Rachel Hathaway, MD, is an internal medicine resident at the Cambridge Health Alliance (CHA). During the last academic year, she and seven other residents participated in a pilot initiative to teach residents how to apply quality improvement methodology through hands-on, year-long projects. The group was fortunate to work with Dr. Maren Batalden — the daughter of legendary quality improver Paul Batalden — who served as mentor and course director. We asked Rachel some questions about the team’s experience and results — they met their goal in two clinical sites, and saw big improvements in all three!

Dr. Chin Ho Fung, a first-year internal medicine resident at Cambridge Health Alliance, submitted a poster about the project that won the innovation award at the New England Regional meeting of the Society of General Internal Medicine.

OS: To get us started, tell us a little bit your team and this program.

RH: We are a group of residents ranging from first to third year, with primary care continuity clinics at three separate sites. With the guidance of Dr. Batalden, senior director of inpatient quality and patient safety at CHA, we embarked on a journey to learn more about quality improvement and engage in meaningful institutional change. At the conclusion of the pilot curriculum, we had led improvements in screening for depression in diabetic patients. Our project won the Innovations Poster Presentation award at the New England Regional Society of General Internal Medicine meeting this March.

OS: How did you use the Open School courses in the program?

RH: As a part of the curriculum, we enrolled in the IHI Open School Quality Improvement Practicum as scaffolding for our quality improvement project. The Open School courses allowed us to use the “flipped classroom” model for learning. We individually completed the Open School online courses to gain foundational knowledge, then we were able to have dynamic and productive didactic sessions when we met as a group. During these sessions, we brainstormed project ideas, drew cause and effect diagrams, and planned our PDSA (plan-do-study-act) cycles. While these sessions were driven by residents, Dr. Batalden acted as a consultant and advocate to help us navigate any roadblocks that we met. A unique aspect of our curriculum is that it is a year-long longitudinal design, which allowed for much deeper learning than the typical month-long resident quality improvement rotation.

OS: Why did you decide to focus on depression screenings in diabetic patients?

RH: CHA is a Harvard Medical School-affiliated, community-based, integrated safety net hospital. So residents who choose to train here are passionate about caring for the underserved. We also care deeply about the intersection between primary care and mental health, because it greatly affects our patients’ health. We have many patients who struggle with both medical and psychiatric illness, and we know that treating both requires a coordinated approach. Fortunately, CHA was already engaged in the Alice Rosenwald Mental Health Integration Initiative to improve mental health integration into our primary care clinic sites. So, we thought that choosing a project that related to broader institutional improvement efforts would allow us to understand how institutional change occurs and to leverage institutional resources and relationships to help our project succeed. Our project aim was to improve annual screening for depression from 50 percent to 70 percent in all diabetic patients with resident primary care providers. We used the PHQ-9 for these screenings.

OS: How did you plan out your tests of change?

RH: Since we had three different continuity clinics, we saw this as an opportunity to try separate PDSA cycles at each of those clinics, while all working on the same aim. I’ll tell you about the PDSA cycles we ran at my clinic, Somerville Hospital Primary Care. First, we ran a learning PDSA cycle, which was a focus group including medical assistants, secretaries, nurses, and preceptors from the resident care teams. During the focus group, we drew the current process map for screening for depression in diabetic patients at our clinic. Then, as a group, we identified three realistic PDSA cycles to run over the next three months. These PDSA cycles were:

1. Test if routine “huddles” or short meetings between residents and medical assistants to identify diabetic patients due for annual depression screening prior to a clinic session improved rates of screening.
2. Test if standardizing roles in the process of documenting depression screening in the electronic medical record improved the accuracy of that screening’s documentation.
3. Learn more about the accuracy of PHQ-9 entry into the electronic medical record. It’s a multi-step process, and we thought perhaps the screenings were happening more often than they were recorded.

The team at the Windsor Clinic tested the theory that depression screening was being appropriately completed but not appropriately documented in the electronic medical record. The team at the Cambridge Hospital Primary Care Unit identified flow-related challenges unique to screening diabetic patients of resident physicians who had only one assigned exam room and invited medical assistants to introduce the screening tool to patients during triage.

OS: How did you gain buy-in from staff?

RH: Although we were fortunate to be able to work on a project within the Mental Health Integration (MHI) initiative, we still had to do a lot of work to recruit ambulatory quality leaders, clinic level leaders, and our primary care team staff. We learned the critical lesson that quality improvement work absolutely requires partnering with important stakeholders at all levels. Not only did we reach out to ambulatory quality directors and stakeholders engaged in the MHI initiative, but also recruited clinic medical directors and preceptors to help sponsor the project at each site. We also learned that having leaders committed to the project doesn’t automatically translate to staff commitment to participate in change. In the end, we found ourselves with a remarkable network of supportive and committed stakeholders, including many of the staff at our clinics. In retrospect, I would have reached out sooner and more frequently to ensure everyone was on board with our project from the start.

OS: What were your results?

RH: When we reviewed the run charts for rates of annual depression screening in diabetics for our clinics over the past several months, we saw a trend toward improvement for all three clinic sites. We met our aim of reaching a 70 percent screening rate in two out of our three clinic sites. It is certainly encouraging that the improvements we made helped to improve rates of screening. However, many other institutional improvements have been made that also have significantly affected these results.

As a part of the IHI Open School Quality Improvement Practicum, we wrote up our PDSA cycles and reviewed the run charts. This was valuable because it allowed us to reflect on the work we had done. It also encouraged us to identify the lessons we learned so that this improvement work can continue institutionally. Thanks to the IHI Open School, we were able to augment our limited didactic time with the Open School courses. This project helped us to gain experiential knowledge and tools to be future leaders in quality improvement.