Planning for quality @ NHSL Quality Academy South Edinburgh CAMHS , Pathway for ADHD Assessment – Improving efficiency and  patient experience. Margaret Introduction to ADHD - ADHD assessment in CAMHS Demographics Margaret Monan Gwyneth Bruce Heather McClelland Maria Holancova Cathy Richards

ADHD Assessment Process in South Edinburgh Why did we choose this? - Introduction of QI to ADHD teams (other parts of CAMHS have very established QI) We have 2 teams in Edinburgh who are carrying out assessments – North and South As the process map shows the assessment pathway complex and can take several months to complete What is the number of referrals to South ADHD team over past year .?

Process Map Gwyneth When we started on our “QI journey” we had a plan to look at both north and South team assessment processes. In fact we met with clinicians from both teams and drew complex process maps with them. We were quickly overwhelmed with information . After our first coaching session we realised we were being over-ambitious and decided to focus down on 1 team.- South Edinburgh team Our aim was to engage and work closely with the clinicians in the ADHD team on this. Our first step was to join the team at a team meeting to introduce the plan to focus on the assessment pathway. Well received . With the help of the South team clinicians we were able to bring our focus to the main parts of assessment process – shown here

Gwyneth We learned the team had been processing referrals in batches so we decided to focus on the assessments of the most recent group. We reviewed the last 13 cases which were formulated and looked at the time from referral to formulation.

Referral to Formulation pt.2 1. Referral to school obs 2. School obs to 1st appt 3. 1st appt to formulation Gwyneth We then broke down of the steps in the assessment pathway !st chart shows waiting list for school obs. Some of variance is created by school hols and organisational issues such as questionnaires not being returned or about arranging a school obs ( absences, slow response from school etc) 2nd chart – variance explained by setting appointment with family. 3rd variance – anecdotally appears to be around setting a formulation and having all the info required to make a diagnosis avalable

Patient Experience The letter we got gave some idea what would happen but the face to face meeting really helped. I knew what to expect . The whole process took 4-5 months , much quicker than I thought. My sons ASD assessment took over 1 year so I expected the same again. We completed the paperwork right away , sent it back then heard nothing for ages, we had to keep phoning . What would help is an idea of timescales and things you can do to help while you are waiting. Its a long time to struggle on for 7 months and its still not really clear what it means. The assessment once you get it is too fast , they didn't really get to know our child or us before deciding. We had already filled out the same paperwork for ASD assessment so we knew what to do and because its different teams we had to do it all over again, that would be the one criticism The questionnaires made me think about how ADHD might be affecting my son . I didn't really know what it was and didn't think he had it but the questions made me think. I felt bad I hadn't noticed the ADHD and thought it was all to do with the autism. I couldn't really remember a lot of the early development , I have 4 children . I was worried I hadn't remembered the right things in the questionnaires. They never asked any more at clinic so i don't know if that affected things. Margaret As well as looking at the data we thought that it would be essential to gather information about families perceptions of the experience of being referred, of waiting and of the different parts of the pathway. We did this by telephone questionnaire .we used 11 questions to enquire about patient/family experience through the ADHD assessment pathway.. . We were curious about the experience of completing the developmental questionnaires and to see if our hunch was correct that families found these very difficult. We wanted an idea of how long families perceived their wait to be against the actual time and any ideas we could use to test change. Give some examples of questions Quotes

Driver Diagram Gwyneth We have reviewed where we have got to and have had further discussions with the team. The information we had gathered – in particular the feedback from families – created a lot of discussion Margaret and I shared the driver diagram with the team and had gone with some ideas about some tests of change and these changed and evolved as we talked with them

A P S D PLAN We heard that families had expressed uncertainty about what the assessment pathway consisted of so we agreed we would develop a flow diagram which shows what will happen.  This could be sent with the initial letter explaining that the family are on the team waiting list. We know that one of the hold-ups for cases being ready to go to formulation is gathering reports from other professionals.  Families will have received these and we agreed that we would request that they bring any reports to their assessment appointment so we can copy them.  This could be inserted into the appointment letter (would need to go through Trak) or could be a separate note attached to letter. The timeframe identified by families as difficult is the period between the assessment appointment  and the feedback of the formulation . This can (depending on availability of info from other professionals) take a while.  We agreed we would develop a letter  explaining the next steps and trial this by sending to a small number of families.  We could then test the change by contacting families for feedback. We also discussed sending information to families  - supports, resources, websites which might be helpful.

Do Develop a flow diagram for families which illustrates the assessment pathway. Develop a paragraph/ short note re bringing report to the assessment . Drafting a proforma for the letter which would go to families post assessment appointment.  Draw up a handout of information with useful advice/ resources etc for families.   The 3rd stage is to study or measure the change We will us the patient experience questionnaire to measure the impact of these changes and look again at the data about the time from referral to formulation We plan to do this again with the team. They have already made suggestions of how we could work together to focus on improvements following assessment ....Our hope is that by working collaboratively we will make improvements to patient experience using QI methodology.