At the time of publication of this article, one of our general hospitals is set to roll out DAPS screening hospital wide with the goal of prospectively identifying patients who might benefit from some form of behavioral health intervention and thus reducing length of stay. Another of our general hospitals is already using the DAPS to reduce hospital readmissions [15]. What started out as an initiative simply to meet a regulatory requirement turned into a novel and efficient means to bring mental health care services to hospitalized patients.
Lessons Learned
Our goal in the Perfect Depression Care initiative was to eliminate suicide, and we have come remarkably close to achieving that goal. Our determination to strive for perfection rather than incremental goals had a powerful effect on our results. To move to a different order of performance required us to challenge our most basic assumptions and required new learning and new behavior.
This social aspect of our improvement work was fundamental to every effort made to spread Perfect Depression Care outside of the specialty behavioral health care setting. Indeed, the diffusion of all innovation occurs within a social context [16]. Ideas do not spread by themselves—they are spread from one person (the messenger) to another (the adopter). Successful spread, therefore, depends in large part on the communication between messenger and adopter.
Implementing Perfect Depression Care within BHS involved like-minded messengers and adopters from the same department, whereas spreading the initiative to the general medical setting involved messengers from one specialty and adopters from another. The nature of such a social system demands that the goals of the messenger be aligned with the incentives of the adopter. In health service organizations, such alignment requires effective leadership, not just local champions [17]. For example, spreading the initiative to the primary care setting really only became possible when our departmental leaders made a public promise to the leaders of primary care that BHS would see any patient referred from primary care on the same day of referral with no questions asked. And while it is true that operationalizing that promise was a more arduous task than articulating it, the promise itself is what created a social space within which the innovation could diffuse.
Even if leaders are successful at aligning the messenger’s goals and the adopter’s incentives, spread still must actually occur locally between 2 people. This social context means that a “good” idea in the mind of the messenger must be a “better” idea in the mind of the adopter. In other words, an idea or innovation is more likely to be adopted if it is better than the status quo [18]. And it is the adopter’s definition of “better” that matters. For example, our organization’s primary care clinics agreed that improving their depression care was a good idea. However, specific interventions were not adopted (or adoptable) until they became a way to make daily life easier for the front-line clinic staff (eg, by facilitating more efficient referrals to BHS). Furthermore, because daily life in each clinic was a little bit different, the specific interventions adopted were allowed to vary. Similarly, in the general hospital setting, DAPS screening was nothing more than a good idea until the nurses learned that it took less time and yielded more actionable results than the long list of behavioral health screening questions they were currently required to complete on every patient being admitted. When replacing those questions with the DAPS screen saved time and added value, the DAPS became better than the status quo, a tipping point was reached, and spread took place.