Clinical Arm

The Data Handbook is a comprehensive data guide for this collaborative.


  1. To achieve an 80% rate of depression screening in youth ages 12-25 years
  2. Eighty percent of youth with a positive depression screen will have a documented follow-up plan.


All surveys and data are collected at the practice level, not the individual clinician, to incentivize systems-level change for participating sites. Sites with multiple clinicians participating will submit one set of data for all participants at that site.

Data Collection Tools

To measure progress, practices will submit baseline and monthly data on depression screening, follow-up planning, and referral confirmation. Practices will also submit pre- and post-intervention data on their office systems related to mental health over the 9-month period.

Office Systems Inventory: Participating practices complete a pre- and post-project inventory to assess the extent to which their office systems promote and support caring for adolescents and young adults with mental health concerns. Each participating site completes and submits the survey as a team. 

Monthly Chart Review: Depression screening and follow-up are measured monthly for nine months: three months of baseline (October - November 2021) and six months of intervention (December 2021 - May 2022). Practices will audit charts of 10 visits per month for patients ages 12-25.

PDSA Log: Practices submit monthly Plan-Do-Study-Act (PDSA) logs to report which strategies the practice is testing to improve depression screening, follow-up planning, or other clinical systems related to depression management. We have created a sample PDSA Log to support newcomers to QI.

Staff Impact: At the end of the 9-month project, practices complete a short, six-question, Staff Impact Survey, which examines the value of the outcomes with the resource investment.  

Data submission

All project data will be submitted through REDCap, an online encrypted data collection system. Data is downloaded for analysis and reporting by NIPN staff. No protected health information (PHI) is submitted. NIPN assigns all practices a unique identifier, so that data cannot be attributed to any site name.

Each participating site designates one person to serve as data liaison. The data liaison is the only person at the practice who receives data links from REDCap and enters, or facilitates entry, of all practice data. 

Chart review and PDSA logs are due the 17th of each month.  If the 17th falls on a weekend or holiday, the data is due the next work day.

Data ToolDue Date

Pre-Project Office Systems Inventory

Chart Review of September 2021 patient visits

October 27, 2021
Chart Review of October 2021 patient visitsNovember 17, 2021
Chart Review of November 2021 patient visitsDecember 17, 2021

Chart Review of December 2021 patient visits

December PDSA Log

January 18, 2022

Chart Review of January 2022 patient visits

January PDSA Log

February 17, 2022

Chart Review of February 2022 patient visits

February PDSA Log

March 17, 2022

Chart Review of March 2022 patient visits

March PDSA Log

April 18, 2022

Chart Review of April 2022 patient visits

April PDSA Log

May 17, 2022

Chart Review of May 2022 patient visits

May PDSA Log

June 17, 2022

Post-project Office Systems Inventory

Staff Impact Survey

Project Evaluation

June 22, 2022

The comprehensive Data Handbook, is a guide to data for the QI collaborative. 

For REDCap return codes, survey links, or other data inquiries, please contact Rachel Wallace-Brodeur at rachel.wallace-brodeur@med.uvm.edu.


This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under #U45MC27709, Adolescent and Young Adult Health Capacity Building Program). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.