Established Child Health Care Quality Measures
Child and Adolescent Health Measurement Initiative (CAHMI): Promoting Healthy Development Survey (PHDS)
Contents
The Promoting Healthy Development Survey© (PHDS) assesses national recommendations for preventive and developmental services for young children such as those included in the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents—Third Edition. The PHDS is a survey of parents or guardians of children 3-48 months of age. Information is gathered on the following issues:
- Anticipatory guidance and parental education by a doctor or other health provider.
- Health information.
- Developmental surveillance: Ask about and address parents' concerns about their child's learning, development, and behavior.
- Standardized screening for developmental, behavioral, and social problems.
- Followup for children at risk for developmental, behavioral, or social problems.
- Assessment of psychosocial well-being and safety in the family.
- Assessment of smoking, drug, and alcohol use in the family.
- Family-centered care (experience of care).
- Helpfulness and effect of care provided.
The PHDS is endorsed by The National Quality Forum as a valid measure for system, plan, and provider-level assessments. The online PHDS is provisionally approved by the American Board of Pediatrics to fulfill components of the Maintenance of Certification requirements.
The PHDS was developed under the rubric of the Child and Adolescent Health Measurement Initiative (CAHMI) (http://www.cahmi.org 
). The CAHMI was established in 1998 by the Foundation for Accountability (FACCT) and the National Committee for Quality Assurance (NCQA) with funding from The David and Lucille Packard Foundation, The Commonwealth Fund, the Federal Agency for Healthcare Research and Quality, the Maternal and Child Health Bureau of the Health Resources and Services Administration, and the Centers for Medicare & Medicaid Services. The purpose of the CAHMI is to provide leadership and resources for measuring and communicating information about health care quality for children and adolescents. The CAHMI currently is housed at Oregon Health & Sciences University (OHSU) in the Pediatrics Department and is guided by a broad-based advisory committee.
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Availability
The PHDS is available free of charge on the CAHMI Web site (http://www.cahmi.org ) and can be administered by mail, telephone, online (http://www.onlinephds.org ), and in pediatric offices. All versions are available in English, and some versions are available in Spanish. Guidelines for implementing the PHDS using various methods are available on the CAHMI Web site. Please contact CAHMI staff at cahmi@ohsu.edu for more information.
Online Resources:
For more information on CAHMI, go to: http://www.cahmi.org. The specific Web site for the online version of the PHDS is http://www.onlinephds.org.
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Child Measures
Included
The PHDS assesses the following aspects of preventive and developmental care for young children:
- Whether parents receive anticipatory guidance and parental education from health care providers on topics such as:
- Physical care of child.
- Child development and behavior.
- Protecting the child from injuries.
- Health information.
- Developmental surveillance: Ask about and address parents' concerns about their child's learning, development, and behavior.
- Standardized screening for developmental and behavioral delays.
- Followup for children at risk for developmental, behavioral or social problems.
- Assessment of psychosocial well-being and safety in the family.
- Assessment of smoking, drug, and alcohol use in the family.
- Family-centered care (experience of care).
- Helpfulness and effects of care provided.
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Users
The PHDS is used to assess health care quality at the national, State, county, geographic region, health plan, medical group, office, and individual health care provider levels.
To date, more than 45,000 surveys have been collected by Medicaid agencies, health plans, and pediatric practices and nationally through the National Survey of Early Childhood Health (NSECH). Components of the PHDS are also in the National Survey of Children's Health. Examples from users include the following:
- Three health plans as part of their quality improvement projects (two in California, one in Ohio).
- The State of Maine, as part of its Medicaid quality improvement effort. The State did analysis at the program (FFS, PCCM), geographic (rural, urban), and practice level.
- The State of Washington, as part of its Medicaid quality improvement efforts. The State did analysis at the health plan, program (FFS, PCCM), and county levels.
- Washington, Vermont, North Carolina, Ohio, Louisiana, Minnesota, and Mississippi Medicaid programs have used PHDS-PLUS to collect baseline information about early childhood services.
- The National Survey of Early Childhood Health and the National Survey of Children's Health (NSCH) used components of the PHDS to collect information about young children.
- Five pediatric practices implemented the PHDS for analysis at the medical group, office, and provider levels.
- Healthy Development Learning Collaborative used the ProPHDS to evaluate improvement efforts.
- The pediatrics department of Kaiser Permanente-Northwest is implementing the PHDS to collect information at the system, office, and provider levels.
- Researchers from the Center for Child and Adolescent Health Policy used the PHDS to evaluate quality of care by whether the provider spoke the same language and/or had the same race-ethnicity as the child's family.
- The Early Developmental Screening & Intervention (EDSI) Collaborative is using the PHDS to guide and evaluate improvement efforts.
- The Children's Health Alliance of Oregon (a not-for-profit association of 110 private practice pediatricians throughout the Portland/Vancouver metropolitan area) used the online PHDS to gather data to inform future quality improvement activities.
Online Resources:
The CAHMI Web site (http://www.cahmi.org ) has guidelines and implementation manuals for using the PHDS. These manuals include detailed instructions for how to administer, score, and use the PHDS. Example reports and testimony from users are available. The manuals on the CAHMI Web site are written specific to the method of administration (mail, telephone, online, in pediatric offices) and provide tips for specific kinds of users (e.g. Medicaid, health plans, front-line providers). The specific section of the CAHMI Web site focused on the online version of the PHDS is http://www.onlinephds.org.
For more information about the National Survey of Early Childhood Health, go to: http://www.cdc.gov/nchs/about/major/slaits/nsech.htm.
For more information about the National Survey of Children's Health, go to: http://www.cdc.gov/nchs/about/major/slaits/nsch.htm.
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Comparisons
and Trends
PHDS results can be used for statistically significant comparisons among health plans, programs, and health care providers. Results can also be used for trending over time provided that the same or comparable populations are being surveyed and that the same mode of administration and version of the PHDS instrument are used.
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Benchmarking
and Databases
CAHMI has worked collaboratively with a majority of the PHDS users and maintains the data related to these applications. Benchmark data findings are presented in the implementation manuals specific to the version and mode of administration that are posted on the CAHMI Web site (http://www.cahmi.org ). At this time, the CAHMI benchmark database is not publicly available.
NSECH and NSCH findings are available on the Centers for Disease Control and Prevention (CDC) Web site (http://www.cdc.gov/nchs/about/major/slaits/nsech.htm). A majority of the items in the NSECH focused on assessing the quality of preventive and developmental health care are derived from the PHDS.
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Service Delivery
and Units of Analysis
PHDS data can be collected and analyzed for multiple units of analysis:
- Geographic region (national, State, county).
- Payer (e.g. Medicaid).
- Program level (health plan, PCCM, or FFS).
- Medical group.
- Office level.
- Individual health care provider and/or provider teams of a doctor and nurse.
- Child and/or parent health, health care, and sociodemographic characteristics.
Results of the PHDS can be used to report eight composite measures assessing domains of preventive and developmental health care recommended for young children:
- Anticipatory guidance and parental education by a doctor or other health provider.
- Health information.
- Developmental surveillance: Ask about and address parents' concerns about their child's learning, development, and behavior.
- Standardized screening for developmental and behavioral delays.
- Followup for children at risk for developmental, behavioral, or social problems.
- Assessment of psychosocial well-being and safety in the family.
- Assessment of smoking, drug, and alcohol use in the family.
- Family-centered care (experience of care).
- Helpfulness and effect of care provided.
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Length-of-Enrollment
Requirements
The length-of-enrollment requirements depend on the purpose for implementing the PHDS and upon the place of administration.
- The in-office administration of the PHDS to assess at the office or individual health care provider level has a visit-based requirement rather than an enrollment-based requirement. This is because most pediatric offices do not have "enrolled" children, and the survey is instead given to parents whose children receive health care at the office.
- For administration at the health plan level, the PHDS recommends that Medicaid children be enrolled at least 6 months, with a break of no more than 30 days. Children with employer-based insurance must be enrolled at least 12 months, with a break of no more than 45 days.
- These rules generally apply to other assessments at the program (PCCM, FFS) and other levels.
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Data Issues
The PHDS can be administered in person, online, by mail, or by telephone. The following manuals on the CAHMI Web site (http://www.cahmi.org ) describe how to collect, analyze, and report the data.
The In-Office Administration of the PHDS Reduced-Item Survey, available on the CAHMI Web site, provides detailed information about how to implement a reduced-item survey in office settings where health care is provided to young children.
Guidelines for Implementing the Promoting Healthy Development Survey provides detailed information about how to plan a PHDS project, administer the survey via mail or telephone, and score and report the survey findings to multiple stakeholders.
The Promoting Healthy Development Survey-PLUS (PHDS-PLUS) Implementation Guidelines describe how Medicaid agencies and other users can implement the telephone-administered version of the PHDS-PLUS.
For the online survey, providers or health systems can customize the online PHDS to meet their measurement and improvement needs by completing the Online Survey Users Form and specifying the following:
- Content: Users can choose to have parents answer the full PHDS, which takes approximately 15 minutes to complete, or only specific sections for which improvement efforts will be focused.
- System, Office, and/or Provider-Level Feedback Reports: Users can choose whether system, office, and/or provider-level reports will be created. After completing the Online Survey Users Form, registered clinicians and health systems will receive access to a password-protected Web site on which customized administration materials, the data feedback reports, and quality improvement tips and resources are provided.
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Sample Sizes
The Online Promoting Healthy Development Survey Provider Toolkit provides detailed information about the sample sizes needed for online application of the PHDS.
The Guidelines for Implementing the Promoting Healthy Development Survey and the Promoting Healthy Development Survey-PLUS (PHDS-PLUS) Implementation Guidelines provide detailed information about the sample sizes needed for specific applications of the PHDS.
The In-Office Administration of the PHDS Reduced-Item Survey provides detailed information about sample sizes needed to assess at the office and/or health care provider level.
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Resource and
Burden Issues
The production of performance measures
is a data-driven activity. Credible survey data require close attention
to proper sampling methods and adherence to survey administration protocols.
These take time and money. Senior-level agency responsibility and sufficient
staff resources are needed to ensure useful results.
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Development
Process
The PHDS was developed and tested through
support from The Commonwealth Fund. It is one of three measurement sets
recommended for use by the national advisory committee of the CAHMI.
A standard and rigorous six-stage process was used
to develop the PHDS, beginning with focus groups with families to identify
the aspects of health care quality that are important to parents in
the area of preventive care for their children. A review of the literature
was conducted, including over a dozen parent surveys on early childhood
development, family-centered care, and other topics; encounter forms;
and checklists used by clinicians to help with the provision of anticipatory
guidance and the assessment of young children and their families.
The six-stage development process included:
- Development of conceptual framework
and investigation of relevance of measure.
- Development of a starting-point
measurement proposal, including initial feasibility studies.
- Development of draft instrument
and implementation methodology.
- Field testing (minimum of three
sites).
- Revision and refinement of survey,
survey administration protocol, and scoring protocol.
- Development of scientific and technical
documentation and larger scale implementation and dissemination.
In the early stages of developing the
PHDS, many existing surveys and tools were reviewed, particularly those
methods designed to evaluate the Healthy Steps project or previously
validated survey-based tools (e.g., Parental Evaluation of Development
Status). Although many of the PHDS survey concepts reflect those represented
in these surveys and tools, nearly all of the PHDS items were newly
developed due to a lack of available, tested candidate items appropriate
for performance assessment in a self-administered survey. The PHDS is
the first parent-reported survey specifically designed and tested for
comprehensive performance assessment of preventive and developmental
health care for young children.
Three advisory groups
within the CAHMI, comprised of pediatricians, family practitioners,
consumer representatives, public health experts, and researchers, regularly
reviewed and provided input on the identification of quality measurement
topics and the development of the PHDS.
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Criteria
Used
The following criteria were used to
select topics assessed in the PHDS survey:
- Appropriateness for all
children 3-48 months old.
- Strength of scientific
evidence.
- Professional consensus.
- Lack of more reliable,
valid, or efficient way to measure the topic.
- Importance of topic to
parents as ascertained from cognitive interviews and focus groups.
- Ease with which topic
can be validly and reliably reported by parents.
- Parsimony (e.g., topic
is not already largely represented by another, related topic in the
PHDS).
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More Information
and User Support
Online Resources:
Partnering with Parents to Promote the Healthy Development of Young Children Enrolled in Medicaid, the results of the PHDS survey conducted in three States, is available on the CAHMI Web site. Go to: http://www.cahmi.org .
Key Measurement Issues in Screening, Referral, and Follow-Up Care for Young Children's Social and Emotional Development, by Colleen Reuland and Christina Bethell, is available from the National Academy for State Health Policy. Go to: http://www.nashp.org/Files/measurement_paper_for_web_final_4.7.05.pdf.
More information about the PHDS survey
development process can be found in "Assessing health system provision
of well-child care: The Promoting Healthy Development Survey," an article
by Christina Bethell, Colleen Peck, and Edward Schor published in the
May 2001 issue of Pediatrics 107(5):1084-94. Abstract available on PubMed®.
Bethell, C, Reuland CH, Halfon N, Schor E. Measuring the quality of preventive and developmental services for young children: National estimates and patterns of clinicians' performance. Pediatrics 2004 Jun; 113(6 Suppl):1973-83.
Blumberg SJ, Halfon N, Olson LM. The National Survey of Early Childhood Health. Pediatrics 2004 Jun; 113(6 Suppl):1899-906.
For more information, contact CAHMI staff at cahmi@ohsu.edu or visit CAHMI's Web site. Go to:
http://www.cahmi.org.
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Overview / CAHPS® / AHRQ QIs / HEDIS® / Title V / CAHMI-YAHCS
State Report Examples / Mental Health Quality Measures
Internet Citation:
Child Health Care Quality Toolbox: Established Child Health Care Quality Measures—Child and Adolescent Health Measurement Initiative (CAHMI): Promoting Healthy Development Survey (PHDS). August 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chtoolbx/measure6.htm
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