1. Practice Key Driver Diagram

2. Starting with the End in Mind: Creating a Reliable System for ADHD Care Chapter Quality Network ADHD Project Jennifer Powell, MPH, MBA, Quality Improvement Consultant

3. Jennifer Powell, MPH, MBA I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation. Commercial Interests Disclosure 3

4.  Articulate the six key drivers that provide a framework to improve ADHD care  Describe characteristics of a reliable system of ADHD care  Describe decision aids and resources to be used at point of care to support parents Session Objectives

5.  Practice-level key driver diagram  Understanding ADHD booklet  Model for Improvement (MFI) Laminated Card  Parent Conversation Checklist Handouts

6. Frameworks: Key Driver Diagram Model for Improvement Elements of a Reliable System Aids and Resources for Parents

7.  WHAT IS A KEY DRIVER DIAGRAM (KDD) AND WHY IS IT USEFUL?  A KDD is a pictorial representation of a system that displays our theories about how to improve an established aim or outcome. It is useful in the following ways:  It creates a visual road map for all organizations and stakeholders  It creates a common vision of what we are trying to accomplish  It documents our theories and ideas of how we think we will reach our aim  It allows us to keenly focus on what we have agreed to… It keeps us focused on the vital activities we need to accomplish our goal Practice Key Driver Diagram

9. Model for Improvement

10.  A tailored packet of resources, tools, approaches  Organized by the practice-level key drivers  Will include “ready made” resources that practices can immediately test and tailor to the needs of the practice  We will introduce today and on monthly practice calls  Sections will be shared as they are developed The ADHD “Change Package”

11. FrameworksReliability Parent Resources

12. Practice Key Driver Diagram

13. Defining “Reliability”  The measurable capability of an object to perform its intended function in the required time under specified conditions. (Handbook of Reliability Engineering, Igor Ushakov, Editor)  The probability of a product performing without failure a specified function under given conditions for a specified period of time. (Quality Control Handbook, Joseph Juran, Editor)  The extent of failure-free operation over time. (David Garvin)

14.  The capability of a process, procedure or health service to perform its intended function in the required time under existing conditions.*  For example, how often (capability) does developmental screening (process) occur (intended function) now (existing conditions)  Our goal is to ensure that the right thing happens every time because our practice has the systems in place to accomplish our goals. Definition of Reliability for Health Care *Institute for Healthcare Improvement

15.  “Reliability” = Number of actions that achieve the intended result ÷ Total number of actions taken  % of visits where ADHD care occurs when and how it is supposed to  Failure rate = 1 – “Reliability”  60% performance of implementing ADHD guidelines means failures occur 40% of the time  It is convenient to use failure rate as an index, an order of magnitude  10 -1 means that 1 time in 10, the process fails to achieve its intended result Quantifying “Reliability”

16.  It is not practiced by the entire organization  No one is keeping track of “failures” (or changes in reliability)  Systems are not documented  It is not ingrained into the culture and reinforced in staff meetings, hiring decisions and orientation to new staff A System is Unreliable When:

17.  Chaotic process : Failure in greater than 20% of opportunities  Level 1 : (10 -1 ) 80-90% Reliability. (1-2 failures out of 10)  Level 2 : (10 -2 ) Approximately 95% Reliability. (<5 failures out of 100)  Level 3 : (10 -3 ) Approximately 99% Reliability. (<5 failures out of 1000) Starting Definitions of Reliability Our current data indicate that our ADHD care processes are not very reliable

18.  Team focus on the outcome goal  Working harder  Feedback of information on performance  Awareness and training  Standardize decision-making (e.g., guidelines) Level 1 ( 80-90%) Reliability

19.  Standardize using orders sets, protocols  Work harder next time  Feedback information to team on compliance  Awareness and training Level 1 Concepts

20. Examples of Level 1 Reliability  Team focus on the outcome goal: Team aim and goals.  Working harder: Better team collaboration  Feedback of information on performance: Monthly measurement and feedback of results  Awareness and training: List of commonly used community resources, training staff in new roles  Standardize decision-making: Practice-wide guidelines

21.  Real time identification of failures  Checklists and observation  Redundancy  Making the “right thing” the “easy thing”  Standardization of process Level 2 (95%) Reliability

22. Examples of Level 2 Change Concepts  Standardize Process : Clear staff and MD roles in ADHD care for each point of contact  Make it easy to do right : mehealth prompts to indicate time to initiate a follow-up Vanderbilt screening  Default to the appropriate option : Parents and teachers receive the Vanderbilt scales whether a physician orders or not.

23.  Redundancy : Two people verify that patients have been notified for a follow-up visit  Checklists : Diagnosis and follow up parent conversation checklist  Real-Time ID of Failures : Daily review of no shows and plan for follow-up Additional Level 2 Examples

24. Level 3 (99%) Reliability  Preoccupation with failure : Real-time awareness of failures (daily monitoring of process), “Process Owner” (who is responsible for registry)  Reluctance to simplify interpretations : learning from each failure and from those doing better.  Sensitivity to operations : staff wiling to remind each other about ADHD processes and utility of registry  Commitment to resilience : response to failures positively! (they are gifts!)  Deference to expertise and experience : Avoidance of strict “Top- Down” culture. Everyone can speak up and state what is happening

25. Standardize decision-making Check Lists, Vigilance Awareness, Feedback Decision Aids, Redundancy Desired Action is Default Real Time Identification of Failure, Standardization of process Mindfulness, Pre-Occupation with Failure, Resilience Standardization of Behavior, System is Visible Level 1 (10 -1 ) Level 2 (10 -2 ) Level 3 (10 -3 ) Level of Reliability Components

26. “ Robust Design ” Outcomes + Situational factors Process/control factors Development Function Learning Level 1 Components Level 2 Components Level 3: Mindfulness Severity of problem Values/habits/lifestyle Preferences Support system Resource availability

27. FrameworksReliability Parent Resources

28. Parent Conversation Checklist

29. Parent Resource at Diagnosis

30. NATIONAL RESOURCES :  CHADD http://www.chadd.org/Support/Directory.aspx?state=279640043&state=279640043 http://www.chadd.org/Support/Directory.aspx?state=279640043&state=279640043  Facts for Families – ADHD – American Academy of Child & Adolescent Psychiatry http://ohioaap.org/wp-content/uploads/2015/12/Facts-for-Families-ADHD.pdf http://ohioaap.org/wp-content/uploads/2015/12/Facts-for-Families-ADHD.pdf  Impact ADHD http://www.impactadd.com http://www.impactadd.com  Incredible Years http://incredibleyears.com http://incredibleyears.com ADHD Resources

31. NATIONAL RESOURCES (continued) :  Keys to Communicating With Your Child - from Centers for Disease Control http://www.cdc.gov/parents/essentials/communication/ http://www.cdc.gov/parents/essentials/communication/  Parent-Child Interaction Therapy International http://www.pcit.org/ http://www.pcit.org/  Triple P – Positive Parenting Program http://www.triplep.net/glo-en/home/ (Provider site) http://www.triplep-parenting.net/glo-en/home/ (Parent site) http://www.triplep.net/glo-en/home/ http://www.triplep-parenting.net/glo-en/home/  WyzAnt Tutoring Services https://www.wyzant.com/ https://www.wyzant.com/ ADHD Resources

32. RESOURCES IN NEW YORK STATE :  Child and Adolescent Psychiatry for Primary Care (CAP-PC NY) http://www.cappcny.org 1- 855-227-7272 http://www.cappcny.org  CHADD of New York City - New York, NY http://www.chadd.net/107 http://www.chadd.net/107  Nassau County CHADD - East Meadow, NY http://www.chadd.net/105 http://www.chadd.net/105  Suffolk County CHADD - Ronkonkoma, NY http://www.chadd.net/160 http://www.chadd.net/160 ADHD Resources

33.  Reliable systems for ADHD… important to start with the end in mind  mehealth portal is designed to assist your practice in moving along the reliability continuum  Rest of today will focus on testing strategies to implement reliable systems  CQN will continue to build a repository of tools, resources and approaches to improve reliability Summary