The Model for Improvement:
The Three Questions
Chapter Quality Network ADHD Project
Jen Powell, MPH, MBA
Objectives
 Outline the 3 components of the Model for
Improvement
 Describe how to conduct rapid cycle testing using
the Plan-Do-Study-Act method
Commercial Interests Disclosure
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.
3
Model for Improvement
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?
Act
Act
Plan
Plan
PDSA CYCLES
Study
From: Associates in Process Improvement
Do
Do
AIM
MEASURES
IDEAS
Three Fundamental Questions for
Improvement
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
SMART AIM
 Specific
 Measurable
 Actionable
 Realistic
 Time-bound
6
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
ADHD Measures
 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%)
Practice Key Driver Diagram
6 Key Drivers
1. Improved
diagnostic accuracy
4. Effective behavior
management
Monitoring and
titrating medications
2.
5. Use of
population health
strategies
3. Effective follow-up
and surveillance for
co-morbidities
6. Peer-to-peer
learning network with
data feedback
ADHD Six Key Drivers
Interventions
Use Parent/Teacher rating
scales to assess med
efficacy and side effects
Registry
Model for Improvement
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?
Act
Act
Plan
Plan
PDSA CYCLES
Study
From: Associates in Process Improvement
Do
Do
AIMS
MEASURES
IDEAS
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
Meet Sam
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
TIME
Prediction
80
70
1
60
50
SECONDS
2
3
40
30
20
10
4
1
2
3
4
5
6
5
6
PDSA CYCLE #
PRECISION
5
Precision
6
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 SCORE
3
2
1
1
2
3
4
PDSA CYCLE #
PDSA: small test of change
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?
Tips for Testing Changes
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
Why is Testing Important?
 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
Source: Langley et al. 1996. The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. p114.
PDSA Cycle Ramps:
Sequential Building of Knowledge
Successive tests of a change
build knowledge AND create a
ramp to improvement
Changes That Result in
Improvement
A P
S D
Implementation of
Change
Best Practice
Evidence
Hunches
Theories
Testable Ideas
Wide-Scale Tests of
Change
A P
S D
Very Small Scale
Test
Follow-up
Tests
The Improvement Guide
Associates in Process Improvement
Objectives
 Outline the 3 components of the Model for
Improvement
 Describe how to conduct rapid cycle testing using
the Plan-Do-Study-Act method