Practice Key Driver Diagram

The Model for Improvement: The Three Questions Chapter Quality Network ADHD Project Jennifer Powell, MPH, MBA, Quality Improvement Consultant Allie Stevens, MPH, MS, Project Manager, Chapter Quality Network

Commercial Interests Disclosure Jennifer Powell, MPH, MBA Allie Stevens, MPH, MS 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.

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

Why Use a Quality Improvement Strategy? Provides a framework to show us how to get from where we are to where we want to be There are several quality improvement strategies and methods. For the purposes of our work, we are using the Model for Improvement. The importance of using a QI strategy is that it provides a framework and gives us a common language for how we can talk about the improvement work we are doing. The Model for Improvement is effective in that it focuses on small tests of change. No implementation without testing. It introduces the critical step of answering the “How” … How will we make a change and how will this work in our practice? And, it uses measurement to make sure that we know whether the changes lead to improvement, or to some other unexpected consequence, or to no change at all. Uses measurement to show us where we are on the journey and to let us know when we’ve arrived at our destination

Three Fundamental Questions for Improvement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES What changes can we make that will result in improvement? IDEAS To be successful, any improvement effort must start by addressing the three basic questions shown here before beginning PDSA cycles. They are the foundation of the Model for Improvement.

Model for Improvement Act Plan Do What are we trying to accomplish? AIMS How will we know that a change is an improvement? MEASURES What change can we make that will result in improvement? IDEAS Once we’ve gotten clear about our aim, what we will measure, and brainstormed some ideas about changes that can lead to our aim – we can start using PDSA cycles to test our ideas. The PDSA cycles are the wheel that moves us forward – they inform our learning quickly and without much upfront investment. Act Plan Study Do Act Plan PDSA CYCLES Do From: Associates in Process Improvement

PDSA: Break it Down/Simplify… 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? We must collect data to understand what REALLY happened. Otherwise, we are making decisions based on what we think happened. What we think and what actually happened aren’t always the same thing!

Build a PDSA Ramp DATA Implement Change: Wide-Scale Tests of Change: Changes That Result in Improvement AIM: Measure for PDSA Ramp: A P S D Implement Change: DATA D S P A This diagram shows the relationship between multiple cycles. The process is iterative with the learning building from one to the other. The slope of the ramp indicates that the cycles are also building in size and scope to increase one’s confidence that the changes will result in the desired improvement. We often begin with ‘1’ – 1 doctor, 1 patient, 1 session, 1 day…as we learn, we expand, we try with different providers, we try on the busiest patient day, we try for a week, etc… On the left, we begin with hunches, theories and ideas. As we move to the right, we have successfully (and sometimes unsuccessfully) completed and learned from PDSA cycles that we have already completed. During this process, we have refined the changes and we have also very probably built confidence and buy in for our changes, which makes moving toward broader implementation easier. It is worth noting that one could test multiple theories, hunches, and ideas at the same time, either addressing the same aim or addressing many different aims. (NB: multiple cycles can be occurring simultaneously. One point to keep in mind: when doing tests, sometimes you will do multiple tests at once and sometimes you won’t. The decision to single out a test and do a staggered approach is usually related to the risk/cost factor – e.g., if you think that something might be having little to no impact, has a negative impact or is expensive, you might want to test it on its own to know the outcome). A P S D Wide-Scale Tests of Change: A P S D Hunches Theories Ideas Multiple PDSA Cycles – Sequential Building of Knowledge – include a wide range of conditions in the sequence of tests before implementing the change Follow-up Tests: Very Small Scale Test:

Failure is just succeeding at learning what doesn’t work! This is really important to remember. In fact, what we saw in October Sky is that the failures probably moved them along faster in understanding how to build a rocket that would have a successful launch. Even if one of their first launches had succeeded, they may not have ended up with the same depth of understanding about why it worked as they did after many failed tests.

Mr. Potato Head, AKA Sam, Exercise 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

Roles 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

Establishing our Baseline 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

Mr. Potato Head Aim Statement 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 Data Sheet PDSA# Theory being tested Prediction   TIME 1 SECONDS 80 70 2 60 50 3 40 30 4 20 10 5 6 PRECISION PRECISION SCORE Write down your theory and a prediction for what will happen on your sheet. 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 Precision 1 - One or more pieces are not on Sam PDSA CYCLE #

Meet Sam

The PDSA Cycle Objective What changes Complete the Carry out the plan Act Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) What changes are to be made? Next cycle? Just like we tested different methods for improving our efficiency and our effectiveness in putting Sam together, we will be using the same process in our practices to test improvement ideas around our ADHD care. What is the workflow that will best support having the initial conversation with parents when a child is diagnosed? What is the process for getting the data into mehealth? How will we make sure we have timely follow-up appts with diagnosed patients? As you begin to come up with ideas for these questions (and other improvement areas), you can begin to plan PDSA cycles for testing. THE PDSA CYCLE: The action portion of the model for improvement. Four parts of the cycle: Plan: Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen? Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test. Do: Carry out the plan. Study: Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test? Act: Given what you learned during the test, what happens next? Have you tested this change enough to feel confident that you can implement it? (Adopt) Will you make refinements to the change and continue testing? Or, will you continue to test on a larger scale? (Adapt) Will you stop testing because you’ve determined the change doesn’t work? (Abandon) Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data

Tips for Testing Changes Stay a cycle ahead Scale down scope of tests – START SMALL Pick willing volunteers (work with those that want to work with you) Avoid the need for consensus, buy-in, or political solutions Replicate changes made elsewhere Pick easy/feasible changes to try Avoid technical slowdowns Reflect on the results of every test (successful AND failed tests) Running small scale tests is critical. Try to break your change idea down into smaller PDSA cycles to test it. Think of dropping down two levels when you plan your test cycle- from years to months, from months to days. Years/Quarters/Months/Weeks/Days/Hours/Minutes Use small scale testing to generate consensus. By testing small scale changes with knowledgeable individuals, we are able to get buy in and see if our ideas work, without a large scale failure. We don’t need consensus here for tests. How would you decide? Multivote? Argue? Let’s run a set of tests if people have more than one opinion. Not having consensus at test time can lead to better learning as more comes from a range of tests. Consensus only needed at implementation time, when we believe we have a lot of evidence for our theory of how the system works. 25

What is Important to Understand About Testing? Change isn’t permanent No support for change beyond test period Learning from testing will be significant—up to 50% of tests not expected to yield improvement Fewer # of people affected by the test (lower risk) It will provide you with the data to prove that a new way works better Implementation still involves testing, but will be over a longer period of time as the stakes are higher. Source: Langley et al. 1996. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. p114.

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