1. 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

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

3. Root-Cause Analysis