Adolescent depression, has been identified as one of the important risk factors for adolescent safety. The American Academy of Pediatrics (AAP) recommends screening the adolescent population for depression with a validated screening tool at least once a year. Given the time constraints in primary care, many physicians tend to rely more on clinical questioning to screen depression.This has the potential to miss many adolescents who may have mild to moderate depression which may prove detrimental to their emotional and physical health.Quality measures had consistently indicated that the validated adolescent depression screening rate in our two pediatric clinics was 10-15% in the past two years starting from 2012. There was a need to increase our screening rate for adolescent depression with a validated questionnaire. The stakeholders identified were physicians, nurses and the health information team (HIT).The Patient Health Questionnaire-2 (PHQ-2) is a standardized tool and serves as a good first step rapid screening of the population. A decision was made to implement the use of PHQ-2 to all the adolescents aged 11-21. A clinic flow protocol was developed. As the patient checks in, there will be a computer pop-up reminding nurses to administer the PHQ-2. The PHQ-2 self-scores in the Electronic Health Record (EHR) and if the score is three or more the nurses would automatically administer the PHQ-9 which is also embedded and self-scored in the EHR.After 12 months of implementing this project with four PDSA cycles, the adolescent depression-screening rate improved from 10-15% from the previous two years to 65% (six month period) and 82% at the end of the 12 month period. The rate of referral to mental health services had also increased in the same time period compared to the previous years. In conclusion, screening for adolescent depression with a brief validated tool in a busy primary care office is possible with the help of the EHR.

Postpartum depression (PPD) is one of the most common and severe postpartum morbidity, affecting 10%–20% of mothers within the first year of childbirth. The adverse effects of PPD, namely, prevention of mother-baby bonding and early cessation of breastfeeding, adversely affects infant growth and brain development. Studies have found that up to 50% of women with PPD go undiagnosed. Despite the American Academy of Pediatrics (AAP) recommendations, only a small percentage of paediatricians are currently screening for PPD. This project aimed to improve PPD screening using a validated tool to 75% in a primary care inner-city clinic serving a predominantly underserved population as per AAP recommendations. Baseline data for 40 charts of 2-month-old and 4-month-old well-child visits showed no documentation of PPD screening. The screening tool used for this project was the Edinburgh Postpartum Depression Scale (EPDS), which is a validated 10-item screening questionnaire for PPD. Three Plan-Do-Study-Act (PDSA) cycles were implemented involving educational strategies, system-based practice improvement and stakeholder participation. Improvement seen after PDSA cycle 1 was minimal. At the end of cycle 2, 16/50 (33%) charts had documentation of screening using EPDS. At the end of cycle 3, 33/40 (82%) charts had EPDS documentation, an increase of 49% from cycle 2. There were eight in total positive PPD screenings between cycles 2 and 3. These patients were provided counselling support through a social worker and referral services through the local community mental health organisation. We achieved more than our 75% target goal for PPD screening implementation at the residency clinic, thereby increasing residents’ awareness of PPD and the importance of PPD screening. Poststudy follow-up shows that screening was maintained at a higher rate but never reached 100%.

Dental caries affect 97% of people during their lifetime. A total of 59% of children aged 12–19 will have at least one documented cavity. The American Academy of Pediatrics recommends fluoridated toothpaste to all children starting at tooth eruption, regardless of caries risk. Besides, fluoride varnish is recommended for all children every 3–6 months from tooth emergence until they have a permanent dental home. This project aimed to increase oral fluoride varnish application for children starting at 6 months or the time of tooth eruption up to 3 years of age by at least 50% over 18 months.The stakeholders identified were physicians, nurses, medical assistants and the health information team. We obtained baseline data about oral health screening and fluoride varnish from both the clinic sites. The quality improvement (QI) project was based on Plan-Do-Study-Act (PDSA) cycles with a 6-month gap in-between the three cycles. For the first cycle, all medical staff members participated in 2-hour knowledge and skills training on dental caries and current recommendations on fluoride varnish. PDSA cycle 2 involved having automatic reminders for providers in electronic medical records. PDSA cycle 3 planned to have automatic fluoride orders for the recommended age groups. The QI team analysed the results after every 6 months, and improvements were made based on the input from data and medical staff.The number of patients who had fluoride varnish applied increased from 14% (n=50) to 55% at the end of PDSA cycle 3. Administration of the varnish did not affect the flow of the patients in busy primary care practice. The rate of improvement was across all the age groups, providers and in both clinical sites. It is possible to adhere to the oral fluoride varnish guidelines in a busy primary care practice, which may help benefit young children who are at risk for caries.

The pediatric clinics of the Michigan State University College of Human Medicine (MSU-CHM) consist of academic pediatricians serving two clinics with a patient population of 5200. The internal quality measures published by the MSU health team had consistently indicated our generic medications prescription rate to be very low, with an average of about 21% for the years 2009, 2010, and 2011. There was an earnest need to increase our generic medication prescription rates, which is considered an indicator of good practice. The stakeholders identified were physicians, nurses, care managers, and the health information technology (HIT) team.The purpose of the project was to increase the prescribing rate of viable low cost and approved generic medications for the patients of the MSU-CHM general pediatric clinics.The stakeholders regularly met every few months to work on increasing the generic medication prescription rates based on the PDSA cycle. Help was sought from HIT to identify and acquire the top 10 brand names the group was prescribing along with individual provider data. The team reviewed the brand names most prescribed, and made a recommendation that the best group to target were the stimulant medications, allergy and asthma medications, and other psychotropics. The HIT team was then requested to add the available generics for all stimulant medications, asthma medications, and others in the electronic medical record (EMR). They were also clearly marked for ease of use, for example: amphetamine-dextroamphetamine extended release “generic for Adderall XR." It was decided that providers would prescribe all stimulants as a generic, unless not available, and nurses would change each brand name of stimulants to a generic every time they refilled a medicine, based on a protocol outlining the appropriate generic medications corresponding to the respective brand names. The physicians and nurses were also urged to discuss with the patients the substitution process and answer any questions from parents. Monthly reports were obtained from the HIT about our progress.After 12 months of implementing this project, the overall generic prescription rate increased from 20% at the end of first quarter 2012 to 53% at the end of 12 months, and 65.5% at the end of two years. This was well above the MSU health team (about six large group practices) primary care average of 34.6%. All brand name medication prescription rates were also decreased. This is a positive outcome for this project in a relatively short period of time, and a further plan will be to repeat the cycle and continue to improve on the generic prescription rate, thereby saving valuable dollars spent on health care.

Aim Learning communities (LCs) have been identified as a structure to support student wellness as well as create a positive learning environment and have been increasingly adopted in undergraduate medical education (UGME). In 2016, Michigan State University College of Human Medicine made curricular changes which integrated basic, social, and clinical sciences. One of the major strategies adopted to deliver this integrated curriculum was to create LCs that served as a central scaffold for students’ academic development. Our primary aim is to describe how the school utilized LC faculty to deliver this core integrated curriculum. Methods Students were surveyed about their perceptions of the effectiveness of the LCs in delivering an integrated science curriculum. Student academic performance in the new curriculum was compared to that of students from the legacy curriculum as a measure of the effectiveness of the curricular changes. Results The percentage of students in each class who responded to surveys ranged between 78.7% and 95.8%. Mean Likert responses (1 = strongly disagree; 5 = strongly agree) for statements ‘the Faculty Fellow is effective in helping me learn the scholar group content’, ‘the Faculty Fellow is an effective teacher in our scholar group’, and ‘the Faculty Fellow is well prepared for our scholar group’ ranged from 4.37 to 4.78, 4.72 to 4.76, and 4.81 to 4.86, respectively. In addition, a comparison of summative exam scores of the new curriculum’s students to the legacy curriculum’s students demonstrated comparable or better performances in the new curriculum. Conclusions Utilizing LCs to deliver an integrated science curriculum is an underutilized strategy in UGME. Surveys on student satisfaction and academic performance are encouraging. Additional outcome measures are planned to continually evaluate this innovative multifaceted integration.