PEDIATRICS Vol. 122 No. 1 July 2008, pp. e163-e171 (doi:10.1542/peds.2007-2700)
ARTICLE |
The Bright Futures Training Intervention Project: Implementing Systems to Support Preventive and Developmental Services in Practice
a Center for Health Care Quality, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
b Piedmont Health Services, Inc, Carrboro, North Carolina
c Department of Pediatrics, University of Vermont, Burlington, Vermont
d Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina
e Stuart Consulting, Hillsborough, North Caroina
f American Academy of Pediatrics, Elk Grove Village, Illinois
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ABSTRACT |
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OBJECTIVES. The objectives of this study were to assess the feasibility of implementing a bundle of strategies to facilitate the use of Bright Futures recommendations and to evaluate the effectiveness of a modified learning collaborative in improving preventive and developmental care.
METHODS. Fifteen pediatric primary care practices from 9 states participated in a 9-month learning collaborative. Support to practices included a toolkit, 2 workshops, training in quality-improvement methods, monthly conference calls and data feedback, and a listserv moderated by faculty. Aggregated medical chart reviews and practice self-assessments on 6 key office system components were compared before and after the intervention.
RESULTS. Office system changes most frequently adopted were use of recall/reminder systems (87%), a checklist to link to community resources (80%), and systematic identification of children with special health care needs (80%). From baseline to follow-up, increases were observed in the use of recall/reminder systems, the proportion of children's charts that had a preventive services prompting system, and the families who were asked about special health care needs. Of 21 possible office system components, the median number used increased from 10 to 15. Comparing scores between baseline and follow-up for each practice site, the change was significant. Teams reported that the implementation of office systems was facilitated by the perception that a component could be applied quickly and/or easily. Barriers to implementation included costs, the time required, and lack of agreement with the recommendations.
CONCLUSIONS. This project demonstrated the feasibility of implementing specific strategies for improving preventive and developmental care for young children in a wide variety of practices. It also confirmed the usefulness of a modified learning collaborative in achieving these results. This model may be useful for disseminating office system improvements to other settings that provide care for young children.
Key Words: developmental screening • preventive care • practice improvement • performance measurement • collaborative learning
Abbreviations: AAP—American Academy of Pediatrics • BFTIP—Bright Futures Training Intervention Project • PSPS—preventive services prompting system • SDA—structured developmental assessment • CSHCN—children with special health care needs • OSI—office systems inventory
Although there are evidence-based practice guidelines to support preventive health care practices that ensure the optimal health and development of young children, numerous gaps have been reported between what is known and recommended with what occurs in practice1–7 and what parents want.3,4,6,7
Previous studies suggested that making changes in office practices may improve preventive care and developmental services.8,9 These changes include the implementation of recall and reminder systems,10 use of a preventive services prompting system (PSPS),8,9,11 use of standardized developmental assessments,12,13 strengthening of linkages to community organizations,11,14 identification of children with special health care needs (CSHCN),15,16 and assessment of parent/child strengths and needs.17,18 Although studies supported each of these individual strategies, the feasibility of combining them in pediatric primary care practices has not previously been explored.
In addition, little is known about how pediatric primary care offices actually implement new strategies, the changes that they must make, and the barriers to improvement that they must identify and overcome. Barriers to delivering recommended and desired preventive services include limitations on provider time,2,5 limited resources, and inadequate training.5 Educational interventions, such as traditional didactic continuing medical education presentations that focus solely on increasing knowledge of providers, are unlikely to change provider behavior or overall office practice.19,20
A promising alternative strategy is engaging an office-based practice team to implement a system for improving preventive and developmental care.8,9 Typically, a primary care practice team (eg, consisting of a physician, an ancillary clinical staff member, and an administrative office representative) participates in the implementation effort. An office system, or organized series of interrelated activities conducted by multiple staff to achieve a specific purpose,21 can overcome barriers to improvement by redistributing responsibility for preventive and developmental care throughout the entire office. The office system acknowledges the necessity of teamwork in improving care.
Bright Futures is a philosophy and approach dedicated to the principle that every child deserves to be healthy and that optimal health involves a trusting relationship among the health professional, the child, the family, and the community.22 The Bright Futures initiative, developed by the federal Bureau of Maternal and Child Health and implemented in collaboration with the American Academy of Pediatrics (AAP), provides a comprehensive set of health supervision guidelines for children from birth through 21 years of age. The 2007 revision of the Bright Futures Health Supervision guidelines incorporated (1) "evidence for effectiveness" as a core criterion for selecting recommendations, (2) age-based priorities to help focus the well-child visit, and (3) an emphasis on appreciating the child's and the family's strengths.
The Bright Futures framework for preventive and developmental services used in this project was adapted from a systems model developed by the Center for Health Care Quality at Cincinnati Children's Hospital Medical Center (formerly the Center for Children's Healthcare Improvement at the University of North Carolina). It consists of a set of strategies and materials and has 3 main elements: (1) key approaches for improving preventive and developmental care in child health care settings; (2) the Model for Improvement (an approach for testing and refining changes)23; and (3) a set of measures that enable practice teams to track progress toward project aims. The efficacy of the components of this framework that focus on preventive services and office systems have been tested in a demonstration project; confirmed in a randomized, controlled trial in primary care practices that care for children; and verified in diverse settings.8,24–26
We report here on the Bright Futures Training Intervention Project (BFTIP), a joint effort of the AAP and Center for Health Care Quality to pilot a set of strategies for implementing Bright Futures. Using a team-based learning collaborative and applying quality-improvement methods, this pilot project tested the feasibility of a training intervention with primary care practices to improve preventive and developmental services for children up to 5 years of age by implementing a bundle of 6 tested office system components.
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METHODS |
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Practice Recruitment
A convenience sample of practices were recruited through AAP state chapter leaders, the Council on Community Pediatrics, and the Community Access to Child Health Program. Practices with patients of diverse cultures and socioeconomic status and from a variety of practice settings (including family physicians, pediatricians, and nurse practitioners) were chosen. Criteria for participation included interest in improving developmental and preventive services, the ability to identify an office team (typically physician, ancillary clinical staff, and administrative representative), willingness to collect and submit monthly data, and team attendance at 2 workshops and monthly conference calls. To minimize expenses and maximize participants' ability to attend in-person workshops, the majority of practices were recruited from the Midwestern United States. All prospective practices were asked to complete a brief application describing practice characteristics, previous experience in quality improvement, reason for applying to participate, and ability to identify a practice team that consisted of 3 to 4 people. The participation of a senior leader, defined as holding an influential position within the practice's health care organization, was encouraged.
Intervention
A modified team-based learning collaborative was used to support practices in improving their office systems for preventive and developmental services.27 The BFTIP model used two 1-day workshops, 1 before and after a single 9-month action period (the second workshop was placed at the end of the project to gather feedback about tools and implementation strategies). At the initial workshop, participants were introduced to 6 key office system components: (1) PSPS; (2) structured developmental assessment (SDA); (3) recall/reminder systems; (4) community linkages; (5) identification of CSHCN; and (6) assessment of parent strengths and needs. For facilitation of implementation of the office system improvements; teams were given tools to support practice improvement; taught the Model for Improvement,23 and trained to use multiple "plan, do, study, act" cycles28 to conduct small-scale tests of change. During the action period, the teams implemented and tested the office system components that they believed would help improve preventive and developmental care. Project staff used twice-monthly conference calls and a project listserv (an e-mail–based mailing list) to coach practice teams and encourage shared learning. At the second workshop, roundtable discussions were conducted to collect participants' views on the feasibility of implementing office system components, optimal sequencing and combination, and barriers to change.
This project used the second edition of Bright Futures and occurred while the guidelines were being revised. Because successful use of preventive and developmental services recommendations requires implementation of office system, the systems framework used in this project was considered applicable for both the second and third editions of Bright Futures.
Data Collection and Feedback
Before the first workshop, participating teams were asked to review 20 consecutive medical charts for children aged birth to 5 years and record baseline data on their delivery of preventive and developmental services. During the action period and for 2 months after the final workshop, practices were expected to conduct 20 medical chart reviews every month and submit them, by fax or online, to the project team. For ensuring that the reviews included children who were exposed to the office systems intervention, only established patients were included, and charts were excluded from review when a child had fewer than 3 visits at the practice. A standardized form was used to assess 4 components of the Bright Futures framework: (1) a PSPS form with at least 1 entry within the previous 12 months; (2) a standardized, structured, parent-completed developmental assessment (either Parent's Evaluation of Developmental Status29 or Ages and Stages Questionnaire),30 performed and documented at the index visit; (3) documentation that a clinician had ever asked the family about the presence of any special health care needs; and (4) assessment of parental strengths using either the written questionnaire or laminated clinician reminder pocket cards provided at the workshop.
For assessment of the use of recall/reminder systems and development of office systems for community linkages, practice teams completed a 21-item office systems inventory (OSI)31 self-assessment at baseline and 10 months. The sum of 4 items constituted a recall/reminder systems score: (1) there was a system for identifying children who needed preventive services; (2) someone other than the physician had responsibility for identifying needed preventive services; (3) there was a system for identifying follow-up for children who missed appointments; and (4) there was a relationship with another agency to track children who needed preventive services. Six items were summed to create a community linkages score: (1) there was an accessible community resource list in the office, (2) someone regularly updated community resource information; (3) referrals to community agencies were centrally coordinated; (4) community resource materials were organized and accessible; (5) communication of referral information to community agencies was standardized; and (6) receiving information from community agencies was standardized. Additional queries examined the extent to which the practice used guidelines, had screening/prompting procedures, relied on team-based care, and monitored quality of care.
At the second workshop, practices completed a self-assessment indicating whether they had tested or implemented each component, the actual order in which they tested components, and the order that they recommended for introducing the components by future practices. Three 20-minute roundtable sessions were held for each component, with 2 to 4 practice teams participating in each session. Each session was led by a project staff or faculty member who used structured questions to facilitate the discussion. Detailed notes were taken of each session.
Practices were given a monthly summary of the aggregate data and run charts graphically displaying their own outcome data via the project Web site. (Run charts are a quality-improvement technique developed by Walter Shewhart that are used to analyze processes and discover patterns over time.32) Teams were encouraged to use the data to guide improvement. Aggregate measurement data were discussed on both conference calls and the listserv, and successful strategies were highlighted. High-performing practices were identified by the project team and encouraged to share outcomes and successful strategies for improvement with the other teams through the various collaborative modalities (eg, listserv, conference calls).
Data Analysis
For medical chart review measures, we aggregated data for all practices and compared the percentage of children birth to 5 years of age with each outcome measure at baseline and at the end of the project, 1 month after the second workshop. To distinguish between true improvement and random variation, we determined follow-up outcome data by averaging medical chart reviews from the final 3 months33 and applied tests of equality of proportions. For OSI practice self-assessments, we calculated and compared median and mean scores for the overall OSI and used the nonparametric signed Wilcoxon rank test to compare the change in scores from baseline to follow-up for each practice site. To compare baseline characteristics for higher implementing practices (
3 components) and lower implementing practices (
3 components), we conducted t tests and Fisher's exact tests as appropriate by using SAS 8.2 software (SAS Institute, Inc, Cary, NC).
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RESULTS |
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Sixteen practices agreed to participate in the pilot project. One practice withdrew after the first workshop because of personal circumstances of the team leader. Another site, a school-based health clinic, did not participate appreciably, because anticipated policy changes allowing young siblings of the student population to be seen did not occur. Sixteen practices participated in the first learning session and 13 in the second workshop. Fourteen practices participated in at least 1 conference call; 3 practices participated in all 10 calls. Three additional calls were arranged at the request of practices (an overview of Bright Futures, a second session on SDA, and using an electronic medical chart for prevention and developmental assessment). In particular, specific information about the validity, utility, and cost of developmental screening tools was reviewed.34 Thirteen practices completed at least 1 measurement report after baseline. Six practices completed 11 of the 12 requested medical chart reviews. Eight practices provided complete follow-up data.
The 15 participating practices were located in 9 states and represented a range of practice types (Table 1). Most were in urban areas. Practices varied in the number of full-time employees and the ethnic background and language spoken by patients. On average, nearly half of the visits were for health supervision, and children up to 5 years of age composed more than two thirds of participating practices' patients. Half of the practices reported previous quality-improvement experience, and 6 had the support of an influential senior leader.
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Recall/reminder systems (87%), community linkages (80%), and identification of CSHCN (80%) were tested or implemented by the greatest number of practices at follow-up (Fig 1). No practice implemented all 6 components. Two practices tested or implemented 5 components, 2 tested or implemented 4 components, 2 tested or implemented 3 components, and the remaining 9 practices tested or implemented 1 or 2 components.
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From baseline to follow-up (Fig 2), there were statistically significant increases in the use of a PSPS and the proportion of families asked about special health care needs (P < .0001). Increases were also noted in the proportion of children who received an SDA at the index visit and use of strength-based approaches, but these were not statistically significant. Figure 3 shows the run charts for each of the 6 components of the Bright Futures framework across the aggregate of practices.
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All but 1 practice improved their use of office systems (Fig 4). Of a possible 21 components, the median OSI at baseline was 10 (range: 6–15) and increased to 15 (range: 10–20) at follow-up. The mean OSI score was 9.7 at baseline and 14.9 at follow-up, with a mean change in score between baseline and follow-up of +5.1 (range: –1 to 10) for overall OSI assessments, +1.2 (range: –1 to 3) for recall and reminder systems, and +0.6 for community linkages. Comparing scores between baseline and follow-up for each practice site, the change was significant for the overall OSI (P = .001), recall and reminder (0.008), but not community linkages. The change for OSI minus the recall and reminder and community linkages items was significant (P = .002).
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Practice teams reported that facilitators of office system implementation included the perception that a component could be implemented quickly and/or easily, especially when a tool or template was immediately available (eg, identification of CSHCN). For example, several practices added the question, "Does your child have any special health care needs?" to well-child visits because it was simple and feasible. Some participants perceived components to be "most easily implemented" when no other practice changes were required (eg, recall and reminder). Others believed that components were easily implemented when they were complementary (eg, identification of CSHCN and community linkages). Barriers included time, cost, lack of agreement with recommendations, and lack of belief that changes would lead to improved health outcomes.
When asked about the sequence of implementation that they would recommend to another practice, 50% of practice teams recommended beginning with PSPS and 21% recommended beginning with community linkages. Fifty-seven percent of practices recommended that SDA be the second or third component tested, and 70% recommended testing assessment of parent strengths and needs be last or next to last.
Participants noted positive feedback from parents after incorporating SDAs and reported that using structured assessments helped to orient the visit around parents' concerns. Some practice teams developed informal methods of assessing parents' strengths and needs, such as asking, "Do you have any concerns or worries about your child?" at the beginning of the visit and subsequently praising positive parenting behaviors observed in the office setting.
Practices noted the utility of a baseline needs assessment (ie, measures and OSI) to determine the optimal combination and implementation sequence of intervention components. In addition, practices reported that the ability to learn from others changes through the collaborative accelerated implementation. Several teams noted that participation in the collaborative had a positive effect on communication within the practice.
Examination of the characteristics of practices (Table 2) that were most successful in testing and implementing office system components (practices that implemented 3 components) revealed that only practice location was statistically significant (P = .026). Sixty-six percent of the higher implementing practices were located in rural areas, whereas 90% of lower implementing practices were located in urban areas.
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DISCUSSION |
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Participating practices varied greatly in size, location, previous quality-improvement experience, and baseline development of office systems. Despite these differences, nearly all practices adopted Bright Futures office systems components.
Practices varied in their ability to implement the 6 components. Having a tool or template available or the perceived ease of implementation facilitated the change. Although recall and reminder systems, improved community linkages, and identification of CSHCN were the components that teams most frequently reported implementing, practices were most successful in achieving increases in identification of CSHCN and use of SDA and PSPS. We believe that the results for SDA were much better than shown in Fig 2. Because methods of developmental assessment used by practices before the project were not structured or validated, we suspect that the true baseline percentage of children who had an SDA such as Parent's Evaluation of Developmental Status or Ages and Stages Questionnaire was close to 0, thus, the aggregate improvement to 45% reflects a more considerable change than might be apparent.
The use of SDAs has been demonstrated to play a role in making a visit more parent centered and family focused.3 In our project, increases in the parent-centeredness of visits with SDAs were a powerful motivator for clinicians to implement SDAs. Finally, this project took place before publication of the AAP's recent policy on developmental surveillance and screening.35 These specific recommendations on when to screen and the use of evidence-based tools may facilitate SDA adoption in future improvement efforts.
The described barriers to adopting new, improved systems for providing preventive services are similar to those that clinicians face in adhering to guidelines in other areas,36,37 such as the introduction of new forms, competing demands on staff time, lack of familiarity with specific methods of screening, and lack of belief that outcomes would be influence by a structured approach to screening. Practices may need guidance on gaining appropriate reimbursement for developmental screening, such as that available from the AAP.34
Teams noted that the availability of PSPS organizing templates, which could be tailored to the practice, facilitated the implementation of this component. Similarly, the ease of incorporating into the practice routine the CSHCN question, "Does your child have any special care needs," was described as facilitating its use. That this question reflected the family-centered emphasis of Bright Futures was also described as contributing to its acceptance.
The use of a framework that emphasized developing organizing systems for care within the practice was noted to be particularly helpful.
Implementation of the "assessing parent strengths and needs" component was challenging because, unlike the other components, this activity had not been extensively piloted with a population of parents of young children before this initiative.
Learning from participants which sequence of components was easiest and most useful to implement will be useful in future efforts to improve office systems for preventive and developmental care. Practices emphasized the utility of a baseline needs assessment to determine the optimal combination and implementation sequence. Despite differences in baseline practice characteristics and implementation experiences, practices were fairly consistent in recommending beginning with PSPS or community linkages. Having a PSPS template made it possible to begin making changes immediately, and having community linkages in place made it more convenient to implement changes such as identification of CSHCN or SDA.
Participation in this collaborative was associated with practice changes beyond those captured in the target outcomes. OSI scores rose for almost all practices. Although some of this was attributable to increases in scores for recall/reminder systems and community linkages, OSI scores increased even when these subscores were excluded. This reflects increases in the extent to which the practice provided team-based care, monitored quality of care, and developed consensus on practice guidelines. Anecdotal feedback suggests that participation in this collaborative effort may have had a generalized effect on communication within the practice and may have contributed to a redistribution of responsibility for ensuring that children received appropriate developmental services. This is consistent with previous descriptions of team-building as an effect of collaborative learning participation.38 The emphasis on a multidisciplinary office team was noted as important to implementation success.
The successful implementation of office system changes in this pilot effort by practices with no previous quality-improvement experience, as well as those with few practice systems at baseline, provides encouragement for the potential feasibility of implementation in future efforts and suggests the generalizability of these office system components. A framework that involved specific and discrete components and accompanying tools for implementation likely contributed to teams' success. In addition, the use of an intervention, the adapted learning collaborative, that involved recognized components of successful continuing education and the emphasis on teaching and coaching about quality-improvement techniques to implement change may have contributed to the teams' successful efforts.19 It is interesting that the practices that had the greatest degree of success in implementation were predominantly rural.
Limitations
The clinicians who participated in this project were volunteers and may have been more likely to adopt changes than nonvolunteers. We used a pre–post study design without a control group. Although it is possible that the participating practices might have improved without the intervention, the use of run charts is useful in demonstrating trends that are likely to reflect real change (Figs 3 and 4).39 The small number of teams involved in this pilot implementation makes it difficult both to analyze the characteristics that contributed to success and to generalize the implementation experiences of this group to other practices. In addition, the target outcomes for this project, using medical chart review and OSI assessments, were self-reported process measures. Participants may have given socially desirable responses on these assessments. Despite this potential for bias, we did see an increase in OSI scores from baseline to follow-up that was unlikely to have been explained by a desire to demonstrate improvement, because teams did not have access to their original self-assessment at the time of completion of the follow-up assessment. Finally, we were not able to assess changes in actual health outcomes as result of this project. Despite these limitations, the results and participant feedback suggest that the framework was able to be implemented and resulted in an improvement in care processes.
Implications
With the publication of the new Bright Futures guidelines and materials,22 it is important that pediatric offices have systems to adopt and incorporate these new recommendations. Although little specific guidance is currently available to child health providers about how to do this, the results of this project suggest that brief, simple questions; the use of tailored materials; and implementation of organizing systems may be 1 way to put the Bright Futures concepts into practice in pediatric primary care. The materials used in the BFTIP will be published in 2009 to help practices implement systems that facilitate the use of the Bright Futures guidelines.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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All 6 office system components tested in this pilot initiative could be implemented by practices as a first step toward incorporating new Bright Futures guidelines. Although not assessed in this project, when these office systems are implemented by a practice team, preventive care and developmental services may improve from the standpoint of both practice teams and families. The BFTIP demonstrates the usefulness of a modified collaborative in producing improved preventive and developmental care in a wide variety of practices. A facilitator's guide and tools, with specific support notes and materials, were developed to assist organizations in implementing the Bright Futures framework used in the BFTIP and will be made available in 2009.22 Improvement partnership models could provide the technical assistance, including coaching and data support, that the project team supplied.25,26,40 The BFTIP could be replicated in other settings that provide care for young children to produce a brighter future for preventive and developmental services for many practices and the families whom they serve.
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ACKNOWLEDGMENTS |
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This project was supported by the Commonwealth Foundation and the Maternal and Child Health Bureau Health Resources Services Administration Pediatric Implementation Project.
We thank the Trailblazer practices that participated in this project: Arnett, West Lafayette, IN; Beaufort, Beaufort, SC; Case Western, Cleveland, OH; CCF-Lorain, Lorain, OH; Children's Hospital Boston, Boston, MA; Children's Healthcare Associates, Chicago, IL; Downtown Health Center, Milwaukee, WI; Hagan & Rinehart, Burlington, VT; Genesis Healthy Generations Children's Clinic, Zanesville, OH; Henry Ford–Detroit, Detroit, MI; Henry Ford-SBC, Detroit, MI; Infant Welfare, Chicago, IL; Marietta (Duvall), Jacksonville, FL; McFarland, Ames, IA; Oxford, Oxford, OH; and St Vincent's, Toledo, OH. We also acknowledge the significant contributions of the Center for Health Care Quality staff for excellent project support, Erin Burgess and Amanda Cornett, and medical writer Pamela Schoettker. We also gratefully acknowledge the vision and continued efforts of Edward Schor, MD, and the Commonwealth Foundation to improve outcomes for children.
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FOOTNOTES |
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Accepted Feb 25, 2008.
Address correspondence to Carole M. Lannon, MD, MPH, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Center for Health Care Quality, 201 Silver Cedar Ct, Suite A, Chapel Hill, NC 27514. E-mail: carole.lannon{at}cchmc.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Bright Futures is a philosophy and approach dedicated to the principle that every child deserves to be healthy and that optimal health involves a trusting relationship among the health professional, the child, the family, and the community.
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| What This Study Adds This training intervention project demonstrated the feasibility of implementing specific strategies and tools for improving preventive and developmental care for children in a wide variety of practices and confirmed the usefulness of a modified learning collaborative in achieving these results.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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