In the Literature
The Bright Futures initiative, developed by the federal Bureau of Maternal and Child Health in collaboration with the American Academy of Pediatrics, has long made recommendations available to help pediatricians and child health clinicians improve the quality of care for their young patients. A new pilot project, supported by The Commonwealth Fund, is helping to implement Bright Futures in providers' offices.
"This project demonstrated the feasibility of implementing specific strategies for improving preventive and developmental care for young children in a wide variety of practices," write Carole M. Lannon, M.D., M.P.H, and colleagues in "The Bright Futures Training Intervention Project: Implementing Systems to Support Preventive and Developmental Services in Practice" (Pediatrics, July 2008). "It also confirmed the usefulness of a modified learning collaborative in achieving these results. The model may be useful for disseminating office system improvements to other settings that provide care for young children."
About the Study
Fifteen pediatric primary care practices from nine states participated in the project to test strategies for improving care. During a nine-month period, a three-to-four-person multidisciplinary team from each practice participated in a learning collaborative. The teams received a variety of support including a toolkit, training in quality-improvement methods, and data feedback. There were also twice-monthly conference calls and an e-mail-based mailing list to provide coaching and encourage shared learning among the teams.
The teams took part in two one-day workshops, one before and another following the nine-month period. Participants were introduced to six office system components, along with the tools needed to implement them, to help improve preventive and developmental services for children up to age 5. These included preventive services prompting systems, structured developmental assessments, recall/reminder systems, community linkages, identification of children with special health care needs, and assessment of parents' strengths and needs. Each team chose the components it wanted to test and implement during the nine-month period.
Implementing Bright Futures
The strategies most frequently tested or implemented by practices included: 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%). No practice implemented all six components. From baseline to follow-up, there were statistically significant increases in the use of preventive services prompting systems and in the proportion of families who were asked about special health care needs.
Practice teams' choice of strategies to implement was influenced by what they thought could be accomplished quickly or easily. For example, several practices added the question, 'Does your child have any special health care needs?' to well-child visits because it was simple to execute. Some practices believed components were most easily implemented when they did not require other changes; others noted that adoption was aided when components were complementary (e.g., identification of children with special health care needs and community linkages). Barriers cited by the teams included cost, time, lack of agreement with the strategy, and doubt that changes would lead to improved outcomes.
The materials used in the training intervention will be published in 2008 to help other practices implement Bright Futures guidelines. The study's results suggest that brief, simple questions, tailored materials, and use of organizing systems will help pediatric primary care practices implement the guidelines.
The intervention yielded other benefits as well. "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," the authors say. They also noted that participation in the study was associated with changes beyond those captured in the outcomes. "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," they write.
Facts and Figures
- The 15 participating practices were located in nine states and represented a range of practice types. Most were in urban areas.
- When asked about the sequence of implementation recommendations they would make to other practices, 50% of practice teams recommended beginning with preventive services prompting systems and 21% recommended beginning with community linkages.