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Inside Quality Improvement: How QI Can Improve Screening for Social Determinants of Health

By IHI Open School | Monday, September 21, 2015
Lisa Miller, an MPH student at Oregon Health and Sciences University, recently completed the IHI Open School Practicum. Her project focused on helping clinic staff at a primary care clinic document patients’ social needs in the electronic medical record, so that clinic staff could address them along with patients’ medical needs. The project was a success (by the end of the work, 100 percent of patients seen by behavioral health staff had their social needs documented in the designated chart location, and the average number of social needs documented per patient increased from one to four.) Lisa says that the real-world experience helped her land her dream job as innovation specialist at CareOregon, a nonprofit that administers Medicaid and Medicare benefits in Oregon. Below, we asked her about how she pulled it off.Lisa-Miller-headshot

Open School: How did you first become interested in quality improvement (QI)?

Lisa Miller: I’ve always naturally sought out better ways of doing things, and when I found out a few years into my health care career that QI was an actual discipline, I knew it was for me! I love having the tools to measure and quantify the results of even small changes. 

OS: How did the IHI Open School courses help you learn QI and do your project?

LM: I found the IHI Model for Improvement to be simple and intuitive to use. The Model for Improvement encourages discipline where it counts — in correctly defining the problem, in establishing how you know a change will be an improvement, and in developing different types of measurement to track progress.    

OS: How did you come up with the idea for your project? What was the problem, and did your project improve it?

LM: I was actually asked by the clinic to help them out with this project as a volunteer, when I was working with them on a class assignment that touched on some of the same topics. The clinic staff I was working with knew that providers were recording patients’ social determinants of health (SDHs), but also knew that there was no consistent format or location for recording it. They hypothesized that if we established a standard way to screen for and track social determinants of health, providers would be able to use that information in their plans of care. And this is what has happened: Now that SDHs are clearly visible, each patient’s needs are discussed as the care team prepares for each day’s appointments.

OS: How did you identify a faculty sponsor or mentor, and how did they help you succeed?

LM: Our Chapter’s faculty advisor was willing to sponsor me, and it was a new experience for us both: I was the first student in our Chapter to have completed the Practicum (click here to learn more about Chapters). She was very helpful in reviewing my charter to help clarify my aim and types of measurements. She also pitched in with moral support at a crucial point, when I was getting frustrated with what I felt was a lack of progress — she reminded me that projects like this always take longer than you expect, and she suggested a few small nudges I could do to get things rolling again. 

OS: What was the biggest surprise in doing the project?

LM: I was quite surprised when the clinic team worked through Plan-Do-Study-Act (PDSA) cycles much more rapidly than I was anticipating! This clinic has a culture of continuous improvement, so they are comfortable testing changes as part of their daily lives. In the timeframe I expected them to complete one cycle, they had already worked through a handful. I would call this a happy surprise. 

OS: What was the most gratifying part of the doing the project?

LM: It was very gratifying to be able to see the measurable results in the number of SDHs tracked and how many patients had their SDHs documented. It was great to see the shift in the control charts because it means the information we wanted to make available to providers is now available. 

OS: What did you learn from working on an interprofessional team?

LM: Working interprofessionally isn’t new to me, but this project just reinforced my prior experience that interprofessional teams have the broadest perspective, reach, and resources.

OS: If you had the chance to start your project all over again today, what would you do differently?

LM: We ran into some communication difficulties that arose because one of the important team members didn’t make it to the first team meeting. If I were doing this project over again, I would take the simple step of confirming prior to each meeting that each team member can still come. I would also hold a one-on-one catch-up with a team member who couldn’t make a crucial meeting. 

OS: How will the improvements you made be sustained over time? 

LM: This project is actually continuing in an expanded form, through my MPH internship. I’m working with a different interprofessional team to 1) conduct a listening campaign with community members to identify the strengths and resources the community can bring to meet the SDHs the clinic is now identifying and 2) create a new community health worker role at the clinic. We hope to hire community members to fill these roles and carry out the interventions developed through the listening campaign. 

OS: What were some key lessons from your experience that you want to share with other QI learners?

LM: Real-world improvement projects are never as linear and clear as they seem when you’re learning QI. Setbacks, delays, and changes in direction are normal and to be expected. Keep good records of your work so you can learn from your own progress later on!

OS: How, if at all, has this experience changed your outlook on your career?

LM: When I started this Practicum project, I had just left a job that was unhealthy for me a in a lot of ways, and I wasn’t sure what I wanted to do next, except that I knew I wanted it to be in health care quality improvement. By working with this clinic team on the project, I built relationships and gained experience that contributed significantly to where I am now: three months into my dream job (I’m an “innovation specialist”!) with what I believe is my dream employer. My professional, academic, and volunteer work all line up with my passions and values  and working through the Practicum was a crucial step on the pathway here.

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