Practice Key Driver Diagram

Chapter Quality Network ADHD ProjectJen Powell MPH, MBA

Edward Lewis MD

Starting with the End in Mind: Creating a Reliable System for ADHD Care

Jen Powell MPH, MBAEdward Lewis MD

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

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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

Practice-level key driver diagramUnderstanding ADHD bookletModel for Improvement (MFI) Laminated Card Parent Conversation Checklist

Handouts

Frameworks:Key Driver DiagramModel for

Improvement

Elements of a Reliable System

Aids and Resources for

Parents

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

Practice Key Driver Diagram

Model for Improvement

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”

Frameworks Reliability Parent

Resources

Practice Key Driver Diagram

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)

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

“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”

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:

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

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

Standardize using orders sets, protocols Work harder next time Feedback information to team on compliance Awareness and training

Level 1 Concepts

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

Real time identification of failures Checklists and observation Redundancy Making the “right thing” the “easy thing” Standardization of process

Level 2 (95%) Reliability

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.

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

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

Standardize decision-makingCheck Lists, VigilanceAwareness, Feedback

Decision Aids, RedundancyDesired Action is DefaultReal Time Identificationof Failure, Standardization ofprocess

Mindfulness, Pre-Occupationwith Failure, ResilienceStandardization of Behavior,System is Visible

Level 1 (10-1)

Level 2 (10-2)

Level 3 (10-3)

Level of Reliability Components

“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

Frameworks Reliability Parent

Resources

Parent Conversation Checklist

Parent Resource at Diagnosis

ADHD NY 1 Parent Resources can be found at www. ny1aap.org in the Resource Section.

Local Resources

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