The Author Responds

I appreciate the comments of Strasser and colleagues in response to the articles on pediatric rehabilitation quality indicators, ^,  and my commentary on them. As they note, we are in agreement on many points, but they suggest a need to focus more intensively on rehabilitation team functioning as another quality indicator. As noted in my commentary, I view structural and process measures as indicators of the types of environments and procedures that are likely to promote delivery of optimally therapeutic experiences. I agree, that among these structure and process measures, team composition and team functioning are likely very important. Having expertise represented on the team will not affect patient care unless team members are comfortable sharing their expertise, unless the sharing of views is well organized and leads to implementable plans, among others. Nevertheless, unless that superior team functioning results in actual differences in treatment decisions for patients or caregivers, I would argue that it cannot affect the quality of outcomes, and thus remains an indirect indicator. That said, we are currently at a very primitive stage of defining the active ingredients of the specific treatments we deliver to patients, which are the ultimate determinants of quality outcomes. Thus, for the foreseeable future, indirect measures of structure and process—including team functioning—may well be the most useful quality indicators we can lay our hands on.