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Much of the existing research on quality improvement for children's health focused on the articulation of "best practices" or "evidence-based" guidelines which, like a well-tested recipe, defined what optimal care meant for different conditions. Typically, these were handed off to doctors and other caregivers through the medical literature and as part of workshops, conferences and seminars. These age-old methods of "CME" --continuing medical education--typically proved to have only limited impact on much of what caregivers did once they returned to work. This was equally so in the arena of children's health where the distance between "best" and "actual" practice proved both substantial and difficult to bridge.

While the main focus of adult health was the hospital and the acute care provided by specialists found there, children received a far greater share of their care from primary care doctors--pediatricians and family doctors--in private practices or community clinics. Hospitals provided an easily identifiable geographical and institutional structure for improvement efforts. The tens of thousands of doctors' offices across the country where most children received care were in a myriad of different settings and plugged into the health system in any number of ways. Putting into practice anything beyond the most essential information gleaned from traditional CME was outside the scope of many practices, where the norm was overscheduled days, overworked staff, and tight budgets that depended on reimbursements from health plans struggling to remain solvent.

In the mid-1990s, Peter Margolis in North Carolina and Charles Homer in Boston were among only a handful of researchers at the time looking into novel ways of getting inside the doctor's office to improve the quality of care there. Rather than requiring caregivers to come to the experts for advice on quality improvement, the experts would come to the caregivers--not for a one-shot workshop, but over an extended period that allowed caregivers the time and support to experiment, get feedback, and find the right fit between "best practice" and their own practice. David Bergman, a pediatrician with the Packard Children's Hospital at Stanford University and an advocate for such measures, characterizes how these approaches made caregivers themselves responsible for improvement efforts:
To the extent that we were going to do something at an office-based level, it was not going to come from an academy looking down on you and telling you what to do, or frankly a hospital telling the medical staff what to do. We really had to create systems within practices that would allow them to assess what they did and improve their quality. 		 
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