Implementation of a Preventive Services Bundle in Academic Pediatric Primary Care Centers.

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.

Development of a bundle measure for preventive service delivery to infants in primary care.

RATIONALE, AIMS AND OBJECTIVES: In the United States, paediatric patients receive only 41% of indicated preventive services. Past improvement efforts have not bundled preventive services to measure the reliability with which infants' physical, developmental and emotional needs are all addressed. We aimed to create a comprehensive bundle measure that reflects reliable delivery of preventive services during primary care visits, as well as overall preventive service status of a population of patients served by three primary care centres. METHOD: Data were collected from electronic health records for cohorts of infants < 14 months old with at least one visit to one of three primary care centres. Immunizations, lead screening, developmental screening and screening for biopsychosocial risk factors (gestational age, parental depression, food insecurity) were chosen by local expert consensus for inclusion in the preventive services bundle measure. Monthly measures of preventive service status at 14 months of age were constructed. A visit-level bundle measure of preventive service delivery was also created. To obtain a baseline for improvement work, bundle completion rates were calculated for infants born in May 2011. Visit-level performance was measured for visits from July to August 2012. RESULTS: Among 278 patients born in May 2011, 22% of patients received the entire bundle of preventive services by 14 months of age. On a visit level, patients received all indicated services at 58% of visits. CONCLUSION: A novel bundle measure can be used to characterize delivery of preventive services and drive improvement at both an individual visit level and a population level.