An annex to the POSTSCRIPT Research Lab are the Quality Improvement (QI) Projects undertaken by Psychiatry Residents and Fellows. These projects followed a full PDSA cycle. Residents and Fellows participated in QI throughout their training at Creighton University and were organized into self-determined teams by shared interest. Creighton’s QI projects were supported by CHI Health, particularly the Behavioral Health Service Line, and Creighton University School of Medicine. The program was selected by ACGME to participate in an ECHO training to enhance the work that we do with training residents and fellows in patient safety and quality improvement. Read below for details on each project. If you are interested in these projects please reach out to Dr. Roley-Roberts through the Contact form.

Cultural Factors

Creating an Open Access Clinic to Increase Psychiatry Appointment Adherence
Resident Lead: Nicholas Distefano

Patients who do not show up (no showing) for appointments significantly impact the functioning of psychiatric outpatient services by reducing efficiency, patients’ access to care, and increasing revenue loss. The current wait time for new psychiatric appointments at CHI Health Lasting Hope Recovery Center Outpatient Services is around 3-4 months. Typical no-show rates are 39% to 50% (May RJ) for first mental health service appointments. For some patients, this wait may lead to decompensation of their mental illness resulting in multiple readmissions and further financial stress on the healthcare system. 

Aim #1: Implement intervention of creating at least four open access appointment slots per clinic day. To accomplish this by October 2022, LHRC staff will begin scheduling one clinic slot each in the morning and afternoon, to be filled within 48 hours prior to that appointment for open access. 

Aim #2: Examine the percentage of patients who utilize the open access clinic slots (percentage of the open access clinic slots that are filled). 

Aim #3: Examine if there are differences in no show rates between October 1, 2021, – March 31, 2022, (when there was no access clinic) and October 1, 2022 – March 31, 2023 (when an open access clinic model is implemented). 

Aim #4: Compare Press Ganey results from October 1, 2021, – March 31, 2022, vs October 1, 2022, – March 31, 2023, to see if there is: 1. A change in provider ratings between providers across the two years, 2. To see if patient satisfaction with ease/convenience of appointments improves. 

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Mechanism

Post-Psychiatric Hospitalization 7-Day Follow-Up
Resident Lead: Alex Dragic

The goal of this project was to determine the root causes of patient non-adherence with 7-day outpatient mental health s/p psychiatric hospitalization. Several causes identified included patients being unaware of their upcoming outpatient appointments/not receiving reminder calls/texts. To eliminate this barrier, the team then developed an intervention wherein therapists on the inpatient unit provided teaching via weekly education groups on the utility of MyChart, and how to sign-up. Patients were able to sign-up before they leave the hospital if they chose to. Goal to improve patient adherence with 7-day outpatient follow-up, to prevent/delay psychiatric rehospitalizations.

Examination of the Implementation of Risking Connections on Provider Burnout & Youth Outcomes
Resident Lead: Rachel Carpenter

The goal of this project was to evaluate the implementation of Risking Connection Training in the Child and Adolescent PRTF, Partial Hospitalization Program, and inpatient settings at CHI Immanuel and Mercy Council Bluffs. Specifically, the team anticipates a reduction in violence against healthcare providers, reduction in staff burnout, improvements in staff attitudes regarding trauma informed care (TIC), and decrease utilization of restraints and seclusion.

Suicide Risk Assessment
Project Lead: Alexander Seger

We previously evaluated the effectiveness of the implementation of the Columbia Suicide Risk Assessment (C-SSRS) with providers working in the Emergency Departments at CUMC-Bergan and University. We know that most people who die by suicide visit a health care provider (not necessarily a mental health provider) in the 6 months before dying by suicide. CHI Health decided to utilize the C-SSRS to screen for suicide risk. The implementation involved two phases. The first was that all non-MD providers would begin using the C-SSRS starting July 1, 2019. Then all providers, including MDs would begin using the C-SSRS starting October 1, 2019. Our team found that overall, the implementation was successful, as screening went from around 10% to 87%. We also found that Latino patients were screened less frequently than all other racial groups. The following year’s focus was on identifying barriers to implementation of the C-SSRS to Latino patients, and providing an intervention for a barrier found. Past hypotheses were that a Spanish version of the C-SSRS may not be available, a translator may not be available, or the time and cost associated with identifying the need for and accessing a translator may present unique barriers for the health system.

Evaluation of Medication Ordering Process at PRTF
Project Lead: Jacob Tooley

In 2019/2020 QI cycle, our team was able to work with the electronic medical record (EMR) team and pharmacy to implement medication orders electronically at the Immanuel PRTF. We asserted that the Immanuel PRTF would benefit from standardization of care, and would show the same reduction in medical error that has been shown in prior research. Aims of the Project this year were as follows:  

Aim 1: Assess impact of the new medication prescription protocol, including medication errors reported in IRIS and their impact on patient care.

Aim 2: Assess how the current medication prescription protocol affects PRTF and ancillary staff (prescribing provider, nurses, pharmacists). 

Delay in the Evaluation and Treatment of Patients with Comorbid Acute Coronary Syndrome and Mental Health Disorders
Project Lead: Andrew Reuss

The goal of this study was to determine if prior mental health diagnoses affected the evaluation and treatment of patients suffering from Acute Coronary Syndrome (ACS). An underlying provider bias towards individuals with a psychiatric disorder, such as generalized anxiety disorder, could cause delays in the ordering of labs, imaging, and/or treatment modalities. Further, providing a mental health intervention post-ACS may reduce the risk of another ACS since mental health comorbidities are risk factors for many chronic health conditions that more directly cause ACS. This study helped to assess these potential problems in our medical system with the goal of developing a post-ACS intervention for mental health comorbidities. 

Evaluation of Dialectical Behavioral Therapy Implementation at the PRTF
Project Lead: Justin Romano

This project evaluated a hybrid effectiveness-implementation trial comparing Daily Living Activities Functional Assessment (DLA 20) scores of adolescent patients who received Dialectical Behavior Therapy and those who received treatment as usual in the same facility. Functional outcomes were described by the DLA20 (9) as physical and mental health practices, housing maintenance, communication skills, ability to maintain safety, and time management. Our project was in line with previous work showing positive outcomes for adolescents receiving DBT while in an RTC. Further, we sought to evaluate whether the current DBT implementation reduces burnout in staff at the PRTF with the goal of identifying opportunities for refinement of the implementation of DBT at PRTF.

Comorbid Mental Health’s Role in Limb Amputation Secondary to Osteomyelitis
Project Lead: Brooke Gertz

Limb amputation is a devastating consequence of osteomyelitis that can often be prevented by early diagnosis and aggressive antibiotic treatment.  Because other studies have identified worse health outcomes for patients with comorbid mental health diagnoses, this aim of this study was to identify the association between amputation secondary to osteomyelitis and comorbid mental health disorders. Specifically, we predicted that among patients with osteomyelitis and comorbid psychiatric diagnosis, amputation occurred at a higher rate compared to patients without a psychiatric diagnosis. We also expected that psychiatric treatment would moderate the relationship between osteomyelitis and amputation. This was a retrospective cohort study using a review of CHI medical records to identify patients with an osteomyelitis diagnosis in the Emergency Department, or outpatient orthopedic and podiatry clinics from 2010 to 2020.  Psychiatric diagnoses were stratified by specific mental health illness. The primary outcome was any type of amputation of the region affected by osteomyelitis within one year of the osteomyelitis diagnosis. Another variable of interest was whether the patient had mental health care prior to the osteomyelitis diagnosis. The results of this study were used to inform innovations in optimal interventions for patients with co-occurring osteomyelitis and mental health disorders.

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Positive Factors

DBT Diary Cards at PRTF
Resident Leads: Mark Mullen and Nick Williams

The goal of this project was to create and distribute daily DBT skills worksheets to staff to reinforce material taught in DBT skills sessions at the Child and Adolescent Psychiatric Residential Treatment Facility with the goals of 1) aiding in de-escalation of crisis situations, 2) increase patient functioning as measured by the Daily Living Assessment-20 (DLA-20), and reduction of problematic behaviors as measured using FRI points, and numbers of restraints/seclusions utilized.

Substance Use Agreement at LHRC
Resident Lead: Brooke Gertz

Within this study, a controlled substance use agreement and provider protocol will be designed and implemented at Lasting Hope Recovery Center (LHRC) outpatient psychiatry clinic. Aims of the Project this year are as follows: 

1. Increase patient autonomy and agency by providing more robust education about controlled medication risks, adverse effects, and potential for misuse/abuse.

2. Decrease provider burnout by empowering providers to set firm boundaries with prescribing controlled substances by clearly communicating clinic policy rather than relying solely on their clinical judgement.

3. Improve patient adherence to safety measures by tracking adherence to urine/saliva drug screens and utilizing a Prescription Drug Monitoring Program (PDMP).

4. Improve therapeutic alliance with patients by providing a framework for management of controlled substance prescriptions that sets explicit, standardized expectations and boundaries.

5. Increase usage of controlled substance agreements within the LHRC CHI clinic.

Pregnancy and Motherhood Among Creighton Resident Physicians
Project Lead: Rebecca Leval

Our team worked on a quality improvement project, in which we aimed to consolidate all university resources relating to resident physician maternity leave and postpartum return-to-work policies/procedures (including policies relating to lactation at work) into a single manual. This manual was created for resident physicians and their supervisors, as a guide, to help provide greater clarity into the process. Included within this resource was information on wellness opportunities and resources for mothers struggling to return to work postpartum given the stress of reintegrating back into the work environment while leaving a newborn at home, in the context of poor sleep, breastfeeding, financial concerns, etc. Recommendations for potential improvements to the process have been provided based on our findings during resource compilation as well as from resident pre- and post- surveys, which have been distributed to all Creighton medical residents.

Medication Adherence
Project Lead: Erin Kindred
(QI Symposium Award: Best Health Disparities Project, $250)

This study was a quality improvement project examining factors that contributed to medication non-compliance with the goal of identifying modifiable factors of compliance. Adherence and compliance are terms used in healthcare to describe the extent to which patients take their medications as prescribed. Psychiatric medication non-adherence is associated with relapse of symptoms, which can lead to decrease in function, suicide, rehospitalization, and increased healthcare costs (Tham et al., 2016). Our team previously identified barriers to medication compliance for established patients who are 19 years of age and older receiving outpatient care at the CHI Psychiatric Associates Clinic at Lasting Hope Recovery Center. We found that the greatest barrier was for patients to remember to take their medications. Our goal was to implement a mobile app, Medisafe, that helped patients remember to take their medications, tracks their medication use and side effects, and can be used to help communicate with their provider. We hypothesized that use of the app would reduce medication nonadherence. Another issue that arose was that it was not well-documented the extent that providers were checking medication adherence, or providing interventions to patients to help improve compliance. Therefore, we aimed to also create an EPIC dot phrase to document that medication adherence and patient attitudes towards meds were assessed, and motivational interviewing was provided.