Hub and Spoke Initiative


​Hub a​​nd Spoke Initiative

What ​is H​ub-a​​​nd-Spoke?

The AAP used the Hub-and-Spoke Model of Improvement to teach, pediatricians across specialties, within AAP districts, quality improvement (QI) methodology. Pediatricians then applied it to projects in their own practices and institutions to build state/regional capacity for improvement. The goal was to build a critical mass of pediatricians trained in QI with the goal of improving children's health across a region on any given topic area.

The purpose of the AAP 5-year cooperative agreement is to raise immunization rates by creating and executing coordinated and connected action-based programs that aim to measurably increase the proportion of pediatricians who implement best immunization practices (per CDC and TheCommunity Guide). The AAP effort will be devoted to building sustainable peer-to-peer and quality improvement (QI) networks for immunization education and increasing vaccination coverage by disseminating professional education and tools designed to aid pediatricians and their office staff to: (1) consistently make strong HPV vaccine recommendations, (2) effectively address parental questions, and (3) implement HPV vaccination-related quality improvement efforts (eg, decrease missed opportunities, use reminder-recall). To enhance the AAP's national reach to pediatricians, the project team will work to form sustainable external partnerships and increase internal prioritization to improve HPV vaccination rates.


  • Increase in providers making a strong HPV vaccine recommendation
  • Increase in pediatrician knowledge of HPV vaccine
  • Increased opportunities for clinician education and QI around immunizations
  • Increased local/regional efforts aimed at promoting a strong provider recommendation for immunizations
  • Greater alignment of organizational and partner strategies for HPV vaccine uptake

Increas​​ed HP​​​​V vaccination rates ​


    In 2015, the AAP developed and began to implement its hub-and-spoke initiative of improvement. Through this initiative pediatricians across specialties within AAP districts learn quality improvement (QI) methodology, then apply it to projects in their own practices and institutions to build state/regional capacity for improvement. The goal is to build a critical mass of pediatricians trained in QI to improve children's health across a region on any given topic area. The original focus of the hub-and-spoke initiative of improvement is on increasing HPV vaccination rates across the country.

    Project Overview

    Over the span of the project period, each District in the Academy has had the opportunity to participate. Below is a timeline of District participation and a map outlining the AAP Districts.


    2014 2015 2016 2017
    CDC awards grant to AAP

    District QI trainings begin;

    HPV Hub-and-Spoke initiative begins in Districts: IV, VI, VII, X

    District QI trainings continue;

    Hub-and-Spoke initiative begins in Districts: I, II, III, V, VIII, IX

    HPV Hub-and-Spoke initiative expands to include more providers in Districts: IV, VI, VII, X
    Project Participants & Design

    The District Hub-and-Spoke Initiative began with QI trainings occurring by regions across the US.

    The District QI Training involved district and chapter leadership along with local champions with clinical expertise in immunizations, HPV, and practice improvement. The training curriculum and worksheets were designed to meet districts where they were in their QI journey and provide opportunities for shared learning. Examples of training topics include foundation QI, the initiative for improvement, measurement, QI tools, and/or sustainability and spread. Specific aims of the training included:

    • Promoting the application of QI methods and implementation strategies to district/chapter efforts
    • Enhancing district and chapter capacity for leading and engaging in improvement initiatives
    • Building leadership for QI among districts and chapters

    Following the district QI Trainings, each Academy Chapter had the opportunity to lead an HPV vaccination QI project in one of the three following ways.

      EQIPP Peer-to-Peer Design Your Project
    OverviewEQIPP is an online quality improvement course that is free for AAP members and offers Maintenance of Certification Part IV credit. Chapter members can sign up as a groupAlso known as academic detailing or EPIC, leader physicians schedule time in offices to teach others key improvement conceptsLeverage existing Chapter resources and networks that exist to spread key improvement concepts
    Know Your RatesA data collection tool is included in the module that measures HPV vaccination rates.Specific project measures can be developed and tracked through QIDA or another mechanism determined by the chapter.Specific project measures could be developed and tracked through QIDA or another mechanism determined by the chapter.
    Education/ InterventionContent is available in the module to support a strong recommendation for HPV and reminder recallThe AAP has a cadre of resources that could support peer-to-peer education.The AAP has a cadre of resources that could support the educational component of the Chapter designed QI effort.

    The HPV Chapter projects aim to improve HPV vaccination rates by spreading QI concepts to pediatric practices. Each AAP chapter in the District was eligible to receive funding to focus their efforts on improving:

    • Initiation of the HPV vaccine series through a strong provider recommendation, and/or
    • Completion of the HPV vaccine series through tools such as reminder/recall

    A total of 23 AAP Chapters participated in Year One of the Hub-and-Spoke initiative, and 33 are currently participating in Year Two

    Year One

    • All chapters noted a positive change/improvement via reminder/recall and/or a strong provider recommendation
    • Estimated reach of Year One's Hub-and-Spoke initiative:
      • Number of Practices: 160
      • Number of Pediatricians: 807
      • Number of Other Physicians: 27
      • Number of Non-Physician: 349
    The 2016 Maintenance of Certification (MOC) completion requirements for this project were:
    • Consecutively submit baseline and an additional 2 consecutive months of data, for 10 consecutive patients, per practice, using QIDA
    • Annotate run charts in QIDA
    • Implement project interventions
    • Participate in 3 team meetings or webinars where data is reviewed and ideas for change are discussed
    • Review run chart data via the QIDA system on a monthly basis and implement PDSAs based on learnings from the data
    Chapter Highlights

    District IV

    South Carolina who worked on their own QI project, worked with a total of 29 practices across the state. Their efforts included a special Charleston HPV Learning Collaborative, integrating more complete HPV into their statewide QTIP learning collaborative and collaboration efforts with the South Carolina Select Health, Merck and Cervical Cancer Free South Carolina. Overall completion rates for the 3-dose series rose in April 2016 from 44% to 56%.

    District VI

    Minnesota took the lead in a multi-state MOC HPV QI initiative. They co-sponsored an HPV Vaccination Summit in April 2016 with over 90 clinicians and researchers in attendance. In addition, Minnesota co-sponsored the HPV MOC4 module for the AAP's District VI and the "virtual HPV learning collaborative" which hosted monthly conference calls and aided with MOC4 process requirements for over 230 Midwest pediatricians.  Lastly, new partnerships and collaborations resulted from the implementation of this MOC initiative including: three large Minnesota health plans, the University of Minnesota, Mayo Clinic, Rotary, Minnesota Cancer Society and the Minnesota Department of Public Health. 

    District VII

    Arkansas participated in a HPV QI MOC initiative. They held monthly webinars/calls at the district and state level to review practice specific data, teach basic QI principles using these specific projects, discuss obstacles, make clarifications and discuss next steps in the project. In addition to these calls, each practice that was participating in the project were given additional training on data collection and QI concepts. It provided education for the practices, but also provided an open forum for peer-to-peer discussion on success and challenges within the initiative. Over 70 pediatricians were reached through Arkansas' HPV initiative.

    District X

    Florida participated in the AAP's Education in Quality improvement for Pediatric Practice (EQIPP) course. To aid it participating providers, Florida hosted virtual conference sessions to discuss different protocols for implementing a reminder recall system and providing a strong and clear recommendation. For the reminder system, parents and teens were encouraged to sign-up for text reminders before they left the office after administration of the first dose, or to make an appointment for the second dose before the left the office. In addition, patients and parents were also called two days before their second appointment to remind them of their next appointment. For a strong provider recommendation, parents and teens were given fact sheets showing the incidence of HPV and the causes for HPV induced illness. Parents and teens were presented with a positive message from the front of the office all the way back to the exam room and told that they would receive their HPV immunization during the visit. Over 40 pediatricians signed up for the Florida EQIPP initiative.

    Helpful Resources

    Please view the HPV Resources page.


    This project was supported by the Grant or Cooperative Agreement Number, 5H23IP000952, funded by the Centers for Disease Control and Prevention (CDC). Special thanks to the HPV Expert Workgroup members and the HPV project's QI Consultant:

    • Sharon Humiston, MD, MPH, FAAP
    • Laura Noonan, MD
    • Kristin Oliver, MD, MHS
    • Rebecca Perkins, MD, MsC

    For more information on the Hub-and-Spoke Initiative, please contact


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