Why It Matters
The Sunset Park Family Health Center at NYU Langone Medical Center serves 3,000 children aged 0–3 in the neighborhood of Sunset Park—an industrial waterfront neighborhood of Brooklyn, NY, with vibrant cultural diversity, a high proportion of young children, and low educational and income levels. The program is integrated within the Family Health Center’s multidisciplinary service delivery model that includes primary care and behavioral and developmental services for children. Maternal depression (along with social determinants of health) is a priority area for our health system, and HealthySteps has reinforced the importance of conducting universal screenings to identify social and emotional barriers and issues with parents or primary caregivers that may affect the health of children. We know that pediatric providers are uniquely well positioned to address mental health needs of parents and caregivers because they have consistent connections to them as well as their children.
Where We Started
As a HealthySteps practice, our health center began universal screening for maternal depression in 2018. After a few months, we noticed that only a small percentage of caregivers were completing the depression screen. We were far from reaching true universal screening, which could result in missed opportunities to identify struggling mothers and connect them to needed supports. We needed a clearer, more efficient process to ensure that all caregivers were screened at appropriate visits. Before we began our continuous quality improvement (CQI) project, our workflow was the following: medical assistants provided the screening tool (the Patient Health Questionnaire-2, or PHQ-2) to caregivers to complete in the waiting area, then the medical provider reviewed the questionnaire and wrote a note in the electronic health record (Epic). However, the number of completed maternal depression screens was low. Our CQI project was a great opportunity for our clinic to explore this issue and intentionally dedicate resources toward improving universal screening.
Our team developed the following goal (SMART Aim): By December 31, 2019, the percentage of Sunset Park Family Health Center’s patients aged 0–3 whose caregivers have a documented depression screen will increase from 31% to 75%.
How We Diagnosed the Problem
With assistance from the Outcome Pilot Project Evaluation Team, we conducted a root cause analysis using a fishbone diagram. We also created a process map to create a clear picture of our screening process, starting from the point when a patient’s appointment is scheduled. As a result of this work, we identified several issues that appeared to affect our screening rates:
- Little integration and alignment into the established workflow
- Inconsistent data collection and entry
- Lack of accountability for ensuring completion and documentation of screens
- Lack of clarity as to ownership of the screening initiative
How We Tested Solutions
To make our screening process more efficient (thus improving workflow), we looked at how to better integrate depression screening into the current established workflow. Medical assistants were entering vital signs and other screens into Epic as part of the rooming process, so we decided to add the depression screen to the rooming process and developed a “smart phrase” in Epic to facilitate data entry. This change captured screening results right after caregivers completed the screen and before they saw their medical provider, minimizing the chances of the paper screen getting lost during the waiting period. It also shifted ownership of the project, and therefore accountability, to our medical assistants, who were entering data into Epic as part of their regular workflow. It alleviated data entry responsibilities for our medical providers who already had very limited time and many competing priorities. The smart phrase also provided a more consistent way to document, track, and run reports on maternal depression screening results instead of relying on free-form notes in Epic. We collaborated with the clinic staff and asked for their feedback to ensure that they would be supportive of the change.
Change Strategy #1: Medical assistants utilized smart phrase to document maternal depression screening results at appropriate visits (adopted)—In our first PDSA (plan-do-study-act) cycle, we started with 2 medical assistants (out of a total of 10) and tasked them with documenting maternal depression screening results using the smart phrase. In our second PDSA, a third medical assistant was added to the group. During each PDSA cycle, we met in brief daily huddles to track our progress. Over the course of 11 weeks, we reviewed the data with our team on a weekly basis, and the Evaluation Team helped us plot our results on weekly run charts.
After 11 weeks of testing this change strategy, we were excited to see our screening rate reach 60%. Tasking medical assistants with using the smart phrase introduced more accountability for the completion of screens and recording the results in a consistent way. Shortly afterward, we discovered a flowsheet for our maternal depression screen in Epic. Because of the way Epic is structured, using a flowsheet instead of a smart note would enable our Epic team to run reports more easily. As a result, we decided to adopt our change strategy and moved on to use the flowsheet to document and monitor maternal depression screening on an ongoing basis. As the next step to our CQI project, we would like to focus on improving our maternal depression screening process for our HealthySteps Tier 3 families. Families who receive Tier 3 services are often first-time parents or parents with identified risk factors that may make them at higher risk for maternal depression. CQI with a smaller team (HealthySteps versus the entire clinic team) would also give us more flexibility to move quickly and conduct PDSA cycles on an ongoing basis.
What the Experience Was Like
Our CQI project presented our team with a valuable opportunity to take a step back, reflect, and collaborate with key stakeholders in our health system. As we brought our data and the results from our CQI efforts to the attention of our leadership, we also succeeded in raising the profile of our HealthySteps program in the process.
We were pleasantly surprised to find that many of our anticipated concerns and challenges, such as families not having enough time to complete the PHQ-2 or staff resistance to the new process, never occurred. In fact, medical assistants and medical providers seemed to appreciate the clearer roles and the efforts to improve the screening process. We also found that engaging in ongoing discussions with our data teams regarding our screening rates helped us all understand the gaps that exist in our data collection and data entry processes. We continue to explore options for improving the collection and recording of information about universal screening, including screening for maternal depression. Engaging in peer learning calls with other HealthySteps sites was also immensely helpful. Finally, and most important, we were able to identify a higher number of caregivers who reported maternal depression concerns, and connect them to needed supports.
Our CQI Team
Team members who led us through this project include our Physician Champion (Iman Sharif), HealthySteps Lead and Manager of Maternal Infant Health Programs (Laura Ibanez-Gomez), HealthySteps Specialist (Gabriela Alvarado), Nurse Supervisor (Gisella Bueno), the VP of Community Programs (Kathleen Hopkins), the Director of Community Benefit Evaluation (Michelle Currie), the Data Analyst for Community Programs (Jose Martinez-Flores), and the Director of Quality Improvement/EPIC Specialist (Doreen Colella).