1. Quality Improvement in Practice: Screening for Depression in the Chronically Ill
ANNIE RUTTER, MD, MS &
ELIZABETH MEZA, MD
UNC-CHAPEL HILL
FAMILY MEDICINE RESIDENCY
IN COLLABORATION WITH:
DANA NEUTZE, MD, PhD
KHALILAH DANN, MD, MPH
KRISTINE ROSS CARPENTER MD, MS
RONALD LANEY, MD, MPH
EMMA WILLIAMS, MD
CALEB PINEO, MD, MPH

2. Objectives
Implement quality improvement initiatives among residents teaching how to use the Plan-Do-Study-Act (PDSA) cycles to assess effectiveness
Understand the importance of screening for depression in patients with chronic disease and have a model for doing so
Recognize the value in letting residents help achieve Patient Centered Medical Home (PCMH) goals within the clinic

3. Quality Improvement Curriculum
Resident driven practice redesign
Ongoing senior chronic disease project
Senior resident class identifies clinical focus for their 3rd year
Leading the Chronic Care Team
Senior residents are “Steering Committee” for project
Experiential learning: carry out series of PDSA cycles
Residents have 4-8 hours per week

4. Deming cycle

5. PDSA Transitions
Resident 4
Resident 3
Resident 2
Resident 1

6. Landscape Registry system for tracking patients with chronic diseases
Developed out of previous resident-lead QIP project
3 Chronic diseases
Diabetes Mellitus
Heart Failure
Coronary Artery Disease

7. Current QI Project Goal
Incorporate depression screening for chronically ill into clinical practice
Depression associated with poorer outcomes
Majority of depression is treated in primary care setting
Behavioral medicine as part of PCMH

8. Project Structure Resident 1: Resident 2: Resident 3: Resident 4:
Identified screening tool
Resident 2:
Incorporated screening tool into chronic disease registry
Educated clinic staff
Resident 3:
Clinic wide implementation of screening
Resident 4:
Initial chart audit of clinic wide implementation

9. Project Structure Resident 5: Resident 6: Resident 7: Resident 8:
Second chart audit, evaluated documentation of positive PHQ-9 in clinic visit note
Resident 6:
Changed registry template to clarify provider responsibilities, audit to assess effectiveness
Resident 7:
Chart review for new diagnoses of depression
Resident 8:
Plan to aggregate data, compare data to national averages

10. QI Project: Depression Screening
Chose standardized instrument for screening
PHQ-2  PHQ-9
Provided in service for clinicians and support staff
Added screening protocol to current registry forms
Pilot on 2 of 4 clinical teams
Initial chart review
87-100% screened if chief complaint (CC) was follow-up for chronic disease
Then launched clinic-wide

11. Example of registry with new sections for depression screening

12. QI Project: Depression Screening
Screening rate was 58%
80% when CC was DM, CHF, or CAD
18% when presented for different CC
Next PDSA cycle: ensure screening at ALL visits
Goal of printing registry forms for all visits
Chart review: to assess documentation of screening
Changed registry form for ease of provider documentation at point of care

13. Results
Number of Patients

14. Lessons Learned Residents can drive QI in academic settings
Residents develop tool set for use in future practice
Quality improvement
PCMH model
Information technology with support is critical
Registry as point of care reminder
Systematic screening for important conditions
Effective communication between residents

15. Thank you!