42Дependency: Children depend on caregivers for many aspects of care. Developmental changes also affect the extent to which children's own assessments can be used to measure aspects of quality, such as patient-centeredness and timeliness.

For example, different schedules and types of immunizations should be measured at different ages. These changes should be taken into account when developing and using measures. One of the first areas of focus for the Alliance for Pediatric Quality will be operationalizing quality improvement in pediatric health care through the use of quality measures, evidence-based medicine, health information technology, shared data, and policy to systematically improve children's health care.Дevelopment: Children experience rapid developmental changes during infancy, childhood, and adolescence. The founding member organizations represent large segments of the pediatric health care community and bring unique and synergistic perspectives to the field of quality care for children. 34 The Alliance for Pediatric Quality was formed by 4 organizations recognized as leaders in pediatric care-the AAP, the American Board of Pediatrics, the Child Health Corporation of America, and the National Association of Children's Hospitals and Related Institutions-which came together to establish a unified voice for issues related to improving the quality of pediatric health care. THE USE OF MEASURESДЇinally, the new Alliance for Pediatric Quality recently launched the Improve First plan to select improvement priorities on the basis of pediatric health care issues that have broad impact and for which there are ongoing, evidence-based improvement programs with associated quality measures. For patients of all ages, safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity are important as well. Pediatric quality measures should also address care at the beginning of life that affects infant mortality and morbidity and the transitions in care throughout the life span. Also, as pediatricians treat increasing numbers of children with chronic illnesses, they may increasingly face management of end-of-life issues. Management of conditions such as upper respiratory infections, acute otitis media, acute gastroenteritis, and bronchiolitis deals with вЂњgetting better.вЂќ The component вЂњliving with illness or disabilityвЂќ addresses the fact that pediatricians routinely manage children with special health care needs (ie, congenital heart disease, cancer, chronic lung disease, diabetes, and ADHD). A significant amount of pediatric health care, such as well-child care, focuses on the вЂњstaying healthyвЂќ part of the matrix. The inclusion of consumer perspectives on health care needs in the matrix is helpful in framing the pediatric approach to quality.

Payers and purchasers are increasingly interested in measures of efficiency, which has been defined as the cost of care associated with a specified level of quality of care. 13 FAACT, a now-closed national not-for-profit organization, coordinated the development of several child quality-measurement tools aligned with this framework under the rubric of the still-operating Child and Adolescent Health Measurement Initiative.

The Foundation for Accountability highlighted consumer needs with regard to navigating the health care system by identifying 4 domains: staying healthy, getting better (acute care), living with illness (chronic care), and care at the end of life. The IOM 14 specified 6 domains for improving quality: safety, timeliness, effectiveness, efficiency, equity, and patient/family-centeredness. Frameworks for assessing and reporting health care quality 13 recommend that quality measures be available across a range of quality domains and address consumer needs across the continuum of care.

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