ARTICLE
Forging a Pathway for
Quality Improvement in
School-Based Health
Centers: A Statewide
Initiative
Ranbir Mangat Bains, PhD, APRN, CPNP, & Jesse White-Frese’, MA, LPC
School-based health centers (SBHCs) provide quality health serv-
ices to the children and youth they serve. Numerous studies have
validated the access provided by SBHCs. The School-Based Health
Alliance has captured descriptive data on the services provided.
However, no standardized quality measures to benchmark perfor-
mance across SBHCs exists. An initiative to establish standards
that would uniformly capture quality of care delivered was essen-
tial. This article describes how five measures developed by the
School-Based Health Alliance were implemented as a state-based
quality improvement initiative after being tested in four states. The
initiative led to the adoption of these measures for all state-funded
SBHCs. J Pediatr Health Care. (2021) 35, 479−484
KEY WORDS
Quality improvement, school-based health centers, quality
measures
Ranbir Mangat Bains, Pediatric Nurse Practitioner, Yale New
Haven Health, New Haven, CT.
Jesse White-Frese’, Chair-Elect, School-Based Health Alliance
Board of Directors, Washington, DC.
Conflicts of interest: None to report.
Correspondence: Ranbir Mangat Bains, PhD, APRN, CPNP, Yale
New Haven Health, 789 Howard Ave., New Haven, CT 06519;
e-mail: bainsgr1@gmail.com.
J Pediatr Health Care. (2021) 35, 479-484
0891-5245/$36.00
Copyright © 2021 by the National Association of Pediatric Nurse
Practitioners. Published by Elsevier Inc. All rights reserved.
Published online June 23, 2021.
https://doi.org/10.1016/j.pedhc.2021.04.014
www.jpedhc.org
INTRODUCTION
The School-Based Health Alliance is a national organization
that represents and advocates for school-based health cen-
ters (SBHCs) nationwide, with 2,584 centers in 48 states
(Love, Schlitt, Soleimanpour, Panchal, & Behr, 2019). An
SBHC represents a shared commitment between a com-
munity’s schools and health care organizations to support
the health, well-being, and academic success of its students
(Love et al., 2019). Typically, schools donate facilities and
utilities for SBHCs, and building-level policies facilitate stu-
dents’ enrollment and use of their services. Local health
organizations provide the expertise and linkages to an array
of services, including medical, nursing, behavioral health
counseling, oral health care, reproductive health, nutrition
education, and health promotion. The goal of the partner-
ship is to create a culture of health within the school and
enable children and adolescents to thrive in the classroom
and beyond.
Over the years, numerous studies have demonstrated the
benefits of SBHCs (Brindis, 2016; Keeton, Soleimanpour,
& Brindis, 2012; Soleimanpour, Geierstanger, Kaller,
McCarter, & Brindis, 2010). Two reviews conducted by
the Community Guide Branch at the Center for Disease
Control evaluated evidence provided in the studies.
Ran, Chattopadhyay, Hahn, and Community Preventive
Services Task Force (2016) reviewed 21 studies on the eco-
nomic cost and benefits of SBHCs, and Knopf et al. (2016)
reviewed 46 studies addressing the advancement of health
equity in SBHCs. Another review by Arenson, Hudson, Lee,
& Lai (2019) examined over 300 articles under the categories
of financial, physical, mental, and educational outcomes. The
three reviews of evidence showed that SBHCs provided
access to health services, reduced time out of school,
September/October 2021 479
provided services in locations where access can be challeng-
ing, and were effective in advancing health equity
(Arenson et al., 2019; Knopf et al., 2016; Ran et al., 2016).
Collectively, the array of services offered by SBHCs vary,
with 65% of sites offering primary care and behavioral
health; and 41% of these offering additional services, includ-
ing oral health, vision, and health education (Love et al.,
2019)
From its inception in 1995, the School-Based Health Alli-
ance has been compiling descriptive national data about the
services provided by SBHCs. Recently, with the changing
health care landscape and an emphasis on health outcomes,
the leaders of the organization embarked on a National
Quality Initiative to establish standards that would capture
the quality of care delivered by SBHCs. They partnered with
select SBHCs to test the quality measures in practice. Con-
necticut was one of four states volunteering to participate in
a national pilot project. In this article, we will describe how
the quality measures developed by the School-Based Health
Alliance were tested in a state-based quality improvement
initiative and ultimately adopted by the Connecticut Depart-
ment of Public Health (DPH).
BACKGROUND AND PURPOSE
In the late 1960s, SBHCs first emerged to meet the health
care needs of adolescents within their school environment
(Gustafson, 2005). Presently, most SBHCs are in urban,
low-income areas and provide essential health care access to
more than six million students annually (Love et al., 2019).
Funding for SBHCs includes federal grants awarded to fed-
erally qualified health centers, state and local grants to vari-
ous sponsoring organizational types, private foundation
funding, and reimbursement revenue from public and pri-
vate insurance (Navarro, Zirkle, & Barr, 2017). Given the
myriad of funding sources, SBHCs may be obligated to sat-
isfy agreements and provide varied data to multiple funders
or their sponsoring organization. Hence, there have been no
uniform state or national standards to measure the quality
of care delivered to students in SBHCs.
Characterized by a multidisciplinary model of primary
care medical and behavioral health services, SBHCs are
well-positioned to undertake quality improvement (QI) ini-
tiatives. Providing care within this environment presents the
opportunity to implement QI initiatives that can address a
broad range of health issues encountered by students in ele-
mentary, middle, and high schools. SBHCs have the unique
ability to engage students in health care within the school
environment, creating an atmosphere of safety, confidential-
ity, and trust. They have the capacity to monitor and track
progress on quality metrics that can improve outcomes for
vulnerable young people.
QI initiatives use frameworks to evaluate improvements
in organizational structures, processes, and outcomes
(Donabedian, 1988). These initiatives are defined as system-
atic and continuous activities leading to quantifiable advan-
ces not only in health care services but also in the health
status of patients (Batalden & Davidoff, 2007). Increasingly,
480 Volume 35  Number 5
QI initiatives have become an essential component of the
sustainability of health care institutions. Effective QI
requires an understanding of systems and data-driven
inquiry into the components and processes of the program.
Importantly, successful and robust QI within a system
requires support from organizational leaders.
The leadership at School-Based Health Alliance long rec-
ognized the need for uniform standards to measure and
improve services provided at SBHCs. In 2014, the School-
Based Health Alliance and the National Center for School
Mental Health at the University of Maryland joined forces to
increase the number of school-based health services and
bolster sustainability by developing national standardized
quality measures. The first task of this collaborative effort
was to develop measures that represent the quality of health
care delivered at SBHCs. A diverse group of stakeholders,
including state, government, education, and SBHC staff,
convened to discuss and score potential measures. They
identified measures aligned with national pediatric measure
sets such as Healthcare Effectiveness Data and Information
Sets and the Child Health Insurance Program Reauthoriza-
tion Act of 2009 and those collected by state SBHC program
offices. It was imperative that the measures accurately
reflected the work of SBHCs and were feasible to collect. In
addition, information gained from the measures had to sup-
port policy development and advocacy for the sustainability
of SBHCs. After 8 months of a comprehensive multistep
process, five quality measures were selected that would rep-
resent the core of work in SBHCs. These physical and men-
tal health quality measures consisted of annual well-child
visits, risk assessments, body mass index (BMI) with nutri-
tion and physical activity counseling, depression screening,
and chlamydia screening. In 2016, the School-Based Health
Alliance outlined the strategy to encourage at least 50% of
SBHCs to voluntarily adopt and report the quality measures
by 2018.
Before a full-scale national adoption of the measures, it
was necessary to test these quality measures. The states that
volunteered to test these measures needed to demonstrate
the ability and willingness to implement data collection, par-
ticipate in a national learning collaborative, and provide
feedback on the process to the School-Based Health Alli-
ance (Langley et al., 2009). States selected for participation
needed to form QI teams consisting of clinical and adminis-
trative leaders, dedicate adequate time for QI activities, and
use an electronic health record (EHR) system for data col-
lection and analysis. Four states expressed interest, met these
criteria, and were selected to participate in the first cohort
with the School-Based Health Alliance.
TESTING THE NATIONAL QUALITY METRICS IN
SBHCS
The first cohort of states to participate included Colorado,
Connecticut, North Carolina, and Seattle-King County, rep-
resenting the state of Washington. These states were
required to attend collaborative peer-to-peer learning ses-
sions and monthly technical assistance calls. In addition,
Journal of Pediatric Health CareÒ
each state formed a core team for the project, developed a
strategic initiative in each participating SBHC site, and
assisted sites with project assessments and data reports. The
Connecticut Association of School-Based Health Centers
(CASBHC), in partnership with the DPH, formed the lead-
ership team for the Connecticut project.
The School-Based Health Alliance provided technical
support and a learning community collaborative model to
the four participating states. The individual SBHCs in each
state engaged in a QI framework to adopt, test, and report
on the national quality metrics. Each participating SBHC
collected data on the measures and entered the information
into a national database to track the progress of each site,
compare with other SBHCs in their state, and compare with
SBHCs engaged in the national project. The technical team
at the School-Based Health Alliance compiled data for each
state and shared it with the leadership teams. With this initial
data, the CASBHC committed to further exploration of the
process.
DEVELOPING A STATEWIDE STRATEGY
The CASBHC is an advocacy and technical assistance and
training organization for the state’s SBHCs. CASBHC invited
agencies that sponsored SBHCs in Connecticut to voluntarily
engage in the national pilot for 12 months. The written call
for participation was extended to all SBHCs in the state and
emphasized specific criteria that would encourage a success-
ful endeavor. The criteria included established use of an
EHR, the ability of the team to attend the in-person learning
sessions and monthly technical assistance calls, support of
the organization’s leadership and approval of dedicated time
for QI team meetings, and the willingness and ability to col-
lect and submit data into the national portal. Only schools
with students in grades 6−12 could apply on the basis of the
ages delineated in the quality indicators to be tested.
As a statewide entity with a deep knowledge of SBHC
programs, CASBHC encouraged organizations with mul-
tiple SBHC sites to participate in the initiative. Priority
was given to SBHCs that had prior significant experience
with QI or had the infrastructure to support the work.
Five SBHC programs applied to the initiative and were
able to meet the core set of requirements. The long-term
goal was to develop a training model that would extend
QI processes to all Connecticut SBHCs, resulting in the
spread and consistent data collection and reporting on
student health outcomes.
IMPLEMENTATION OF A STATE-BASED
INITIATIVE
Of the five SBHC sponsoring organizations selected for
cohort 1 in Connecticut, three were federally qualified health
center organizations, one was an SBHC program sponsored
by a board of education, and another was a program spon-
sored by a private nonprofit organization. The mix of orga-
nizational types was reflective of the programs funded by
the DPH. Each sponsoring organization self-selected two
SBHC sites for the implementation of the project. In total,
www.jpedhc.org
there were 10 SBHC sites in the first cohort, including two
kindergarten to eighth-grade schools, six middle schools,
and two high schools. All the sites were in medium and
large-sized urban communities.
Each of the 10 SBHC sites constructed a QI team com-
posed of a licensed medical clinician, a licensed mental
health clinician, and an administrative team leader. Some
sites included data entry personnel with expertise in EHRs
on their team. Most sites used administrative staff to enter
information from encounter data and ran monthly queries
that gathered indicator-specific data. Each of the 10 sites
uploaded this data into the national School-Based Health
Alliance portal. The Alliance created monthly run charts for
each team to objectively measure their progress and bolster
their ongoing improvement efforts. Data from the Connecti-
cut team is illustrated in the Figure and demonstrates the
data collection trends over 14 months on BMI and depres-
sion screening rates. The dip in rates in July and August are
concurrent with the summer closure of school; the dip in
January is due to a lack of reporting data from one sponsor-
ing organization.
As the sites met and identified systems and processes that
would be employed in the project, several factors critical to
success emerged in each participating organization. Most
importantly, it was quickly apparent that the organization’s
information technology (IT) staff were an integral part of
the team. Data were drawn from the five measures needed
to be easy to electronically document, extract, and made
readily available for reporting purposes. Before this QI
initiative, certain visit data was often entered in the notes
section of the EHR and could not be readily extracted
or aggregated. In some cases, this required reconfiguring
sections of the EHR, providing access to existing data
fields that had not been available to SBHC staff, and
building new reports. Regular communication between
SBHC project staff and IT staff contributed to a greater
understanding of the reporting needs of clinicians and
better data outcomes.
The teams met quarterly for collaborative learning ses-
sions and shared their experiences in the use of QI techni-
ques such as daily team meetings, developing data registries,
and creating formalized methods for referral and follow-up
between providers within the SBHC. Data were collected by
an assigned team member and interpreted collectively by the
team. As illustrated in Table 1, the SBHC dental team collab-
orated with the medical provider to provide risk assessments
to each student seen for care. Those with positive screens
were referred to the SBHC for further services, thereby
increasing engagement with all services provided by the
SBHC. The team deployed improvement study cycles using
the Plan-Do-Study-Act technique to measure incremental
changes and adapt processes on the basis of the results. At
the end of the 12-month project year, data demonstrated
increased enrollment in full SBHC services, risk assessment
screening, and referrals led to greater mental and physical
health follow-up, and 90% of enrolled students received
depression and BMI screens.
September/October 2021 481
FIGURE. Aggregated Connecticut teams—run
charts
Note. Charts provided by School-Based Health
Alliance Standardized Performance Measures Col-
laborative Improvement and Innovation Network.
Aggregate data from the five Connecticut teams on
depression screening and body mass index screen-
ing measures. The school-based health centers are
>
closed from June through late August.
(This figure appears in color online at www.jpedhc.
org.)
Those SBHC organizations in the project that used the
same EHR exchanged knowledge of the platform’s capabil-
ity, thus creating data efficiencies among all team members
and fostering innovation in practice processes.
EVALUATION AND REFLECTION OF THE STATE-
BASED INITIATIVE
The leadership of CASBHC was deeply engaged in this
project and closely partnered with DPH throughout the
12 months, attending all learning sessions and monthly
technical assistance calls. The teams experienced initial
successes that paved a pathway to expand QI and data col-
lection to other SBHCs. As the initial 12 months neared
completion, DPH recognized the value of the measures
and announced that reporting on all five measures would
be integrated as a requirement for all state-funded SBHC
482 Volume 35  Number 5
programs in the following contract year. To enhance and
strengthen the initiative, planning for future expansion
was essential.
EXPANSION OF EARLY SUCCESSES
In conjunction with the cohort 1 participating organizations,
CASBHC determined that the QI model would be strength-
ened with individual site-level technical support and a state-
specific learning collaborative. With funding from Connecti-
cut Health Foundation (CHF), the five organizations in
cohort 1 committed to participation in a state-based initia-
tive for an additional 12 months. The extension offered sites
the opportunity to further address the five quality measures
and embed a QI approach into their SBHC operations.
QI consultants from John Snow International, Inc. (JSI;
Boston, MA) were engaged to provide additional support
and expertise. Individual technical assistance was an impor-
tant factor in each team’s success, followed by the value of
convening teams throughout the year to exchange informa-
tion, innovations, and shared learning. JSI provided one-on-
one support to the SBHC programs throughout the 12
months and periodically convened the teams in collaborative
learning sessions.
INTEGRATING QI PROCESS WITHIN SBHCS
STATEWIDE
Building on the success of the five original teams, CASBHC
envisioned that all Connecticut SBHCs could integrate the
quality framework into their operations, report on the meas-
ures, and use data to improve outcomes for students using
SBHC services. With this objective, CASBHC recruited four
additional SBHC organizations to adopt the measures, test
the training and technical assistance model, and determine if
the framework could be spread to other SBHC organiza-
tions. Adding new SBHCs to the initial cohort presented
new challenges and opportunities.
The School-Based Health Alliance facilitated the initial
learning session with the teams in cohort 2. They familiar-
ized the sites with the National Quality Initiative, the Model
for Improvement, and the quality measures (Langley et al.,
2009). The initial cohort served as mentors to cohort 2,
accelerating improvement and working toward improved
outcomes. After the kick-off session, the four organizations
new to the initiative worked closely with JSI staff for 12
months. Several key principles learned from the first group
were quickly adopted by cohort 2. These included engaging
IT staff early in the project, selecting one measure for a 12-
month focused initiative, using daily team meetings to accel-
erate learning, and focusing on improved data reporting.
Table 2 illustrates a series of improvements designed to stan-
dardize a depression screening tool among SBHC providers
in one site, ensuring that meaningful data could easily be
extracted and aggregated.
Ultimately, cohort 2 obtained benefit from the experien-
ces of the inaugural group. Each team reported improve-
ments in practice flow, teams visually tracked their progress
through monthly charts on the measures, and modifications
Journal of Pediatric Health CareÒ
 TABLE 1. Cohort 1: Risk assessments and access to care
Case report 1

Pre-NQI Improvement processes Outcome

 School-based medical/mental health
services in a separate location from den-
tal services
 Students receiving dental services given
risk assessments, depression screens,
body mass index screens; but many
unaware of services other than dental
 Advanced practice registered nurses pro-
vided risk assessment visit to all students
who saw a dental hygienist
 Plan-Do-Study-Act cycles tested the com-
munication between the dental program
and SBHC services
 Students are given an enrollment form for
SBHC
 Risk assessment score triggered referral to
SBHC medical or mental health clinician
 Increased engagement with full SBHC
services
 Risk assessment referrals led to mental
and physical health follow-up
 At the end of the school year, 90% of
enrolled students received depression
and body mass index screens

Note. NQI, National Quality Initiative; SBHC, school-based health center. Measure: percentage of unduplicated SBHC clients aged ≥
12 years with ≥ 1 age-appropriate annual risk assessment during the school year.

to EHRs allowed for easier data collection and reporting.
Each site developed QI initiatives that were pertinent to
their sites, and these included risk assessments, BMI with
nutrition and exercise counseling, depression, and chlamydia
screening. With support from the site leadership, these initia-
tives were embedded into routine practice at the SBHCs. To
encourage further statewide and national adoption of the
measures, cohort 1 and 2 teams developed storyboards at
the end of 12 months to demonstrate their process and
progress. The storyboards were shared at statewide and
national conferences.
CONCLUSIONS
In Connecticut, DPH funds 93 SBHCs and requires
data collection from all of them. As partners in the
SBHC QI project, they saw the value of all SBHCs collecting
and reporting on the same measures. Representatives
from DPH participated in the learning sessions and part-
nered with CASBHC throughout the project to develop a
strategy and vision that all SBHCs in the state would
adopt and report on this first-ever set of national SBHC
quality measures. As a result, DPH contractually required all
state-funded SBHCs to annually report their progress on the
five national SBHC standardized quality measures.
Deep engagement of CASBHC in the development and
execution of the learning collaborative was essential for suc-
cess. Grant funding from the CHF provided stipends as
incentives to the sites in cohorts 1 and 2 that met specific
participation and reporting requirements. The structured
use of the Model for Improvement enabled success for each
team (Langley et al., 2009). The learning collaborative sup-
ported group interaction and the individual innovations of
the teams. Individual team coaching provided crucial sup-
port as they learned improvement principles, adapted to
change, navigated roadblocks, and sought creative solutions
to achieve their goals.
Several key factors were necessary to achieve these end
goals; the most important factor was support from the orga-
nizational leadership. The agencies that run the daily opera-
tions of the SBHCs had to be willing to participate in the
initiative and give the SBHC team time to attend all the
working sessions. Multidisciplinary team members were an
essential component of the success and strength of the col-
laboration. The ability to decipher data from the EHRs was

TABLE 2. Cohort 2: Standardizing depression screening

Case report 2

Pre-NQI Improvement processes Outcome

 SBHC medical clinician screened for
depression only during annual well-visits
or for students displaying depression
symptoms, with referral to SBHC mental
health clinician
 Medical and mental health clinician used
different screening tools
 No process for documentation of com-
pleted referral or follow-up in EHR
 Depression screen by medical clinician
using PHQ-2 for every 10th grade student
at well-child visit
 After several testing cycles, expanded to
every student using PHQ-2 for well-child
and all medical visits; students with positive
screen referred to mental health clinician
 PHQ-9 given by mental health clinician with
documentation in EHR
 Eighty percent of students with positive
PHQ-9 received counseling services in
SBHC
 Successful process expanded to mid-
dle school SBHC
 Screening tool embedded into EHR for
use by all SBHC clinicians

Note. EHR, electronic health record; NQI, National Quality Initiative; PHQ, Patient Health Questionnaire; SBHC, school-based health center.
Measure: percentage of unduplicated SBHC clients aged ≥ 12 years with documentation of screening for clinical depression using an age-
appropriate standardized tool and follow-up plan documented if positive screen at least once during the school year.

www.jpedhc.org September/October 2021 483

a key component to success. Funding from the CHF enabled
CASBHC to build on the collaborative model and partner
with experts to provide high-quality training and support to
the SBHC staff through the process.
With increasing pressure to demonstrate high-quality
health care delivery, this QI initiative allowed SBHCs to test
and adopt the measures statewide. Because of this initiative,
data across all the Connecticut SBHCs are uniform and con-
sistent. Access to this data allowed providers to improve
services at their sites and compare and exchange QI ideas
with other SBHCs. Administrators and policymakers have
used the data to advocate for enhanced services and
increased funding for SBHCs. Going forward, researchers
and policymakers will benefit from the availability of uni-
form data.
ETHICAL STATEMENT
Hereby, I, Ranbir Mangat Bains consciously assure that for
the manuscript, Forging A Pathway for Quality Improve-
ment in School-Based Health Centers: A Statewide Incen-
tive, the following is fulfilled:
1) This material is the authors' own original work, which
has not been previously published elsewhere.
2) The paper is not currently being considered for publi-
cation elsewhere.
3) The paper reflects the authors' own research and anal-
ysis in a truthful and complete manner.
4) The paper properly credits the meaningful contribu-
tions of co-authors and co-researchers.
5) The results are appropriately placed in the context of
prior and existing research.
6) All sources used are properly disclosed (correct cita-
tion). Literally copying of text must be indicated as
such by using quotation marks and giving proper ref-
erence.
7) All authors have been personally and actively involved
in substantial work leading to the paper, and will take
public responsibility for its content.
The violation of the Ethical Statement rules may result in
severe consequences.
To verify originality, your article may be checked by the
originality detection software iThenticate. See also http://
www.elsevier.com/editors/plagdetect.
484 Volume 35  Number 5
I agree with the above statements and declare that this
submission follows the policies of Solid State Ionics as out-
lined in the Guide for Authors and in the Ethical Statement.
Date: 2/2/2021
Corresponding author’s signature:
Ranbir Mangat Bains
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Journal of Pediatric Health CareÒ