Jean L. Raphael MD, MPH is an Professor of Pediatrics and Vice Chair for Clinical Affairs at Baylor College of Medicine, where he is also Director of the Center for Child Health Policy and Advocacy. He is a pediatrician and health services researcher with expertise in minority health policy. He received his MD at Harvard Medical School and Master of Public Health at Harvard School of Public Health with a concentration in Healthcare Management and Policy. He completed his pediatric residency, including chief residency, at Children’s Hospital Boston. After clinical training, Dr. Raphael completed the Commonwealth Fund Harvard University Fellowship in Minority Health Policy.
Dr. Raphael’s work combines health services research and behavioral interventions to enhance care delivery for minority children with chronic conditions. He is currently principal investigator on NIH and Aetna Foundation funded studies. Dr. Raphael leads several key research projects that include: developing a patient navigator intervention for children with sickle cell disease, assessing the impact of the patient-centered medical home on health outcomes and health inequities among children with special health care needs, and examining how the erosion of employer sponsored insurance influences the health care of children with special health care needs. Dr. Raphael's research is complemented by policy efforts toward improving the care of vulnerable populations. Over the past several years, Dr. Raphael has assumed an increasing leadership role in advocating for policy to improve the outcomes of vulnerable populations. He has testified in public hearings on health disparities in both Massachusetts and Texas. In 2009, Dr. Raphael was appointed to the Texas Health Disparities Task Force by the Lieutenant Governor. He has authored a strategic plan to address health disparities with approval by the Texas Health and Human Services Commission. Dr. Raphael is also a member of the Medical Home Workgroup through the Texas Department of State Health Services. Nationally, he serves on the Public Policy and Advocacy Committee and the Medical Home Workgroup of the Academic Pediatrics Association. Dr. Raphael is also a member of the American Academy of Pediatrics and AcademyHealth. He is President-Elect of the Academic Pediatric Association.
Jean Le Clerc Raphael, MD, MPH
Division Chief, Academic General Pediatrics; Director, Center for Child Health Policy and Advocacy; Vice Chair for Clinical Affairs; Professor of Pediatrics; Department of Pediatrics; Baylor College of Medicine, Houston, TX; President Elect, Academic Pediatric Association
2011
2010
2009
2008
2007
Dr. Jean Le Clerc Raphael is now the founding Director of the Center for Child Health Policy and Advocacy at Texas Children’s Hospital (TCH). This Center reflects a groundbreaking institutional commitment to comprehensively serve the needs of children through advancement of impactful policy and advocacy.
Opportunities to Improve Pediatric Emergency Services Using Reliability Concepts
Background:
Since the Institute of Medicine’s publication of To Err is Human and Crossing the Quality Chasm, there has been an increasing focus on quality in the healthcare delivery system. Historically, measures of healthcare quality for pediatric emergency services have not been as well developed as those for adults. In 1993, the Institute of Medicine published Emergency Medical Services for Children which reviewed the nature and extent of pediatric emergencies and the emergency care available to children. It also provided general recommendations to improve pediatric emergency services.
Here, we apply reliability principles as a quality framework to the state of pediatric emergency services. Reliability principles—methods of evaluating, calculating, and improving the overall reliability of a complex system—have been used effectively in industries such as aviation to improve safety. To apply reliability, a system’s ability to avoid failure is categorized according to different processes with corresponding levels of performance. 10-1 performance indicates no articulated common processes. 10-1 characteristics include protocols and standards. It yields a defect rate of 10%. 10-2 performance indicates processes with medium to high variation. 10-2 characteristics include error proofing and specific safeguards against human error. It is associated with a defect rate of 1%. 10-3 performance indicates a well-designed system that focuses on processes, structure, and their relationship to outcomes. 10-3 characteristics include emphasis on the interaction of systems. Its corresponding defect rate is 0.1%.
Our rationale for this study is that emergency settings that care for children should function as highly reliable organizations with improvement minimally aimed at the 10-2 level. The objectives of this study were to 1) assess current data on established pediatric emergency performance levels and 2) identify processes in place to improve care.
Methods:
A Medline search was conducted to identify established performance levels for pediatric emergency services. CDC preparedness results on pediatric emergency services, expertise, and equipment were restated into reliability measures. A web search of pediatric and emergency medicine societies was conducted to identify processes in place to improve guidelines and procedures. A qualitative study was conducted with pediatric emergency experts to identify priorities for improvement.
Results and Conclusions:
There are very limited data on established performance levels in pediatric emergency services. Existing data show poor reliability with high failure rates. There are little systematic strategies in place to improve processes. Current efforts for improvement will most likely result in only 10-1 performance.
Recommendations:
In order to attain 10-1 performance, pediatric emergency services must maintain national standards for performance. Clinical practice guidelines must also be adopted at a national level. In order to achieve 10-2 performance, we recommend that pediatric emergency services implement computer order entry, automate processes, and incorporate innovative concepts such as patient satisfaction guarantees.
Faculty Preceptors:
Peter Lachman, MD, Institute for Healthcare Improvement
Charles Homer, MD, MPH, National Initiative for Children’s Healthcare Quality
