Using the Quality Improvement (QI) Tool Failure Modes and Effects Analysis (FMEA) to Examine Implementation Barriers to Common Workflows in Integrated Pediatric Care

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.