigm of randomizing patients to different treatments, but instead borrows process-improvement methods from manufacturing to integrate evidence-based treatments into healthcare by focusing on improvements at the system level of care. As described in the articles in this special issue, QI sets up a series of iterative improvement cycles known as Plan, Do, Study, Act (PDSA) in which the best evidence is systematically applied to every patient and outcomes are collected on every patient. A PDSA can target implementation of best evidence as well as the effects of best