Lesson 4 of 12
In Progress

Step 2: Form the HCT Quality Improvement Team

Dr. Rob December 12, 2023

Implementing and sustaining changes in your practice requires strong, effective partnerships.

These partnerships should not only be within your practice but also with adult partners and

community-based organizations. You will need a dedicated team. This team should be led by a

practice employee who is vested with the authority to coordinate the team’s efforts and

implement practice changes. The most effective teams include representatives from clinical and

administrative staff, and families, youth, and young adults.

A. Identify Team Members

Choose an energized and empowered team leader

The team leader must have both enthusiasm for QI and the clout to spearhead practice

change. If the team leader is not part of the practice’s senior leadership, senior leadership

must make it clear that the team leader has the authority to lead. In addition, the team

leader should be able to facilitate input from all team members, including families and

youth/young adults.

Involve key stakeholders

Key stakeholders include, but are not limited to, pediatric care champion(s), adult care

champion(s), care coordinators, parents/caregivers, and youth/young adults. Having a

youth/young adult patient and/or parent/caregiver on the team is essential. These team

members can provide invaluable first-hand insight on what they experience and how

systems and communication can be improved. To identify youth/young adults and

parents/caregivers consider the following:

• Ask for volunteers – including current youth or former young adult patients or

parents/caregivers of transition-aged youth who are typical of your patient

population – to join the HCT improvement team.

• Connect with a family based organization, such as the Family-to-Family Health

Information Center in your area/state or other entity that could connect with/find

youth/young adults and parents/caregivers.

• Provide compensation unless they are paid staff members.

• Be flexible about meeting times and modalities (phone, Skype) to accommodate


• Consider recruiting more than one youth/young adult and parent/caregiver so their

views and opinions are always represented.

• Articulate roles and provide training, if needed (including from other consumers who

have taken leadership roles in the practice)

Include at least one motivated and respected representative from each area of your


In small practices, it often works best to include most or all of your clinical and

administrative staff members. In large practices, it is important to include at least one

representative from each area of your practice. Team members may include but are not

limited to:How to Implement the Six Core Elements of Health Care Transition™ 3.0 5

• Clinician

• Nurse

• Social worker

• Medical assistant

• Practice manager

• Front office staff

• Billing staff/payers

• Community-based organization that, for example, can assist in providing services in

your transition process such as patient education.

• Public health programs that, for example, can assist by raising awareness around

HCT needs and improving services

• Others (as part of the team or to participate on ad hoc basis) such as

epidemiologists, care coordinator/key support staff, clinic support staff from both

pediatric and adult practices/clinics, electronic medical record (EMR) representative,

data administrator who can pull system/practice data to support the initiation and

evaluation of the process, senior leader, or payer. While a data person and an EMR

analyst don’t need to attend all the meetings, they are critical as the process

evolves, so plan on and budget their involvement early.

Keep the size of your team manageable

A team with more than 12 members can make it hard to get things done.

B. Bring Team Members Together

• Have an initial meeting to introduce the topic and educate your team, introduce the

Six Core Elements package and its sample tools, and review the goals of

implementing HCT in your practice.

• Ask at least one or two team members to review the full Six Core Elements package

carefully to become familiar with its contents.

C. Have Subsequent Meetings and Establish Routine Reporting

• Schedule regular team meetings. Frequent meetings may be needed at the outset

(e.g., twice a month). Meetings can take place less frequently once your

implementation activities are underway.

• Early on and throughout the process, it is important to clarify each team member’s

role and responsibilities.

• Report progress on a monthly basis in a templated format, including data, to the

practice’s senior leadership to maintain accountability and team engagement.