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									                                          PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

Project Lead        Alexis Ponder, Stacy                        Title                  Depression Screening in
                    Cowherd                                                            Diabetic ACC Patients: “PDSA”
                                                                                       Review of the Process

Team                                                            Change                 Screening Process Analysis
Date Range          7/2009                                      Cycle #                1
                                                                Key Words



BACKGROUND: What led you to start this project? Is this cycle a continuation of another
cycle? Why is this topic relevant? Include any baseline data that has already been collected.
Include relevant information from literature.

The connection between depression and medical non-compliance is well established in the
medical literature (DiMatteo 2000, Anderson 2001). There is some debate about the causal
relationship between depression and diabetes (Nutting 2002, Nau 2007, Gazmararian
2009); however, it is generally accepted that since these two diagnoses are related,
alleviating burden of suffering from one may reduce morbidity from the other. At the UNC
Ambulatory Care Center (ACC) we have developed a screening program to improve our
recognition and, hopefully, treatment of depressed patients. The electronic diabetes
database (est. 2003) provides a convenient patient population with which to study the
effectiveness of depression screening, as these patients have good, easily accessible
medical records and compliance data. Our project involves a critical analysis of the way
depressed patients are currently identified and treated in the ACC. Previous PDSA cycles in
this arena have shown that screening patients for depression does actually improve the
documentation and treatment of this diagnosis (Brill). Previous PDSA cycles have also lead
to use of walkie talkies, which improve communication between providers and facilitate the
screening/treatment process (Boone). We hope to take these works a step farther by
examining the entire process of depression: screening through treatment and follow-up,
from the perspectives of health care providers. From this project we hope to suggest ways
to streamline the screening/treatment process, and ultimately improve burden of suffering
from depression in the entire clinic.


       Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-
        analysis. Diabetes Care. 2001; 24: 1069-1078.
       DiMatteo MR, Lepper HS, Crogan TW. Depression is a risk factor for noncomplaince with medical treatment: meta analysis of
        the effects of anxiety and depression on patient adherence. Arch of Int Med. 2000; 160: 2101-2107.
       Nutting PA, Rost K, Dickinson M, Werner JJ, Dickinson P, Smith JL, Gallovic B. Barriers to initiating depression treatment in
        primary care patients. J Gen Intern Med. 2002 Feb;17(2):103-11.
       Nau DP, Aikens JE, Pacholski AM. Effects of gender on oral medication adherence in persons with type 2 diabetes mellitus.
        Gend Med. 2007 Sep;4(3):205-13.
       Nau DP, Chao J, Aikens JE. The relationship of guideline-concordant depression treatment and patient adherence to oral
        diabetes medications. Res Social Adm Pharm. 2005 Sep;1(3):378-88.
       Gazmararian JA, Ziemer DC, Barnes C. Perception of Barriers to Self-care Management Among Diabetic Patients. Diabetes
        Educ. 2009 Jun 25.




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______________________________________________________________________________
PLAN:
Aim/Objective Statement for this cycle What do you hope to learn? What are you trying to
improve (aim), by how much (goal) and by when (timeframe)?
For this PDSA cycle, the goal is to critically analyze the depression screening/treatment
process for our diabetic patients in the ACC. We hope first to understand the current
system-wide process for helping depressed patients. Many people, including RNs, CAs, and
physicians are currently responsible for detecting and treating patients with depression.
These health care professionals use a variety of documentation tools (yellow sheets,
diabetes database, WebCis) and information often gets lost or confused as patients proceed
forward from a positive depression screen. We hope to analyze the system to determine its
strengths and weaknesses, or areas where patients who have depression are “lost,” which
presumably leads to substandard care. After we improve our understanding of the system
and its strengths/weaknesses, we will formulate suggestions for system-wide improvement.
-Aim to thoroughly analyze the current system for taking care of depressed patients at every
level
-This process should be completed between 7/1/2009 and 7/14/2009


Specific questions to address in this cycle:
1. Are we screening patients appropriately?

2. What is happening to patients after a positive screen?

3. What seem to be the hold-ups for continuing to treat depressed patients?

Predictions/Hypotheses (What do you think will happen?)

     Noncompliance with PHQ-2 screening performed by nursing staff can be attributed to
      lack of formal orientation to depression screening protocol and time constraints
      during patient visit.
           An underlying barrier that will be identified is level of comfort with mental
              health discussion.
     Patients who screen positive for depression are often lost in follow-up secondary to
      unreliable, non-standardized methods of communication between care assistants
      and physicians.
     Physicians underutilize community mental health resources for patient counseling



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     Patients who are successfully being followed-up for depression are the result of good
      communication between the nurses, care assistants, physicians


Plan for change/test/intervention
Who (target population): Patients with depression in the Diabetes Database

What (change/test): Examination of depression screening and treatment process

When (dates of test): 7/2009

Where (location): ACC

How (description of plan):

     Poll clinic staff
           How does is the current depression screening process and follow-up
               supposed to work?
     Surveys
           Nurses and care assistants
                    Define formal orientation to PHQ-2/9 depression protocol
                    Assess comfort level with depression screening and barriers to
                       communication
     Chart Review
           WebCIS review of physician notes to determine which patients with positive
               screens actually have this documented in their chart over time
                    Interventions
                    Follow-Up


Measures (What will you measure in order to meet your aims? How will know that a change
is an improvement? Will you use outcome or process measures?)

We plan to measure both survey responses and WebCIS data collected in the chart review.
These measurements will be successful #1) If we are able to get enough data from survey
respondents and WebCIS charts, and #2) If we are able to use this data to find system-wide
“lesions” in the depression screening process. Outcomes, or meaningful data, will hopefully
be gleaned from these efforts.


Plan for data collection
Who (will collect):
Alexis, Stacy

What (measures):


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-Survey info from nurses and care assistants
Nurses:
9 question survey to identify: Length of employment, Orientation to and familiarity with PHQ-
2/9 protocol, Level of comfort with depression screening, Familiarity with community
resources for depressed patients, Accessibility of Care Assistants, Barriers to consistent
screening
Care Assistants:
11 question survey to identify: Length of employment, Orientation/familiarity with PHQ-2/9
protocol, Level of comfort with depression screening, Familiarity with community resources
for depressed patients, Accessibility of Nurses and Physicians, Preferred method of
communication for contacting nurses and physicians, Barriers to consistent communication,
Suggestions to improve communication among staff

Chart information on diabetic/depressed patients in WebCIS who had a positive screen to
determine: If patients had depression documented in WebCIS after a positive screen, what
interventions were employed, and how well patients were followed-up over time after a
positive screen

When (time period):
7/2009

Where (location):
ACC

How (method):
-Paper surveys with analysis in Excel
-Chart review with documentation and analysis in Excel




_____________________________________________________________________________
DO: Carry out the change/test. Collect data.
Note what actually happened, when completed, observations, problems encountered, and
special circumstances. Include names and details.

SURVEY:
NURSES: 10 IN CLINIC, 8 SURVEYED
CARE ASSISTANTS: 4IN CLINIC, 3 SURVEYED
SURVEY WAS SUCCESSFULLY CREATED, DISTRIBUTED, AND RECOLLECTED WITHIN THE
COURSE OF 1 WEEK. WE DESIGNED QUESTIONS ON THE SURVEY TO IDENTIFY BARRIERS IN
THE SYSTEM OF DEPRESSION SCREENING AND BREAKS IN THE CHAIN OF
COMMUNICATION. BOTH NURSES AND CARE ASSISTANTS WERE VERY EAGER AND PROMPT


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WITH THEIR RESPONSES. THE ONLY STAFF WE WERE NOT ABLE TO SURVEY WERE THOSE
ON VACATION OR EXTENDED LEAVE. NO PROBLEMS WERE ENCOUNTERED. RESPONSES
WERE EASILY INTELLIGIBLE AND EASILY PLOTTED IN EXCEL.



CHART REVIEW:
48 CHART REVIEWS OF PATIENTS LIFTED FROM THE DIABETES DATABASE WHO WERE
IDENTIFIED AS HAVING DEPRESSION.

ALL 48 CHARTS, WITH INITIAL AND 2 SUBSEQUENT VISITS, WERE ANALYZED WITHIN 1
WEEK. MEANINGFUL INFORMATION FROM CHARTS (DATES OF APPT, ADDRESSING
DEPRESSION, INTERVENTIONS, FOLLOW-UP) WERE RECORDED INTO EXCEL. NO PROBLEMS
WERE ENCOUNTERED IN THIS CHART REVIEW. THE DIABETES DATABASE AND ITS IT
CONSULTANTS (S. MCDONALD) WERE EXTREMELY HELPFUL. VERY EASY TO EXTRACT DATA
FROM THE DIABETES DATABASE.


STUDY: Summarize and Analyze data (quantitative and qualitative). Include charts, graphs.


Observation 1. Nurses are less aware, as a group, of the procedure following a positive
depression screen than are care assistants.


                           Awareness of Positive Screen Protocol


                                6                                5

                                4        3    3

                                2
                                                                      0
                                0
                                        Yes                      No
                  Nurses                  3                      5
                  Care Assistants         3                      0




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______________________________________________________________________________


Observation. The majority of nurses and care assistants are moderately comfortable with
depression screening. A greater proportion of the care assistants describe themselves as
“extremely” comfortable with the screening, as compared to the nurses.


                                Comfortability with Screening

                               6

                               4


                               2


                               0
                                    N/A       None         Moderately Extremely
                  Nurses             0          2              5          1
                  Care Assistants    0          0              2          1

Observation. The majority of nurses were not aware of community resources for mental
health. Care assistants were more likely to have been notified of outside mental health
resources in the form of counseling, therapy, etc.




             Community Resource Awareness


                           6


                           4

                           2


                           0
                                    Yes                      No
Nursing Staff Perspective
     Nurs es                          2                       6
      Care As s is tants              2                       1

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 Observation:
 The majority of care assistants think nurses are moderately accessible and the majority of
 nurses think care assistants are extremely accessible for communication about PHQ-9.


            Care Assistants Accessability
                             N/A, 0, 0%
                             Not at all, 0,
                                 0%
                                                Moderately,
                                                 3, 38%


Extremely, 5,
    62%

                                                                 Nurse Accessability


                                                                             N/A, 0, 0%

                                              Extremely, 1,                  Not at all, 0,
                                                  33%                            0%




                                                                                              Moderately, 2,
                                                                                                  67%




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Observation:
Nurses think time constraint is the biggest barrier to depression screening; care assistants
think communication w. nursing is the biggest barrier.



     Barriers to Consistent Depression Screening


             10%
                             20%                None
                                                Form not user friendly
    20%                             0%          Time Constraints
                                                CA assessability
                                                Forget to Screen
     10%                                        Logistical
          0%                 40%                Patient Comprehension


                                  Barriers to Consistent Communication

                                                   0%
                                                                           None
                                                   0%
                                 25%
                                                                           Database not user
                                                                           friendly
                                                                           Communication with
                               0%
                                                                           Nursing
                                                                           Physician follow-up

                                                             75%           Patient follow-up




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Observation: Lower percentages of patients have depression addressed and followed-up on
at subsequent visits.

                                                Documentation of Depression in WebCis After Positive Screen

                                          70%
                                                         65.00%

                                          60%
                                                                                   54%
              % of Pts w. Documentation




                                          50%
                                                                                                          41%
                                          40%


                                          30%


                                          20%


                                          10%


                                          0%
                                                         Visit 1                  Visit 2                 Visit 3




Visit #1 Observations:

     31/48 patients (65%) with a positive depression screen had this documented in
      WebCIS on screening day
     Among people who had depression documented in WebCIS:
          The majority (73%) of cases involved direct communication between the RN
             and the CA
          The overwhelming majority (87%) of cases had direct communication
             between the CA and the MD
     35% (17/48) of patients who screened positive for moderate/severe depression did
      not have this diagnosis documented in WebCIS
          Why?
                 10 did not see MD on the day they were screened for depression
                 7 did see MD on depression screening day




Observation: Interventions on first visit were likely to include both medications and
community resources.



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                           12 Pts. W.                       10 Pts. W.
                           Medications                      Medications and
                           Only Addressed                   Community
                                                            Resources
                                                            Addressed



    




                                                   1 Pt. W. Community
                           8 Pts. W.               Resources Only
                           Regular                 Addressed
                           Psychiatrist



See powerpoint for information on second and third visits.


Characteristics of patients who were successfully screened and followed thru 3 follow-up
visits:
     Patient #1
           Depression score 24
           RN contacted CA, pt saw MD on screening day, saw same MD on all 3
              occasions
           All 3 appointments w.in 4 months
     Patient #2
           Depression score 10
           Patient has psychiatrist
           RN contacted CA, pt saw MD on screening day, saw same MD on all 3
              occasions
           All 3 appointments w.in 6 months
     Patient #3
           Depression score 14
           RN contacted CA, pt saw MD on screening day,
           All 3 appts. W.in 4 months, saw same MD on 2/3 occasions


    SUMMARY (ACT):
    Major Conclusions:



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    Noncompliance with PHQ-2 screening was most commonly attributed to:
          Lack of formal orientation to protocol for nursing staff
          Time constraints during patient visit (avg. allotted time 20 minutes)

     Patients lost to follow-up most likely due to:
          Physician not seeing patient on screen day
          Other medical problems considered more important than depression at MD
             visits
                  Lack of continuous documentation of depression management at
                     each visit
          Non-standardized method of communication between Care Assistants and
             Physicians
          Limited patient participation in mental health screening
                  Underutilization of community resources


                Communication Barriers
                                     •   Lack of knowledge/participation in screening
           Patient

                 • Time constraints of visit schedule

                                                                      Nurse
                           •Level of comfort w/ screening

                                                                            • Unreliability of
          • Limited                                                         communication
   communication                                                            tools
   w/ patient after      Care Assistant
   positive screen

                • Unreliability of                                    •Level of comfort w/
                 communication                                        management
                            tools                                     •Patient follow-up
                                                 Physician
                                                                      • Community
                                                                      Resources




Define next steps. Are you confident that you should expand size/scope of test or
implement? What changes are needed for the next cycle?

    1. Empower patient to ask about depression and contact community resources on their
       own accord (eg. Through posters in patient rooms, brochures in patient rooms)


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    2. Better connection between CA and MD (ie. PHQ-9 score as vital sign in WebCIS)
    3. Having patient complete PHQ-2/9 screening at kiosk in lobby before checking in
    4. “STOP and refer for immediate evaluation” tab for nursing in PHQ-2 section of yellow
       sheet for nursing staff




                                NURSES




                               You!!
                                                        CARE
          PHYSICIANS
                                                      ASSISTANTS




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                           Brochures
            If you’re          COMMUNITY              •The Durham Center
        DEPRESSED,                                    501 Willard St.
       you’re NOT alone        RESOURCES
                                                      (919)560-7100
                                                      24 hr. crisis line:
                             •UNC Psychiatry
                                                      (800)510-9132
                             Clinics:
                             (919)966-5217            •Wake Co. Human
                                                      Service
                             •Mental Health
                                                      202 Swinburne St.
                             Assoc. in Orange Co:
                                                      Raleigh, NC 27620
                             (919)942-8083
                                                      (919)250-3133
                             •Crisis Service Line:
         We can HELP         (919)966-2166                      We’re
          you find the                                         here for
         care you need!                                         you!




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