Implementation of a Preventive
Services Bundle in Academic
Pediatric Primary Care Centers
Zeina Marcho Samaan, MD, Courtney M. Brown, MD, MS, John Morehous, MD, Alison
A. Perkins, BA, Robert S. Kahn, MD, MPH, Mona E. Mansour, MD, MS
BACKGROUND AND OBJECTIVES: Previous studies have documented poor rates
of delivery of preventive services, 1 of the core services provided in the
primary care medical home setting. We aimed to increase the reliability
of delivering a bundle of preventive services to patients 0 to 14 months
of age from 58% of patient visits to 95% of visits. The bundle includes
administration of routine vaccinations, offering influenza vaccination,
completed lead screening, completed developmental screening tool,
screening for maternal depression and food insecurity, and documentation
of gestational age.
METHODS: The setting was 3 academic pediatric primary care clinics that serve
31 000 patients (>90% Medicaid). Quality improvement methodology was
used and key driver diagram was determined. Patient “Ideal Visit Flow”
and the Responsible, Accountable, Support, Consulted, and Informed Matrix
were developed to drive accountability for components of the ideal flow.
Plan, Do, Study, Act cycles were used to develop successful interventions.
The percent of patients seen who received all bundle elements for which
they were eligible was plotted weekly on a run chart, and statistical
process control methods were used to determine a significant change in
performance.
RESULTS: The preintervention percentage of patient visits ages 0 to 14
months receiving all preventive service bundle elements was 58%. The
postintervention percentage is 92%.
CONCLUSIONS: Innovative redesign led to improvement in percentage of
patients age 0 to 14 months who received the entire preventive services
bundle. Key elements for success were multidisciplinary site-specific teams,
redesigned visit flow, effective communication, and resources for data and
project management.
More than 10 years ago, the Institute
of Medicine called attention to the
suboptimal performance of the
United States health care system,
concluding: “Current care systems
cannot do the job. Trying harder will
not work. Changing care systems
will.”1 In pediatrics, a 2007 publication
revealed that patients receive only
41% of indicated preventive services.2
Past efforts to improve quality in
pediatric primary care have focused
mostly on individual services, such
as improving immunization rates3
or lead screening.4–6 Yet, pediatric
practices continue to struggle
with comprehensively delivering
preventive services in light of lengthy
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PEDIATRICS Volume 137, number 3, March 2016:e20143136
abstract
Division of General and Community Pediatrics, Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio
Dr Samaan was involved in conceptualization and
design of the study, data analysis, and drafted the
initial manuscript; Drs Brown, Morehous, Kahn, and
Mansour also contributed to the conceptualization
and design of the study, data analysis, and reviewed
and revised the manuscript; Ms Perkins designed
the electronic data retrieval program and analyzed
the data; and all authors approved the final
manuscript as submitted.
DOI: 10.1542/peds.2014-3136
Accepted for publication Jul 13, 2015
Address correspondence to Zeina Marcho Samaan,
MD, Cincinnati Children’s Hospital Medical Center,
ML 2011, 3333 Burnet Ave, Cincinnati, OH 45229.
E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no financial relationships
relevant to this article to disclose.
FUNDING: This study was conducted with internal
funding from the Cincinnati Children’s Hospital
Medical Center and the Division of General and
Community Pediatrics.
POTENTIAL CONFLICT OF INTEREST: The authors
have indicated they have no potential conflicts of
interest to disclose.
To cite: Samaan ZM, Brown CM, Morehous J,
et al. Implementation of a Preventive Services
Bundle in Academic Pediatric Primary Care
Centers. Pediatrics. 2016;137(3):e20143136
QUALITY REPORT
health maintenance guidelines and
short visits.7–12 The challenges of
delivering comprehensive well
child care underscore the need
for true system transformation
rather than intense focus on a
single measure. In other areas of
medicine, “bundle measures” have
been used to measure whether every
patient receives every service every
time.13–15
We identified 1 previous study
of a bundle measure in pediatric
primary care. This bundle
included services related only to
physical health (immunization,
lead screening, anemia, and
tuberculosis) and was implemented
in nonacademic practices.16 This
2004 study demonstrated that it
is possible to improve care across
multiple measures through system
improvement. However, changes in
the scope of well child care in the
past decade call for a more broadly
defined measure that includes
services beyond screening for
physical illness and exposures.17
Locally, our medical center was
redesigning primary care, with
a global aim to improve health
promotion, chronic disease
outcomes, and patient and family
experience, while decreasing cost
of care at a population level. The
intervention described in this article
focuses on our goal to improve
health promotion. The scope of this
quality improvement (QI) study was
to improve delivery of preventive
services, including assessment of
development and family well-being,
during visits at our 3 primary care
centers in the first 14 months of life.
We aimed to measure and improve
a “preventive service bundle” of 5
indicators of promoting an infant’s
physical health, cognitive and social
development, and family well-being.
We used an all-or-none bundle
measure to obtain a more accurate
picture of the quality of care that
individual patients received18 during
office visits. We theorized that,
e2
by monitoring performance on a
bundle measure and using the data
to drive small tests of change, we
could optimize performance during
each stage of an office visit (eg,
registration, intake, order entry).
We could then clearly define roles,
standardize processes, and transform
our system to achieve highly reliable
preventive service delivery.19 We
aimed to improve the percentage of
visits at which patients received all
bundle elements for which they were
eligible from 58% to 95% within 1
year.
METHODS
Setting
Cincinnati Children’s Hospital
Medical Center (CCHMC) has 3
primary care centers involved in
primary care redesign. Sites 1 and
2 (urban) and site 3 (suburban) are
the medical homes for ~18 000,
7000, and 6000 patients, with
~37 000, 14 000, and 15 000 visits,
respectively, per year. The payer mix
is uniform across the centers: 90%
Medicaid, 3% private insurance,
and 7% self-pay/uninsured. All 3
sites train large number of learners.
All sites have been using Epic, an
electronic health record (EHR), since
May 2011. In 2012, CCHMC and the
Division of General and Community
Pediatrics invested $250 000 to
conduct a large-scale primary care
redesign that aimed to improve
health promotion and prevention,
outcomes for children with chronic
diseases, patient and family
experience, and decrease cost of care.
This article focuses on 1 phase of the
redesign and describes the QI tools
and processes used to improve health
promotion and prevention for infants
in our patient population. This
study was granted exemption by the
CCHMC Institutional Review Board.
Study Population and Outcome
We sought to design a
comprehensive, efficient, and
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effective preventive service delivery
system. We focused on the first 14
months of life when opportunities
are greatest for engaging families in
primary care.20
The following services were selected
for inclusion in the bundle of
preventive services that all infants
should receive during the first 14
months of life: administration of
routine immunizations, seasonal
influenza vaccination offer,
lead screening, standardized
developmental screening using
Ages and Stages Questionnaire,
and screening for bio-psychosocial
risk factors including gestational
age, parental depression, and food
insecurity. These services were
chosen by the primary care redesign
steering committee, explained below,
based on American Academy of
Pediatrics recommendations,21 with
minor modifications.
Team Structure
A team structure was developed to
support all phases of the primary
care redesign. Some of the team’s
time focused on preventive services
for infants. The team included the
following: (1) a steering committee
that provided overall guidance
and consisted of a project sponsor,
project leader, physicians, patient
services manager, business director,
QI consultant, and advisors; (2)
a project manager that guided
resources to achieve specific goals;
(3) support teams that provided
content expertise on family
engagement, training, finance,
resident education, QI data analysis,
information technology (IT), and
communication; and (4) sitebased teams at each of 3 primary
care clinics spearheaded the work
while participating in a hands-on
QI training program. Participating
physicians did not have extra
protected time. Nurses and medical
assistants (MAs) received payment
for the hours they spent in these
planning and training activities. At
SAMAAN et al
a staff kick-off meeting, the project
vision, mission, and goals were
reviewed and feedback was collected.
An office system inventory22
was used to provide a baseline
assessment of our preventive
services delivery system. Our
redesign aligned with the National
Committee for Quality Assurance/
Patient Centered Medical Home
requirements.23
Development of Key Driver Diagram
and Interventions
Improvement work began in June
2012. Preventive service support and
site-based teams met throughout the
planning and implementation phases
to develop a theory of change, plan
tests of change, and review data. The
Model for Improvement was used.24
This model is based on 3 fundamental
questions: (1) What are we trying to
accomplish? (2) How will we know
that a change is an improvement? (3)
What changes can we make that will
result in improvement? The team
organized its theory of change by
using a key driver diagram25 (Fig 1).
Interventions were tested by using
Plan, Do, Study, Act cycles.24
Optimizing patient visit flow was
expected to improve preventive
service bundle delivery. The project
manager, consultant, and site-based
teams mapped the detailed existing
patient visit flow for each clinic. Clinic
staff roles and responsibilities were
identified by using a Responsible,
Accountable, Support, Consulted,
and Informed (RASCI) Matrix. RASCI
is an acronym derived from the 5
responsibilities most typically used:
Responsible, Accountable, Support,
Consulted, and Informed. This
matrix describes the participation by
various roles in completing tasks26
and allows for prioritization of work.
The current process map and RASCI
matrix were used to develop ideal
patient visit flow with the goal of
optimizing each care team member’s
role to maximize individuals’ training
and skills. Roles were redefined
PEDIATRICS Volume 137, number 3, March 2016
FIGURE 1
Key driver diagram. aPreventive services bundle includes routine immunizations, offering flu
vaccine, blood lead screening, standardized developmental screening, and screening for risk factors
(gestational age, food insecurity, parental depression). SMART, Specific Measurable Actionable
Relevant Time-bound.
and reassigned, and Plan, Do,
Study, Act cycles tested integrating
reassignments into visit flow. In
addition, the IT team optimized the
EHR to display patients’ preventive
service needs on the patient schedule.
This information was referenced by
providers and staff during relevant
steps in the ideal flow.
Several key changes were made to
visit flow. First, 2 types of “huddles”
were implemented. The nurse
manager huddled with nurses and
MAs in the morning to discuss
potential flow challenges that day.
In addition, at the beginning of each
morning, afternoon, and evening
clinic session, each provider huddled
with their assigned MA to review
the preventive service needs of
each scheduled patient. Second,
registration staff preassembled
standardized, age-specific packets
that included developmental and
social screening forms.27,28 These
were distributed at registration for
parents to complete before rooming.
Third, much of the informationgathering and EHR documentation
for well visits was shifted from
providers to intake staff. This
ensured screening questions were
documented and allowed physicians
to focus the visit on areas of concern.
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Fourth, intake staff preordered
immunizations and screening tests
for providers to review and sign.
Finally, the patient discharge process
was standardized and included
a staff member checking that all
appropriate preventive services had
been delivered. Clinic start time was
not changed, and the number of visit
was not reduced during ideal flow
implementation.
Methods of Evaluation
A measure of the reliability of daily
preventive service delivery was
created, with the visit as the unit of
analysis. This measure calculated
the percentage of 0- to 14-monthold visits during which the patient
received all elements of the bundle
for which they were eligible that
day. More details on the measure are
provided in a separate publication.29
Figure 2 summarizes expectations
for preventive service delivery at
each age. For example, any visit for a
9-month-old patient would require
administration of any overdue
immunizations, developmental
screening, lead testing, and influenza
vaccine offered if seasonally
appropriate. Although ill visits were
included in our study, if a provider
decided to defer immunizations
e3
through visits and collect feedback
that was used to improve processes.
As a balancing measure, patient cycle
time (time from patient sign-in to
discharge) was collected pre- and
postinterventions.
RESULTS
Over an 8-week baseline period
(June through July 2012), the entire
bundle of preventive services for
which patients age 0 to 14 months
were eligible was delivered at 58%
of visits. Postintervention results
revealed a median performance of
92%, achieved by May 2013 and
sustained over 1 year (Fig 3).
FIGURE 2
Visit-level measure scoring. aGestational age and screening for parental depression and food
insecurity documented in EHR, if not already in patient chart. bMust get all listed immunizations. If
patient did not get vaccine, check the visit date and count as a “yes” if the patient got the vaccines
indicated due to the date of the visit and recommended interval from last dose of vaccine. cRotavirus
#1 rule: If patient did not get vaccine but age is ≥ 106 days, score as yes (too old to start the
series). dRotavirus #2 rule: If patient received first rotavirus vaccine but did not get second rotavirus
vaccine and age is ≥ 224 days, score as yes (too old to get second dose). eThe American Academy of
Pediatrics recommends screening at 9 months. Given low adherence to well child schedule in this
patient population, clinic processes include screening at any well visit occurring between 6 and 14
months of age to ensure developmental delays are detected in a timely way for children who miss
a well visit. Measure includes at least 1 completed screen. fLead screening to be completed once
between 9 and 12 months of age. gRefusals count as yes if appropriately documented. ASQ, Ages and
Stages Questionnaire; DTaP, diphtheria-tetanus-acellular pertussis, Hib, Haemophilus influenzae type
b; IPV, inactivated polio vaccine; MMR, measles, mumps, rubella; PCV, pneumococcal vaccine.
because of acute illness and
documented this with an appropriate
diagnosis code, this was not counted
as a failure.
Performance data on bundle delivery
were retrieved directly from clinical
documentation in the EHR. Reports
on this measure were constructed
through an iterative process. An
automated data report was initially
formulated, then compared with
manual chart reviews to ensure
interrater reliability and to identify
unique situations for which decision
rules needed to be created. The
automated report was then modified
and the process was repeated. In its
final form, the report was automated
with quality checks done manually by
a data manager who followed a list of
decision rules.
e4
Daily data were collated into weekly
rates and plotted on a run chart.
Standard probability-based rules
were used for interpretation of run
charts.30 In accordance with these
rules, the median was recalculated
when a “shift” of 8 consecutive points
above or below the median was
observed. Initially, chart audits were
performed by the data manager for
all failures, and appropriate timely
feedback was provided to staff and
providers. Weekly data were shared
with all.
Throughout the QI process,
qualitative data were collected from
front-line staff regarding barriers
to implementing interventions and
impact of interventions on clinic flow,
patient care, and resident education.
QI consultants were on-site during
implementation to shadow patients
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Interventions fell into 2 major
categories: structural and functional.
Dates of intervention implementation
are annotated on the run chart (Fig
3). Structural interventions included
team development, shared vision,
expert consultation, QI training,
divisional support, and project
and data management. Functional
interventions included prioritization
of work, optimizing the EHR, previsit
planning, improving communication,
and implementation of ideal visit
flow. Interventions were temporally
associated with shifts on the run
chart (Fig 3). Cycle time remained
the same pre and postinterventions
(average 75 minutes).
Qualitative data collected from frontline staff indicated that early in our
testing, a majority of failures were
due to family refusal of preventive
services or failure to document
services that were completed
or deferred due to acute patient
illnesses. In addition, more failures
happened on evenings or weekends,
and when transient providers
worked in our clinics. There was no
difference in failures by age group.
Failures were addressed by having
QI consultants coach providers on
proper documentation, observe
and evaluate flow, and provide
feedback and recommendations
to optimize the ideal flow map. A
SAMAAN et al
separate in-depth study looked at the
effects of primary care redesign on
residents’ educational experience. It
is presented in a separate publication
currently under review. Overall,
residents had improved perceptions
of patient flow and physician/
nonphysician teamwork.
Our bundle delivery rate was
sustained at a median of 92%
over a 1-year period. We planned
for sustainability by developing a
standardized orientation and training
process for all newly hired staff
and providers. We also performed
frequent assessment and retraining
of existing staff and providers to
ensure the ideal flow protocol was
being followed.
DISCUSSION
Between June 2012 and June
2013, we increased delivery of a
preventive services bundle from
58% of visits to 92% of visits for
patients 0 to 14 months of age, and
we sustained the improvement
for over 1 year. Interventions
that coincided temporally with
improvement in bundle delivery
included prioritization of work,
previsit planning, preclinic huddles,
and implementation of ideal flow.
Through improvement on the bundle
measure, we now reliably address
infants’ physical health, cognitive and
social development, and family wellbeing during primary care visits. We
have also transformed our system
to create effective mechanisms
for communication among staff
members and more failsafe processes
for identifying patients’ health
maintenance needs.
Our study was strengthened by
rigorous use of QI methods, with
on-site QI consultants who ensured
fidelity to the interventions. We
maximized the sustainability of our
intervention by studying our system
under various conditions, including
during evening and weekend
hours and clinic sessions staffed by
PEDIATRICS Volume 137, number 3, March 2016
FIGURE 3
Percent of primary care patients seen 14 months and younger who have received the entire bundle
of preventive services for which they are eligible.
transient providers (moonlighters
and learners). By collecting
performance data directly from
the EHR, we were able to include
all visits in our data. Because we
audited charts and coached providers
on proper documentation, we are
confident that our data closely reflect
actual preventive service delivery.
Our findings support those of other
studies in which system-based
improvements resulted in improved
preventive service delivery. Shaw
et al6 and Young et al31 showed that
practices who set goals and used
QI methods achieved improvement
in at least 1 preventive service. In
accordance with recommendations
by Solberg et al,32 we used
strategies that considered multiple
characteristics of participating clinics.
Our findings were consistent with
those of Bordley et al,5 who achieved
improvement in immunization
rates, anemia, and lead screening
through implementation of previsit
planning, risk assessment forms,
provider prompts, and redistribution
of responsibilities among office staff.
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Given findings by Shojania et al33
that point-of-care EHR reminders
alone achieved small effects, and
Lanham et al34 that relationships and
respect among office staff contribute
to primary care quality and success
of improvement initiatives, our
initial structural interventions
(eg, formation of site-based teams
with nonphysician team leaders)
likely played a key role in laying the
groundwork for our success.
To our knowledge, ours was the
second study to measure delivery
of a “bundle” of preventive services
in pediatric primary care. Margolis
et al16 measured a bundle of 4
preventive services (immunizations,
and screening for tuberculosis,
anemia, and lead) at 18 nonacademic
practices and achieved improvement
from 7% to 34%. Because Margolis
et al16 used a patient-level measure
rather than a visit-level measure,
we cannot directly compare our
success. However, our findings build
upon the work by Margolis et al16
by expanding the bundle to include
services related to developmental
e5
and social well-being and also
demonstrate that it is possible to
achieve significant sustainable
improvement in large academicaffiliated pediatric practices.
Expansion to this setting is important
in ensuring high quality care for
low-income children, given the
large percentage of publicly insured
patients who are served by academicaffiliated safety net hospitals.35
Our study had some limitations.
Because we did not consider
decisions to defer immunizations
because of illness a failure to
deliver indicated services, our data
do not capture potential missed
opportunities to vaccinate in
situations where the patient is ill
but immunization deferral is not
clinically indicated.36 Additionally,
because we are no longer performing
chart audits on all failures, it is
possible that some preventive
services are being delivered but not
documented; therefore, our actual
performance may be better than
what is shown.
In considering whether our findings
are generalizable to other practices,
we acknowledge context-specific
factors that may have contributed to
our success including the financial
support for external consultation,
data analysis, a project manager, QI
consultants, and QI methodology
training for front-line staff. We
believe these resources were integral
to our success given the size and
complexity of our settings. However,
because the fund was not entirely
used for this particular phase of the
redesign and the support staff had
multiple other job responsibilities,
it is difficult to quantify the exact
cost of our preventive service
improvement. It is notable that
our improvements were achieved
without hiring extra staff or reducing
patient volume. We believe that small
and less complex practices can learn
from our experience to implement
some changes with minimal project
management resources. Universal
e6
strategies from our work that may
be applied without a lot of further
testing include the following: (1)
developing EHR-based prompts
about services due; (2) creating
standardized packets for each
patient age with appropriate
developmental and social screening
forms,27,28 which can be distributed
by registration staff and completed
by parents during waiting time; (3)
shifting some history-taking and
EHR documentation to intake staff
to maximize the time and skills of
all clinical team members. Also,
new health care models with permember per-month payment systems
may soon incentivize investment in
personnel to facilitate improvement
work and quality measurement
because funding these activities may
provide returns on investment by
improving outcomes for patients
for which the health system is
accountable.
Reaching our original goal of 95%
would require higher reliability
interventions, such as increased
automation of tasks.32 We will
continue to work closely with our
IT team to implement these types of
changes. Future directions include
improving preventive service
delivery on a population level
and measuring preventive service
bundles for other patient age groups.
CONCLUSIONS
Using QI methods, we achieved
and sustained a preventive service
bundle delivery rate of 92% of
primary care visits for patients 0
to 14 months of age. The bundle
included administration of all
routine immunizations, offering
influenza vaccine to eligible
infants, and screening for lead,
developmental delay, gestational
age, food insecurity, and parental
depression at appropriate intervals.
Our bundle is the first, to our
knowledge, to include preventive
services in multiple domains of child
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and family well-being. Our study
demonstrates the dramatic increase
in reliability that is possible with
system transformation, even in
complex settings serving low-income
populations.
ABBREVIATIONS
CCHMC: Cincinnati Children’s
Hospital Medical Center
EHR: electronic health record
IT: information technology
MA: medical assistant
QI: quality improvement
RASCI: Responsible, Accountable,
Support, Consulted, and
Informed
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e7
Implementation of a Preventive Services Bundle in Academic Pediatric Primary
Care Centers
Zeina Marcho Samaan, Courtney M. Brown, John Morehous, Alison A. Perkins,
Robert S. Kahn and Mona E. Mansour
Pediatrics 2016;137;; originally published online February 17, 2016;
DOI: 10.1542/peds.2014-3136
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Implementation of a Preventive Services Bundle in Academic Pediatric Primary
Care Centers
Zeina Marcho Samaan, Courtney M. Brown, John Morehous, Alison A. Perkins,
Robert S. Kahn and Mona E. Mansour
Pediatrics 2016;137;; originally published online February 17, 2016;
DOI: 10.1542/peds.2014-3136
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/137/3/e20143136.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on July 31, 2017