Harbor Community Clinic – Depression Screening Project Lead: Aracely S. Facilitator: Juan M./John S. Project Champion(s): Project Team: Aracely S. Date Updated: 09/17/18 Problem Statement: (description of the problem and its effect) Resource/Staff issues No workflow for this measure prior to discovery meeting Providers can benefit from additional measure training and how to complete the FHQ9 form to assist with measure 5) Solutions: (action plan and findings of tested solutions) Root Cause Tested Solution Responsible Due Finding No Champion for this measure due to staff resource shortage In the process of acquiring new staff Aracely September 2018 Aracely Scerra will provide support for this measure Provider PHQ9 form awareness Provided refresher training on how to complete the PHQ9 form in eCW and reminded provider how to complete the form during the provider meeting August 2018 This is assisting measure by scheduling the service to meet guideline AZARA FHQ9 positive ≥ 10 or eCW positive ≥ 0 differences causing measure confusion Center will contact Azara to correct issue or provide clarification of issue eCW was combining PHQ2 and PHQ9 scores. Issue corrected and providing true accurate numbers Missing workflow for this measure Workflow created to assist measure compliance Daniel/Aracely Implementation of workflow has assisted measure data capture and compliance 2) Current State: (depiction of the current state, its processes, and problem(s) Current target percentage is 56% from Jan 1st 2018 through August 31th 2018 PHQ9 issues due to provider not completing form correctly Center utilizing PHQ2, PHQ9 and Structure Data Lost lead M.A Referral category is mapped correctly in eCW Rx group set up correctly in eCW 3) Goal: (how will we know the project is successful; standard/basis for comparison) The project will be considered successful by meeting measure target of ≥75% 6) Study: (Summary of the solutions’ results, overall goal success, and any supporting metrics) With the addition of staff, project champion and patient non-compliant campaign the measure target has increased and looking to provide a positive impact to the measure 4) Root Cause Analysis: (investigation depicting the problems’ root causes) No champion for this measure due to resource/staff shortage Provider needing additional PHQ9 training/refresher AZARA FHQ9 positive ≥ 10 or eCW positive ≥ 0 differences causing measure confusion No workflow for this process Goal & Metrics Baseline Target Current Depression Screening 0% ≥75% 56% 7a) Lessons Learned: Project champion can impact measure in a positive way. Providers receiving frequent measure reminder/training will provide positive impact and refocus staff to meet target 7b) Standardize & Share Out: (Method for standardizing gains & communicating/spreading successes) Physician’s Trust Measure Specific Quick Sheet (source: eCW 2016 UDS user manual) 7c) Further Actions/Next Challenge: Follow up visit scheduled to review tested solutions and impact to measure *This document used with permission from UCLA Health

Depression Screening Data Trailing Year Aug. 2017 – Aug. 2018

Root-Cause Analysis