Hub and Spoke Initiative


​Hub a​​nd Spoke Initiative Focused on Improving HPV Vaccination Rates​​


    In 2014, the American Academy of Pediatrics (AAP) was awarded a 5-year cooperative agreement by the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) to develop and offer programs designed to measurably increase the proportion of pediatricians who implement immunization best practices (per CDC and The Community Guide) and ultimately increase human papillomavirus (HPV) vaccination rates. 

    Hub and Spoke Model

    To achieve maximum reach and impact, the AAP developed a Hub-and-Spoke model of improvement through its network of districts and chapters to teach quality improvement (QI) methodology to pediatricians and clinical and non-clinical staff within pediatric practice. Once trained, pediatricians, other clinicians and non-clinical staff then apply QI methodology to efforts in their own practices and institutions, building state/regional capacity for improvement over time. By building a critical mass of pediatricians and members of the pediatric care workforce trained in QI, the goal is to improve children's health across a region on any given topic area.

    Project Overview

    Through this cooperative agreement, the AAP is implementing its Hub-and-Spoke model of improvement to build sustainable peer-to-peer and QI networks through which to disseminate 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 QI efforts (eg, decrease missed opportunities, use reminder-recall).

    To further improve HPV vaccination rates and enhance the national reach to pediatricians, the AAP is working to form sustainable external partnerships and increase prioritization of HPV vaccination internally. More specifically, activities within the cooperative agreement are organized into the following four overarching strategies:

    • Provide outreach and training to pediatric offices on immunization delivery issues.
    • Disseminate immunization educational materials to pediatricians.
    • Form strong partnerships to complement AAP expertise on immunization delivery topics, enhance spread of common messages, and avoid duplication of effort.
    • Prioritize HPV vaccination efforts within the AAP structure.

    By implementing effective activities within each of these four strategies, the AAP seeks to achieve the following outcomes:

    • Increase in providers making a strong HPV vaccination recommendation
    • Increase in pediatrician knowledge of HPV vaccine
    • Increase in opportunities for clinician education and QI around immunizations
    • Increase in local/regional efforts aimed at promoting a strong provider recommendation for immunizations
    • Greater alignment of organizational and partners strategies for HPV vaccination
    • Increase in HPV vaccination rates in the office setting

    Overall, activities through the Hub and Spoke Initiative Focused on Improving HPV Vaccination Rates will lead to AAP districts and chapters being prepared to effectively improve immunization rates, whether independently or through state level partnerships; positioning the AAP as a key voice, leader, and partner in promotion of HPV vaccination; and greater expansion of collaborations with cooperative agreement partners and other organizations.

    For a two-page project overview, click here.

    Project Participants & Design

    QI Training & Grants to AAP Districts and Chapters

    The Hub and Spoke Initiative began in 2015 with QI trainings occurring by AAP districts across the United States (US). Since 2015, additional QI trainings have been provided to participants that build on skills and ideas presented in earlier QI trainings. Over the span of the project period, each AAP district has had the opportunity to participate. Below is a timeline of district participation and a map outlining the AAP districts.​







    CDC awards cooperative agreement to AAP

    Districts IV, VI, VII and X receive QI trainings and 23 chapters receive mini-grants to implement HPV QI projects.

    Districts I, II, III, V, VIII, and IX receive QI trainings and 33 chapters receive mini-grants to implement HPV QI projects.

    All districts are offered additional QI trainings and 11 chapters from Districts IV, VI, VII, X receive mini-grants to spread their HPV QI projects to additional providers.


    All districts are offered additional QI trainings and 16 chapters receive mini-grants to spread their HPV QI projects.




    ​All districts are offered additional QI trainings and 13 chapters receive mini-grants to spread their HPV QI projects.

    The QI trainings involve district and chapter leadership along with local champions with clinical expertise in immunizations, HPV, and practice improvement. Training curriculums were designed to provide an ongoing and shared learning experience for districts and chapters. Examples of training topics include foundational QI, the Model for Improvement, measurement, QI tools, sustainability, and spread. Aims of the trainings included:

    • Promoting the application of QI methods and implementation strategies to district and chapter HPV immunization and/or other health-related efforts
    • Enhancing district and chapter capacity for leading and engaging in QI initiatives
    • Building leadership for QI among districts and chapters

    In addition to the opportunity to receive QI and HPV training and education, AAP districts and chapters have had the opportunity through the Hub and Spoke Initiative to apply for funds to spread QI concepts to pediatric practices in one of the four ways listed in the table below. Each AAP district and chapter is 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

     ​​Education in Quality Improvement for Pediatric Practice (EQIPP)AAP Maintenance of Certification (MOC) ProjectAAP HPV ECHO*Design Your Own Project
    OverviewEQIPP is an online QI course that is free for AAP members and offers Maintenance of Certification (MOC) Part 4 credit. Chapter participants can sign up as a group. The AAP MOC project offers MOC Part 4 credit to participating providers and focuses on initiation and/or completion of the HPV vaccine series.ECHO is a virtual learning collaborative that works to spread QI knowledge.Districts or chapters leverage existing resources and networks to spread key improvement concepts.
    Know Your RatesA data collection tool is included in the course module that measures HPV vaccination rates.Participating practices utilize the AAP Quality Improvement Data Aggregator (QIDA) for practice level data collection. Participating practices utilize QIDA for practice level data collection.Specific project measures could be developed and tracked through QIDA or another mechanism determined by the district or chapter.
    Education/ InterventionContent is available in the course module to support a strong recommendation for HPV vaccination and reminder recall.The project supports a strong recommendation and/or reminder recall intervention.The project supports a strong recommendation, reducing missed opportunities, and completion rates. The AAP has a cadre of resources that could support the educational component of the district – or chapter-designed QI effort. ​

    *AAP HPV ECHO project was initiated for the 2017-2018 project year. 


    QI Trainings Year One – Five

    Over 450 pediatricians, health care providers, and AAP chapter staff have participated in one of 18 QI trainings offered to date by the AAP to learn QI methodology and then apply it with HPV projects in their own practices and institutions to build state/regional capacity for improvement.

    District/Chapter QI Projects Year One - Five

    • All chapters noted a positive change/improvement via reminder/recall and/or a strong provider recommendation
    • Estimated reach of the Hub and Spoke Initiative:
      • Number of Practices: 1007
      • Number of Pediatricians: 2,827
      • Number of Other Participants: 3,615
    • For chapter projects that disseminated the EQIPP adolescent immunization course in 2016-2018, 181 participants completed the course and are eligible for Maintenance of Certification (MOC) Part 4 credit.
    • For chapters that completed the HPV QI MOC project, there were over 1,180 pediatricians that received MOC Part 4 credit.

    Project Highlights

    1.       Quality Improvement Coaching

      • Chapters that utilized existing QI experts or hired external QI coaches were more likely to note having a more successful experience with implementing their QI project. Practices found the personalized guidance and feedback from the coaches useful. 

    Best Practices:

      • Hire an external QI coach or share a coach with another chapter or QI project
      • Utilize an existing chapter member as a QI expert

    2.       Staff Involvement

      • Families interact with various clinic staff prior to seeing a pediatrician. Practices expressed the importance of involving all staff in the clinic in the QI project, including front office staff. 
      • Practices noted that moving the full responsibility away from the providers to all clinic staff helped with increasing immunization rates and implementing systematic change.

    Best Practices:

      • Front office staff would receive education on how to use key and consistent messaging on HPV and HPV immunizations.
      • All staff would receive education on HPV cancers.
      • During staff meetings or lunch and learns, practices would invite cervical cancer survivors to share their story.  

    3.       Collaboration

    • Chapters created or utilized existing partnerships and collaborated with local and national organizations including local health departments and local immunization coalitions. This allowed chapters to form new partnerships and utilize existing resources, which paves the way for sustainability or spread of future projects.
    • Some chapters implemented a district-wide or multi-state project. Chapters reported feeling supported and found the collaboration to be beneficial, especially for those implementing a QI project for the first time. 

    Best Practices:

      • Chapters partnered with organizations, such as the American Cancer Society, to provide printed or electronic resources.
      • Chapters partnered with their local health department to recruit practices to be involved in the HPV QI project. 

    For additional highlights, please view the HPV QI Lessons Learned

    Helpful Resources

    ​Please view the HPV Champion Toolkit​


    This project is supported by the Grant or Cooperative Agreement Number, 6 NH23IP000952-05-01, funded by the Centers for Disease Control and Prevention (CDC). Special thanks to the Expert Workgroup members and QI consultant for the Hub and Spoke Initiative:

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

    For more information on the Hub-and-Spoke Initiative, please contact us here​.


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