title: Depression screening optimization in an academic rural setting.
abstract: OBJECTIVE
  Primary care plays a critical role in screening and management of depression. The purpose of this paper is to focus on leveraging the electronic health record (EHR) as well as work flow redesign to improve the efficiency and reliability of the process of depression screening in two adult primary care clinics of a rural academic institution in USA.
  
  
  METHODS
  The authors utilized various process improvement tools from lean six sigma methodology including project charter, swim lane process maps, critical to quality tree, process control charts, fishbone diagrams, frequency impact matrix, mistake proofing and monitoring plan in Define-Measure-Analyze-Improve-Control format. Interventions included change in depression screening tool, optimization of data entry in EHR. EHR data entry optimization; follow up of positive screen, staff training and EHR redesign.
  
  
  RESULTS
  Depression screening rate for office-based primary care visits improved from 17.0 percent at baseline to 75.9 percent in the post-intervention control phase (p<0.001). Follow up of positive depression screen with Patient History Questionnaire-9 data collection remained above 90 percent. Duplication of depression screening increased from 0.6 percent initially to 11.7 percent and then decreased to 4.7 percent after optimization of data entry by patients and flow staff.
  
  
  CONCLUSIONS
  Impact of interventions on clinical outcomes could not be evaluated.
  
  
  CONCLUSIONS
  Successful implementation, sustainability and revision of a process improvement initiative to facilitate screening, follow up and management of depression in primary care requires accounting for voice of the process (performance metrics), system limitations and voice of the customer (staff and patients) to overcome various system, customer and human resource constraints.
authors.affiliation: Allergy and Immunology, University at Iowa, Iowa City, United States and (formerly) Department of Medicine, Geisel School of Medicine, Lebanon, New Hampshire, United States.
authors.forename: Sohaib
authors.initials: S
authors.lastname: Aleem
authors.forename: William C
authors.initials: WC
authors.lastname: Torrey
authors.forename: Mathew S
authors.initials: MS
authors.lastname: Duncan
authors.forename: Shoshana J
authors.initials: SJ
authors.lastname: Hort
authors.forename: John N
authors.initials: JN
authors.lastname: Mecchella
mesh_terms: D000328:Adult; D003863:Depression / Q000175:diagnosis*; D017598:Efficiency, Organizational; D057286:Electronic Health Records; D006780:Hospitals, Rural; D006801:Humans; D008403:Mass Screening / Q000592:standards*; D009513:New Hampshire; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement; D015203:Reproducibility of Results; D012424:Rural Population; D057188:Workflow
keywords: Depression screening; Lean thinking; Patient centredness; Primary care; Process redesign; Quality improvement; Six sigma; USA