Children - Key Activity 1


Convene a Multidisciplinary Implementation Team Focused on Pediatrics


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity provides guidance for developing, launching and sustaining the team or task for within your practice that will be responsible for the planning and implementation of all of the foundational key activities in this guide and overseeing related quality improvement and equity efforts, as outlined in Appendix A: Sample Idealized System Diagram.

The implementation team is so important that it appears first in our sequenced list of foundational activities. Improving your practice’s key outcomes for each population of focus and reducing equity gaps requires the aligned efforts of all care teams and nearly all functional areas of the practice, not just those working directly with patients.

This team is responsible for ensuring that the foundational key activities in this guide, including those related to screening for social needs, are implemented. As a minimum standard for screening for social needs, consider addressing social needs included in the areas recommended by the AAP/Bright Futures periodicity schedule.

In identifying potential members of this multidisciplinary implementation team, the practice should identify a diverse group of staff who are reflective of the community served and who represent the lived experience of patients. Practices may also consider mechanisms for ensuring that patients and families are informing the decisions and actions of the multidisciplinary implementation team, including but not limited to embedding patients and/or family members on the team and creating an active patient and family advisory group, all of whom are paid for their expertise and time in compliance with any relevant local, state, or federal laws and regulations.

In addition to implementing the key activity focused on applying a systematic approach to decrease health inequities, the team should apply a trauma-informed care approach and equity lens to every step outlined in this guide to help ensure that any improvements are equitably spread among the patient population. See Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey for further guidance. To achieve optimal functioning and impact, all members of this diverse multidisciplinary team should have their perspectives proactively included.

Relevant health information technology (HIT) capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination (see Appendix D: Guidance on Technological Interventions). To enable team coordination, thought must be given to how to access relevant technology and how data is consistently captured, can be distributed, integrated into workflows, and how data is accessible across team members. Where possible, it is desirable to avoid duplication of data entry, siloing of information in standalone applications and databases, and the need to work in multiple applications requiring separate login.

Action steps and roles

1. Develop a time-limited group of leaders within the practice to start this process.

Suggested team member(s) responsible: Chief medical officer or equivalent and office manager or quality improvement (QI) coordinator.

Start with a small group of leaders from your practice, some of whom will be on the implementation team. These people will help refine the charge or scope of work of the implementation team and identify and engage the people and roles that will be required to implement the scope of work of the team.

2. Develop a preliminary scope of work or charge outlining the responsibilities of the implementation team.

Suggested team member(s) responsible: Time-limited group of practice leaders.

This scope or charge includes (but may not be limited to) enabling, aligning, leveraging and supporting the planning and implementation of all foundational key activities in this implementation guide so that the practice meets the foundational competencies.

However, there may be further foundation building work needed at your practice in order for you to succeed at the above key activities. The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multidomain assessment that is used to understand current population health management capabilities of primary care practices. This self-administered tool can help your practice identify opportunities and priorities for improvement.

If your practice has not scored high in the domains of leadership and culture, the business case for population health management, technology and data infrastructure, or empanelment and access, consider implementing the activities listed in the four guides on Building the Foundation before or in parallel to working on key activities related to pediatrics.

3. Identify leadership and key actors for the implementation team.

Suggested staff responsibilities: Time-limited group of practice leaders.

The multidisciplinary implementation team should include those empowered to make changes in workflows, policies and staff assignments. They should be respected influencers in the organization (early adopters) who can also guide the change management process.

  • Appoint a champion or lead person (e.g., pediatric prevention coordinator) to oversee the implementation and coordination of the team.
  • Identify key actors who will be the core members of the implementation team. This could include a core team and an expanded team. Potential members include.
    • Pediatricians.
    • Medical assistants.
    • Panel managers.
    • Quality improvement lead.
    • Community health workers and other community outreach staff.
    • A member of the information technology (IT) or electronic health record (EHR) team (as part of the expanded team).
    • Billing manager or similar (as part of the expanded team).
    • A data lead.
    • A frontline staff member who interfaces with patients by phone and at check in.
  • Invite identified people to become part of the implementation team and ensure that they have designated time for their participation.


4. Launch the implementation team and set it up for success.

Suggested team member(s) responsible: Clinical coordinator or chief operating officer (COO) or chief medical officer (CMO).

This work includes:

  • Ensuring that the team understands their charge or scope of work and developing a outlining this work: see the Multidisciplinary Implementation Team Charter Template.
  • Defining roles and responsibilities, including the anticipated commitment (in hours) on a monthly basis.
  • Establishing a meeting structure, file structure and communications structure to support effective, efficient work.
  • Dedicating time and effort to forming, storming, norming and performing as a team. The Team Communication and Working Style Template is one tool that team members can complete and share with other teammates to accelerate this process.
  • Understanding baseline data related to outcomes of interest (e.g., baseline immunization rates, baseline well-child visit completion rates), along with data related to known and perceived barriers to these outcomes.
  • Prioritizing elements within the scope of work, informed by baseline data and identified population needs.
    • We recommend that practices consider planning and attempting to implement the activities in the sequence provided in this guide, focusing first on the foundational activities before focusing on the activities noted as Going Deeper activities. However, different practices may follow different paths toward implementation.


5. Develop a simple yet robust measurement strategy and learning system to guide your improvement efforts.

Suggested team member(s) responsible: Implementation team.

A learning system enables a group of people to come together to share and learn about a particular topic, to build knowledge, and to speed up improved outcomes. A simple yet robust measurement strategy and learning system:

  • Contains a balanced set of measures looking at outcomes, processes and possibly unintended secondary effects (e.g., increased cycle time and impact on team well-being).
  • Incorporates the patient perspective and the perspective of staff (front desk and others), care team members, and management.
  • Allows the team to determine if the process or system has improved, stayed the same, or gotten worse.
  • Helps guide improvement efforts and informs practice operations. See Appendix A: Sample Idealized System Diagram: Weaving Your Measurement Strategy and Learning System into Practice Operations for a sample system diagram for how your measurement strategy can be used to support practice operations.

Your practice should track the core and supplemental measures for childhood immunization status, well-child visits in the first 15 and 30 months of life, well-care visits, and immunizations for adolescents. These highly endorsed well-child and immunization guidelines can be considered proxy measures for outcome measures for improved child health.

In addition to the core and supplemental measures, practices should track process measures and balancing measures. Appendix C: Developing a Robust Measurement Strategy describes and defines the key milestones in the development of a robust measurement strategy, including definitions for each of these terms

Suggested process measures:

  • Percentage of children zero to 30 months of age who were sent a reminder for recommended immunizations during the measurement year.
  • Percentage of children five years of age who were sent a reminder for recommended immunizations during the measurement year.
  • Percentage of children zero to 21 years of age who are identified as missing one or more recommended immunizations during the measurement year. For greater clarity and more actionable insights, also track completion rates by vaccination, such as:
    • Percentage of children 21 months of age who are identified as missing one or more tetanus, diphtheria, acellular pertussis (Tdap) vaccines.
    • Percentage of children 21 months of age who are identified as missing one or more inactivated poliovirus vaccine (IPV) vaccines.
    • Percentage of children 18 months of age who are identified as missing one or more measles-mumps-rubella (MMR) vaccines.
    • Percentage of children 18 months of age who are identified as missing one or more Haemophilus influenzae type b (Hib) vaccines.
    • Percentage of children nine months of age who are identified as missing one or more hepatitis B (Hep B) vaccines.
    • Percentage of children six months of age and older who are identified as missing the annual influenza (flu) vaccine.

Suggested balancing measures:

  • One or more measures related to patient satisfaction.
  • One or more measures related to staff satisfaction.

Practices can also look at other metrics to understand the progress of specific improvement initiatives over time. This may include:

  • Progress on the Population Health Management Capabilities Assessment Tool (PhmCAT).
  • Progress towards foundational competencies listed in this implementation guide. For example: “Yes or No: Did your practice achieve the following foundational competency: ‘Create a health-related social needs screening process that informs patients’ treatment plans.’”
  • Any other care gaps, clinical guidelines or measures your practice feels are important to prioritize.


Applying an equity lens

Your practice may be achieving better outcomes with some patients than others. To understand these disparities, practices should stratify their data based on race, ethnicity and language (REAL), sexual orientation and gender identity (SOGI), and other patient characteristics (e.g., social needs, etc.). The advancing equity through data quality and reporting section of the PHMI Data Quality and Reporting Guide provides more guidance on this.

Putting it all together

We recommend that your practice record your measurement strategy in one place. This Measurement Strategy Tracker contains all the fields we believe are most useful, and it can be customized to meet your practice’s needs.

6. Plan and hold regularly scheduled meetings of the implementation team.

Suggested team member(s) responsible: Team lead or clinical coordinator or other individual tasked with coordinating the work of the team.

Hold time on team members' calendars for standing meetings. Consider biweekly (twice monthly) meetings to start with. The frequency, duration and focus of these meetings may change as you consider additional populations or subpopulations and additional sites or locations and as the nature of the work changes.

Develop a system to efficiently report on all workstreams and track follow-up items. The Action Plan Template is a tool that can be used to focus your team around the foundational competencies and define responsibility for actions and steps to be taken for each project your team has prioritized to work on.

7. Make adjustments based on data from the team’s measurement strategy and feedback loops.

Suggested team member(s) responsible: Implementation team.

Review data and feedback at least monthly, and adapt efforts as needed. Adaptation could include any or all of the following:

  • Amending the charge or scope of work.
  • Modifying meetings or meeting structures.
  • Changing the team composition (adding or removing members).
  • Refining key activities to better meet the needs of patients and practice staff, improve outcomes or reduce inequities.
  • Modifying the measurement strategy and/or feedback loops to better understand what is and isn’t happening.

Create opportunities for celebrating small wins, progress and measured improvement.

On an annual basis, the team’s charter and core membership should be reviewed. As the goals of the implementation team are met, the team could disband, meet less frequently (e.g., twice per year), or fold this meeting into a similar standing meeting that occurs separately.


Health Center Quality Measurement Systems Toolkit

Health Alliance of Northern California created a summary crosswalk of measurement sets that provides an overview of alignment between measurement systems. It includes in-depth information on each Uniform Data System (UDS) or Quality Incentive Pool (QIP) clinical measure for childhood immunizations, immunizations for adolescents, well-child visits (zero to 15 months), well-child visits (three to six years), child and adolescent well care visits (three to 17 years), which are contained in a spreadsheet. The document also shares suggested clinical interventions and community interventions for childhood and adolescent immunizations status in rural northern California.