Why It Matters
Summit Healthcare Regional Medical Center serves community members who reside in a 3,000+ square mile area of the White Mountains in rural northeastern Arizona. Our community consists of full- and part-time residents, as well as visitors enjoying winter sports and relief from the heat. Our service area includes nontribal communities in Navajo and Apache counties, and tribal communities of the Navajo, Hopi, White Mountain Apache, and San Carlos Apache reservations.
We were concerned with the incidence of perinatal mood and anxiety disorders (PMADs) in our community. Research supports that early identification and treatment of PMAD leads to stronger attachment between mother and child. One focus of the HealthySteps model is improving mental health outcomes for the caregiver-child dyad. Our HealthySteps team suspected mothers with PMAD symptoms were reluctant to discuss these feelings because they were afraid of being judged, and we were aware of barriers to treatment. Our community suffers from a lack of mental health care providers. Other obstacles include the vastness of our service area, prohibitive costs or insurance issues, and the likelihood that mothers did not realize the impact their depression had on their family or on their child’s development.
Where We Started
Our team has extensive experience around the subject of postpartum depression. All team members are certified to provide support for PMADs. At the time we began to engage in continuous quality improvement (CQI) through the HealthySteps Outcome Pilot Project, our service delivery protocol included using clinical interviewing skills and screening moms for PMAD. Using the Edinburgh Postnatal Depression Screening (EPDS), we were screening at two time points (1 or 2 months and 9 or 12 months) during the baby’s first year. If we were concerned about a particular mother, we would screen her outside of our regular screening schedule. If the EPDS score was elevated, we would refer her to the very limited resources in our area. Due to the lack of community resources, we trained for and launched our own mothers’ support group, which we continue to offer.
At the beginning of our CQI project, we gathered baseline data on the EPDS completion rate. We thought we were completing many more EPDSs than the data demonstrated. We estimated we had a 70% EPDS completion rate, but the baseline data revealed a 41% completion rate. During the process of collecting this data, we realized we needed to make our practice more data driven. HealthySteps Specialists began to understand that CQI could guide our work to improve screening completion rates. Because we are committed to the families we serve, we are highly motivated to provide the highest quality of care. Our director recognized that the CQI process would help us make changes in our practice to progress toward fidelity to ZERO TO THREE’s HealthySteps model.
Our team developed the following goal (SMART Aim): By August 30, 2019, the Summit Healthcare HealthySteps team will increase the rate of completed maternal depression screenings (using the EPDS) at identified intervals among maternal primary caregivers from 41% to 60%.
How We Diagnosed the Problem
In partnership with the Outcome Pilot Project Evaluation Team, we created a process map to identify each step of the HealthySteps Specialists’ screening process. Our team met several times to discuss the problems preventing higher EPDS completion rates. We documented those problems on a fishbone diagram. This work identified potential root causes of low screening rates, such as parent refusal, HealthySteps Specialists’ discomfort with the topic, gaps in data collection and entry, and pediatric providers’ difficulty with including the mother’s information in the child’s medical record. Through this process, we identified improvements we could test to standardize the introduction of the EPDS. We felt that this change could help destigmatize PMADs.
How We Tested Solutions
We then brainstormed ways we could try to change current practices (change strategies). After discussing several change strategies, we chose to test a standard script to introduce the maternal depression screen at the 1- or 2-, 4-, and 12-month well-child visits. Before we initiated our first test, we were mindful of the need to provide HealthySteps Specialists sessions of practicing, coaching, and reflective supervision. We then revised the script. We thought using phrases like, “We offer it to all moms and dads,” would help decrease stigma. In collaboration with the Evaluation Team, we developed an Excel spreadsheet to track the testing of our change strategies and document our results. Once we began testing, we reviewed our data and plotted our results on a weekly run chart, which we posted in our office. Our pediatric providers could then see the improvement we were making, and they began to cheer us on. Our team was becoming a data-driven practice!
Over the course of 19 weeks, we tested the following strategies:
Change Strategy #1: Use script introducing the maternal depression screening (adopted)—On the day we planned to start testing the script, we felt we did not yet have buy-in from providers. We decided to engage the office manager, other staff, and providers in our plan and start the PDSA (plan-do-study-act) cycle a few days later. We started with one HealthySteps Specialist testing the script with one family. The next day, two HealthySteps Specialists tested the same script with all families who attended the appropriate well-child visit. At the end of each day, the HealthySteps Specialists and data analyst met to discuss using the script, documenting results, and making any needed changes. We continued with this process of testing and examining our results, and the screening rate quickly increased to around 90%.
The Script: You may remember hearing about how common it is to have feelings of depression or anxiety during this time of so many changes. All of us here really care about you and we want to check in on how you are feeling. To help us with that, it’s important that you complete this short questionnaire before you leave today.
Change Strategy #2: Use revised script with maternal caregivers who were being rescreened during subsequent visits (adopted)—After implementing the first change strategy, it felt inappropriate to use the same script for subsequent screenings. As our second change strategy, we modified the script to use when moms were screened at subsequent visits. We tested this strategy to see if we could continue to improve our maternal depression screening rate, which increased to around 95%.
Rescreening script for subsequent visits: We’ve given you the postpartum depression screen before. At this visit we screen again to check on how you are feeling. I’ll leave this for you to complete before the end of your visit.
We were able to increase our maternal depression screening rate from 41% to 92% over 19 weeks, far exceeding our goal! To keep the momentum and sustain the gains we made, we integrated these change strategies into our daily practice. We also continue to monitor our screening rate.
What the Experience Was Like
This CQI project allowed our HealthySteps Specialists to reflect on their personal discomfort addressing maternal depression. Barriers included religious beliefs, general comfort addressing sensitive topics, and concerns about “prying” into moms’ mental health status during pediatric well-child exams. During reflective supervision, we were able to talk through the barriers. After we developed our first test script, our HealthySteps Specialists still felt nervous. We reminded each other that CQI is about process change more than achieving perfection. We needed to continually reassure the HealthySteps Specialists that this process was not punitive. During change strategy testing, failures were acceptable. In fact, failures led to further quality improvements. We also reminded ourselves that it was important to follow the CQI approach—start small, test the script with one Specialist and one patient, revise the script as needed, and then continue testing before fully implementing the script.
“I think a common challenge for us as HealthySteps Specialists and professionals is holding an expectation of perfection for ourselves in a field where there can be a great deal of subjectivity… [There is] always room for growth and improvement. As professionals we want to provide the best possible care for families but measuring our success with this and taking concrete steps to improve can be elusive.” –Barbara Baum, HealthySteps Specialist
“We learned as HealthySteps Specialists that we are capable of learning new things and changing our practice. Despite our initial reservations, we all agree that the process of CQI is highly beneficial.” –Heidi Robison, HealthySteps Specialist
Our CQI Team
The Summit Healthcare HealthySteps team consists of our physician champion (Andrew Jones), three HealthySteps Specialists (Barbara Baum, Heidi Robison, and Maddie Nielson), a HealthySteps Coordinator (Leigh Parker), an administrative assistant (Shelly Hartman), a data analyst (Becky Benda-Dodd), and department Director (DeAnn Davies). Each team member served a vital role in our successes with the CQI project.