1. Chapter Quality Network ADHD Project Jen Powell, MPH, MBA The Model for Improvement: The Three Questions

2. Objectives  Outline the 3 components of the Model for Improvement  Describe how to conduct rapid cycle testing using the Plan-Do-Study-Act method

3. Jen Powell 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. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? ActPlan Do From: Associates in Process Improvement ActPlan StudyDo AIM MEASURES IDEAS Model for Improvement PDSA CYCLES

5. 1.What are we trying to accomplish? AIM 2.How will we know that a change is an improvement? MEASURES 3.What changes can we make that will result in improvement? IDEAS Three Fundamental Questions for Improvement

6.  Specific  Measurable  Actionable  Realistic  Time-bound SMART AIM 6

7. SMART AIM for ADHD Project  Global Aim: Improve ADHD care processes  Specific Aim: Implement key strategies from AAP ADHD guidelines  SMART Aim: 80% of patients diagnosed with ADHD are prescribed behavior therapy (where indicated) by November 2016

8.  Receive Vanderbilt assessments from parent/teacher within 30 days of assessment initiation (90%)  Thorough, documented conversation with parent about ADHD/give ADHD Resource Kit (90%)  Med initiation f/u by Vanderbilt Assessment scales from multiple sources within 30 days (60%)  Patients prescribed behavior therapy (where indicated) (80%)  Reduction in ADHD total Symptom score from initial assessment to most recent follow-up assessment (25%) ADHD Measures

9. Practice Key Driver Diagram 1. Improved diagnostic accuracy 2. Monitoring and titrating medications 3. Effective follow-up and surveillance for co-morbidities 4. Effective behavior management 5. Use of population health strategies 6. Peer-to-peer learning network with data feedback 6 Key Drivers

10. ADHD Six Key Drivers Use Parent/Teacher rating scales to assess med efficacy and side effects Registry Interventions

11. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? ActPlan Do From: Associates in Process Improvement ActPlan StudyDo AIMS MEASURES IDEAS Model for Improvement PDSA CYCLES

12.  What we will learn :  How an aim statement will inform testing  Understand rapid cycle PDSA testing  Understand how theory and prediction aid learning  See how to collect real-time measurement  Appreciate the opportunity of collaborative learning Mr. Potato Head, AKA Sam, Exercise

13. Meet Sam

14.  Master Clinician – will put Sam together based on groups/predictions/theories  Documenter – will record data on data sheet to create our run charts  Time Keeper – will use their stopwatch on mobile phone to report time for each cycle  Score Inspector – judge precision according to the scale on the worksheet  QI Team Members – generate theories for testing, encourage the process Roles

15.  Our gracious volunteer is going to come up and help us establish our baseline data for this improvement initiative.  We will start the clock when the volunteer starts… stop clock when hands are off Mr. Potato Head  Time Keeper will record; Score Inspector will rank precision; Documenter will put data points on charts Establishing our Baseline

16. By the end of this session, our master clinician will correctly put Sam together - exactly as pictured in the photo - in 50 seconds or less. We will use iterative testing (plan, do, study and act) to identify implementation strategies. Mr. Potato Head Aim Statement

17. PDSA#Theory being testedPrediction TIME 1 SECONDS 80 70 2 60 50 3 40 30 4 20 10 5 123456 PRECISION 6 PRECISION SCORE 3 2 1 123456 PDSA CYCLE # 3 - All pieces are on Sam and are positioned correctly (as shown in the picture) 2 - All pieces are on Sam, but one or more is out of place or out of position 1 - One or more pieces are not on Sam Precision Mr. Potato Head Data Sheet PDSA CYCLE #

18. Plan – Figure out the questions you want to answer, plan a way to answer the questions, and predict results Do – “Just do it” (i.e. do the plan); collect the data Study – What did you learn? Act – What will you do with the knowledge you learned? What do you want to do next? Adapt, Adopt, Abandon? PDSA: small test of change

19.  Scale it down – small test of change  Short period (days), small # of patients/providers  Change something – test an idea  Pick willing volunteers (work with those that want to work with  Avoid the need for consensus, buy-in, or political solutions  Pick easy/feasible changes to try  Replicate changes made elsewhere  Change/test should be linked to a goal/measure  Complete the cycle – P – D – S – A  Predict, then test  Reflect on the results of every test (successful AND failed tests)  Discard what doesn’t work/Spread what works Tips for Testing Changes

20.  Provides you with the data to prove that a new way works better  Up to 50% of tests not expected to yield improvement  Yet significant learning from testing  Fewer # of people affected by the test (lower risk)  Change isn’t permanent  Need to formally implement desired changes Why is Testing Important? Source: Langley et al. 1996. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. p114.

21. PDSA Cycle Ramps: Sequential Building of Knowledge Best Practice Evidence Hunches Theories Testable Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change The Improvement Guide Associates in Process Improvement Successive tests of a change build knowledge AND create a ramp to improvement

22. Objectives  Outline the 3 components of the Model for Improvement  Describe how to conduct rapid cycle testing using the Plan-Do-Study-Act method