Using the quality improvement (QI) tool Failure Modes and Effects Analysis (FMEA) to examine implementation barriers to common workflows in integrated pediatric care.

Abstract

Objective: To use quality improvement tools to optimize pediatric behavioral health (BH) integration, a promising approach to increasing access to behavioral health care services for children. Method: As part of the practice transformation efforts of a pediatric BH integration initiative implemented in three community health centers, we used Failure Modes and Effects Analysis (FMEA), a quality improvement tool, to examine barriers in implementing 2 core BH integration workflows: universal screening to identify developmental and behavioral concerns and implementation of real-time “warm” hand-offs. Results: Failure modes fell broadly into 2 categories across both workflows: (a) parental/caregiver characteristics and receptivity to the new workflow and (b) consistent implementation of the workflow by health center staff. Failures related to parental/caregiver characteristics included low literacy, language incongruence, and feeling burdened, intimidated, or offended by the screening process. Failures related to implementation of the workflow involved difficulties in administration of the correct age-appropriate screening form and incomplete hand-offs between primary care providers and behavioral health clinicians. Improvement strategies were identified to address both workflow failures, including making changes to electronic medical record functionality, modifying behavioral health clinician scheduling template, and retraining staff. Conclusions: Pediatric primary care practices planning for, or in the early stages of, BH integration may consider using the FMEA tool to support successful implementation.

Introduction to the special issue on integrated pediatric primary care: Placing “how” in the context of now.

“…Semistructured interviews with clinical stakeholders revealed perceived barriers related to time pressures, providers' perceptions of the intervention, and organizational factors. In concert with Tamene et al (2020), these papers highlight the importance of utilizing QI and implementation science methods to advance the dissemination of IPC practices.…”

“…Two papers in this special issue illustrate methods of examining implementation processes. Tamene, Morris, Feinberg, and Bair-Merritt (2020) used failure modes and effects analysis, a QI tool, to examine barriers to implementing IPC workflows. They identified failures related to caregiver characteristics (low literacy, language barriers, feeling burdened, intimidated, offended by the screening process) and failures related to implementation of the workflow (difficulties in administration of screening tools or execution of WHOs).…”

Adaptation of an evidence-based parenting intervention for integration into maternal-child home-visiting programs: Challenges and solutions

“…Intervention process mapping together with failure modes and effects analysis (FMEA) are tools that aid in intervention adaptation and are used within health services (Broder-Fingert et al, 2019; Lins et al, 2018; Tamene et al, 2020). The coupling of process mapping with FMEA aims to identify and reduce challenges inherent in complex interventions by gathering diverse perspectives of community members and addressing potential problems prior to implementation (Failure Modes and Effects Analysis (FMEA) Tool, 2017).…”