Los Angeles County Maternal Mental Health Access (LAMMHA) is a five-year program funded by the California Health Care Foundation (CHCF) to support community health centers in identifying and treating perinatal mental disorders in primary and prenatal care. Affecting at least one in seven childbearing persons in the U.S., perinatal depression is one of the most common complications of pregnancy and the postpartum period. Having clinical protocols and workflows for early detection and management is critical in achieving the best care and outcomes for both parent and infant.
The Plan-Do-Study-Act (PDSA) cycle
The Plan-Do-Study-Act (PDSA) cycle is a structured approach to implementing quality improvement initiatives in healthcare settings. PDSA cycles are used to improve patient safety, quality of care, and efficiency by testing changes on a small scale before making them standard practice. PDSA’s are continuous and iterative, and follow the IHI Model for Improvement framework, which asks three key questions: What are we trying to accomplish? How will we know a change is an improvement? and What changes can we make that will result in improvement? Each step of the PDSA process is a key component towards this framework:
- Plan: Develop a SMART goal (Specific, Measurable, Achievable, Relevant, and Time-Bound), plan action items, identify how the PDSA will be tracked to measure its impact, and collect baseline data prior to beginning the PDSA.
- Do: Conduct the PDSA, checking in frequently to ensure action items are being taken towards the improvement goal.
- Study: Collect the data and analyze the results.
- Act: Determine the next steps based on whether the goal was met. Will the team adopt the change (e.g., goal was achieved), adapt the change and try a new approach (goal was not achieved), or abandon the change (e.g., the change worsened the outcome)?
Importance of practice change and PDSA work in improving detection and outcomes
PDSA cycles are important and impactful in healthcare because they directly improve early detection, timely intervention, and patient outcomes in a safe, evidence-based way. Practice change helps ensure that evidence-based practices are consistently upheld in the clinic. PDSA cycles can help teams identify where processes break down, make detection practices more reliable, and reduce variation between providers or shifts. Tracking the impact of each PDSA cycle is essential to measure the effectiveness of the change and to validate what the true root cause of the issue is.
“PDSA cycles are essential tools that help us identify more effective approaches to patient care and tailor interventions to their individual needs, ensuring the highest quality of care.”
– Dr. King, Regional Medical Director, St. John’s Community Health
PDSA best practices and application in perinatal mental health
When developing a PDSA, it is critical to take time in the “Plan” phase to brainstorm and identify the potential root causes of the issues seen. For example, if depression screenings are lower than expected, assess the reasons why that may be. Could it be attributed to workflow inconsistencies, data discrepancies, or another factor? What issues may occur within the workflow, or the data reports? It is important to fully explore together as a team to help identify the root cause(s), and then decide one place to focus. The Five Why’s is a proven framework to help identify the root cause during this exploration phase. As PDSA’s are iterative, the goal is to conduct short, measurable cycles of change, and build upon the change to try a different approach or address a different root cause at the next iteration. A recommendation is to hold a team meeting to create the opportunity to Plan the PDSA, and set ground rules for the brainstorming session, including creating a no-judgement zone and focusing on processes instead of people. Identifying a concrete data source and setting continuous check-ins to assess progress towards the PDSA will further drive success.
When developing a PDSA to address a clinic’s perinatal mental health, consider the following components: depression screenings, case finding, referrals, and enrollment in LAMMHA or other mental health programs, such as integrated behavioral health (IBH). Utilize the data to assess how well the clinic is performing in each component, compared to what clinicians may expect based on their day-to-day operations. Often, the best place to start is depression screenings, as high rates of depression screening lay the foundation to then find and treat patients in need of perinatal mental health services. Within the screening process, consider the performance of each type of visit where patients are typically screened – are screenings underperforming within prenatal visits, postpartum, or well child visits? What opportunities are there, when patients come in, that are being missed? Approaching the perinatal mental health space in this stepwise fashion helps to ensure clarity in the process and have more meaningful impacts towards patient care and outcomes.
“In the LAMMHA (Los Angeles Maternal Mental Health Access) program, Plan-Do-Study-Act (PDSA) cycles are driving meaningful improvements. By testing small, one at a time changes, our teams have strengthened perinatal screening, improved community partnerships, and fostered a culture of collaborative, high-quality care for patients and families.”
– Nancy Guzman, Behavioral Health Care Manager (BHCM), TCC Family Health
Examples of completed PDSAs within the LAMMHA program
- Implementing Screening Best Practices for Prenatal Visits: LAMMHA requires two screenings during prenatal visits (PHQ9, PHQ2, and/or the EPDS are eligible screeners), typically given during the initial prenatal visit and in the third trimester (24-28 weeks). Workflow changes were required to screen more than once, which involved changes for the front desk, MAs, and providers. Avenues were explored to ensure the workflow was consistent, such as CDSS alerts in the EHR when a screener is due. The expanded screening workflow process during the prenatal period enabled clinics to increase prenatal screening rates, impacting clinician’s identification of prenatal patients with PMADs, and providing further access to timely treatment and support throughout the duration of pregnancy.
- Volume of Positive Screenings/Case Finding: Across the board, clinics have low average positive screening rates, indicating low case finding for perinatal depression. In the populations served within the FQHC clinics, we would expect between 15-20%, on average, of perinatal patients to have depression. However, the rates seen during LAMMHA implementation are often variable, with most clinic averages ranging between 0-5%. PDSAs were conducted within clinics to identify new ways to engage the patient in appropriate response and train staff to introduce the depression screeners. One example of this was to hold a PHQ-9 Introduction Training, to implement workflows for front desk and/or MAs to introduce the PHQ-9 with de-stigmatizing language. This provides clarity around the purpose of the screener, letting the patient know that this information is a part of their whole-person health and that the care team values the patient’s responses as a part of their care.
- Incorporating New Referral Processes: Several clinics, prior to participation in the LAMMHA program, already had robust IBH or in-house behavioral health services, where patients are often referred. Once LAMMHA was implemented, clinics created new processes/criteria to triage patient referrals appropriately. PDSAs were conducted within clinics to review referral workflows and identify issues, educate staff, improve awareness of LAMMHA criteria, and create brochures for staff and patients.
“In LAMMHA, PDSAs improved the reliability of perinatal mental health screening using tools such as the PHQ-9 and EPDS. Through PDSAs, teams identified ways to make screening more consistent and easier to follow-up on such as clarifying who reviews results, when next steps occur, and how information is shared across the collaborative care team. These small changes helped ensure that positive screens are addressed with greater confidence. PDSAs also strengthened collaboration between clinic teams and community-based mental health partners, creating clearer referral pathways and smoother warm handoffs. Most importantly, these improvements benefit patients. Clear systems support timely care, continuity, and a more supportive experience during pregnancy and postpartum. PDSAs help us learn together, strengthen teamwork, and deliver compassionate, high quality maternal mental health care.”
–Nancy Guzman, Behavioral Health Care Manager (BHCM), TCC Family Health
Resources for Clinicians
During the two-year program, the participating LAMMHA clinics receive intensive on-going support and training to implement and sustain Collaborative Care. Please visit the CCALAC LAMMHA program page for more program information and previous LAMMHA blog posts. For more information and resources around maternal mental health in California, please visit the California Department of Public Health – Maternal Mental Health page.
LAMMHA program partners: Community Clinic Association of Los Angeles County (CCALAC), Elevation Health Partners (EHP), Maternal Mental Health Now (MMHN), Concert Health, University of Pennsylvania (UPenn), University of California, Los Angeles (UCLA) and the Department of Psychiatry and Behavioral Sciences at the University of Washington (UW).