ADHD Pathway Team
Lead - Noreen Ryan, Consultant Nurse
Cath Ashworth, NurseSteve Worswick, Nurse
Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician
Anita Wood, Clinical Support
170 cases per annum
Time from Choice to 1st
Diagnosis Point
10 weeks
: A.D.H.D. Pathway
ADHD Pathway Team
Lead - Noreen Ryan, Consultant Nurse
Cath Ashworth, NurseSteve Worswick, Nurse
Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician
Anita Wood, Clinical Support
170 cases per annum
Time from Choice to 1st
Diagnosis Point
10 weeks
: A.D.H.D. Pathway
Reduced Use of Complex
Assessment(CAMHS Day
Unit)
ADHD Pathway Team
Lead - Noreen Ryan, Consultant Nurse
Cath Ashworth, NurseSteve Worswick, Nurse
Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician
Anita Wood, Clinical Support
170 cases per annum
Time from Choice to 1st
Diagnosis Point
10 weeks
: A.D.H.D. Pathway
Reduced Use of Complex
Assessment(CAMHS Day
Unit)
Improved Waiting Time to
Complex Assessment
•Referral to ADHD ASSESSMENT pathway•Choice clinician•Consent to contact school for school report and observation•Conners questionnaire
At Choice
•CST request and score questionnaires•School report request primary proforma, teacher Conners questionnaire and teacher SDQ• School report request secondary 'round robin', teacher Conners questionnaire and teacher SDQPost Choice
•School observation and short 10 point Conners•Contact with teacher and•Collect school report and teacher Conners and SDQ
School Observation
•Review of file and allocated to clinician•Developmental interview using proforma , observation of child and review of all information•Diagnosis of ADHD remain on ADHD pathway•Further school liaison completion of the CHATTI questionnaire•No diagnosis consider whether day unit assessment appropaiate or other pathway
Initial Interview
: A.D.H.D. Pathway
0
5
10
15
20
25
30
35
40
Parent Conners
Parent SNAP
Self Conners
School Conners
School SNAP
School Report
Completed Questionnaires
Yes No N/A
: A.D.H.D. Pathway
So how did we apply LEAN thinking?
• ‘Whole Service Change’ vs. change in a single area or process– Must adhere to the goals of the whole CAMHS Vision and Strategy
– Must be part of a number of linked improvement events
– Achieving sustainable, measurable change over time
• Focused on ALL MEDICATION prescribed in CAMHS
• BUT ‘Psychopharmacological treatment for A.D.H.D. approximately 60% of CAMHS prescribing
• To achieve through a Rapid Improvement Event – A 3 day event that achieves rapid measurable change
: A.D.H.D. Pathway
Rapid Improvement Event (RIE)?
• STEP ONE:
1. Agree the need
2. Develop the accompanying A3 including the aims of the Rapid Improvement Event, Initial and Target State
: A.D.H.D. Pathway
1. Reason for Action
Context: Therefore improvements are required to:
No GoGo
a
b
c
d
Constraints:
A Five year Vision and Strategy for CAMHS
The primary drivers for service development and direction over the next 5 year period:
Local Drivers:- The organisational ‘true north’ goals, improved health, best possible care, value for money, joy and pride- Making it Better
Regional Drivers:- CAMHS network - CAMHS tier IV Commissioning review- CSIP NW.
National Standards:- The NSF standard 9- NICE
- Policy Drivers:- Improving access to psychological therapies (IAPT), - Pushed / Out of the Shadows, - Every Child Matters
To become a patient driven service whereeffective user involvement drives servicedevelopment and cost effective delivery(Value for Money):
Achieving a comprehensive CAMHS asdescribed in the National ServiceFramework Standard 9* (*NICE guidelines)(Best Possible Care)
To be a CAMHS service that activelysupports, challenges and develops itsworkforce in a positive and forwardthinking manner within an environment fitfor purpose (Joy and Pride):
To provide effective child and adolescentmental health services to vulnerablechildren (e.g. Looked After Children,Children with learning disabilities andchildren within paediatric services, BMEcommunities. (Improved Health)
Multiple competing drivers, present CAMHS staff ratios below nationally recommended levels (15 wte per 100,000: 39.4 wte vs. 28.4wte, multi-agency commissioning context, limited to nil opportunity to income generate due to no PBR Child Mental Health Tariff, recent excessive staff turn-over and present process of multiple recruitment
Go
1. Reason for Action
Context: Therefore improvements are required to:
No GoGo
a
b
c
d
Constraints:
ISIP – trust savings plan, (get details) Cost savings – 80% of non salary budget devoted to medication spend approx £30,000 per year (Value for Money)
Reducing CAMHS medication errors, in line with high risk audit strategy (Joy and Pride)
The patterns of prescribing are non standard both for disorder and drug type
To consider the role of non-medical prescribers within the CAMHS department
Standard work around process of identification, assessment, monitoring, psycho-education, initiation (Joy and Pride)
All within the context of NICE guidance on ADHD, Depression, Schizophrenia, PTSD, Anxiety, OCD, etc. (NSF compliance, Best Possible Care) and the organisation’s focus on services that are compliant with the standards outlined in the NICE guidelines
? Effective use of present resources to improve this aspect of service / intervention
Non standard monitoring, management and response to side effects (Improved Health)
CAMHS Vision & Strategy
Patient driven goal, inclusion of young people (? Day unit) and parent / carer
Trust – BICS programme and true north goals, world class services for children
CSM advice re: antidepressants
Specialist nature of what CAMHS prescribe
Role of GPs (communication) standardised, shared care plans
Within present resources,
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
)
nnd
tt
sm
rdo-
hipnrd
tin
anve
S
d
Bn
dv
n rio tod
e wit
a Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
1. Reason for Action
Context: Therefore improvements are required to:
No GoGo
a
b
c
d
Constraints:
ISIP – trust savings plan, (get details) Cost savings – 80% of non salary budget devoted to medication spend approx £30,000 per year (Value for Money)
Reducing CAMHS medication errors, in line with high risk audit strategy (Joy and Pride)
The patterns of prescribing are non standard both for disorder and drug type
To consider the role of non-medical prescribers within the CAMHS department
Standard work around process of identification, assessment, monitoring, psycho-education, initiation (Joy and Pride)
All within the context of NICE guidance on ADHD, Depression, Schizophrenia, PTSD, Anxiety, OCD, etc. (NSF compliance, Best Possible Care) and the organisation’s focus on services that are compliant with the standards outlined in the NICE guidelines
? Effective use of present resources to improve this aspect of service / intervention
Non standard monitoring, management and response to side effects (Improved Health)
CAMHS Vision & Strategy
Patient driven goal, inclusion of young people (? Day unit) and parent / carer
Trust – BICS programme and true north goals, world class services for children
CSM advice re: antidepressants
Specialist nature of what CAMHS prescribe
Role of GPs (communication) standardised, shared care plans
Within present resources,
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
devoted to medication spend approx £30,000 per year (Value for )
nnd
tt
sm
rdo-
hipnrd
tin
anve
S
d
Bn
dvice re: antidepressants
n rio tod
e wit
b Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
1. Reason for Action
Context: Therefore improvements are required to:
No GoGo
a
b
c
d
Constraints:
ISIP – trust savings plan, (get details) Cost savings – 80% of non salary budget devoted to medication spend approx £30,000 per year (Value for Money)
Reducing CAMHS medication errors, in line with high risk audit strategy (Joy and Pride)
The patterns of prescribing are non standard both for disorder and drug type
To consider the role of non-medical prescribers within the CAMHS department
Standard work around process of identification, assessment, monitoring, psycho-education, initiation (Joy and Pride)
All within the context of NICE guidance on ADHD, Depression, Schizophrenia, PTSD, Anxiety, OCD, etc. (NSF compliance, Best Possible Care) and the organisation’s focus on services that are compliant with the standards outlined in the NICE guidelines
? Effective use of present resources to improve this aspect of service / intervention
Non standard monitoring, management and response to side effects (Improved Health)
CAMHS Vision & Strategy
Patient driven goal, inclusion of young people (? Day unit) and parent / carer
Trust – BICS programme and true north goals, world class services for children
CSM advice re: antidepressants
Specialist nature of what CAMHS prescribe
Role of GPs (communication) standardised, shared care plans
Within present resources,
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
)
nnd
tt
sm
rdo-
hipnrd
tin
anve
S
d
Bn
dv
n rio tod
e wit
c Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
1. Reason for Action
Context: Therefore improvements are required to:
No GoGo
a
b
c
d
Constraints:
ISIP – trust savings plan, (get details) Cost savings – 80% of non salary budget devoted to medication spend approx £30,000 per year (Value for Money)
Reducing CAMHS medication errors, in line with high risk audit strategy (Joy and Pride)
The patterns of prescribing are non standard both for disorder and drug type
To consider the role of non-medical prescribers within the CAMHS department
Standard work around process of identification, assessment, monitoring, psycho-education, initiation (Joy and Pride)
All within the context of NICE guidance on ADHD, Depression, Schizophrenia, PTSD, Anxiety, OCD, etc. (NSF compliance, Best Possible Care) and the organisation’s focus on services that are compliant with the standards outlined in the NICE guidelines
? Effective use of present resources to improve this aspect of service / intervention
Non standard monitoring, management and response to side effects (Improved Health)
CAMHS Vision & Strategy
Patient driven goal, inclusion of young people (? Day unit) and parent / carer
Trust – BICS programme and true north goals, world class services for children
CSM advice re: antidepressants
Specialist nature of what CAMHS prescribe
Role of GPs (communication) standardised, shared care plans
Within present resources,
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
)
nnd
tt
sm
rdo-
hipnrd
tin
anve
S
d
Bn
dv
n rio tod
e wit
d Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 25%
So what’s a Rapid Improvement Event (RIE)?
• STEP TWO:
Gather pre-event data:
1. Standard Service Data• Referral data• Disorder / diagnosis• Audit data re: NICE• Medication costs• Medication errors
2. Non - Standard Service Data• Young people and parents / carer
information
3. National & Service Guidelines • NICE, Good Practice guidelines etc.
: A.D.H.D. Pathway
So what’s a Rapid Improvement Event (RIE)?
• STEP TWO:
Gather pre-event data:
1. Standard Service Data• Referral data• Disorder / diagnosis• Audit data re: NICE• Medication costs• Medication errors
2. Non - Standard Service Data• Young people and parents / carer
information
3. National & Service Guidelines • NICE, Good Practice guidelines etc.
Part one of ‘meaningful’ service user involvement
Standard S
P
se
: A.D.H.D. Pathway
Initial State No GoGo
Benefits to customers:
Improved Health improved compliance by 5%
Best Possible Care improve to a minimum of 95%
Joy and PrideSatisfaction improvement 25%
Value for Money Reduce drug expenditure 10%
a b
c d
0
50
100
Compliance
Pre RIE
Target
Post RIE 0
50
100
NICE Compliance
%
Pre RIE
Target
Post RIE
02000400060008000
10000
Drug Expenditure
Pre RIE
Target
Post RIE0
20406080
YP Inclusion in decision
% Pre RIE
Target
Post RIE
Target State No GoGo
Benefits to customers:
Improved Health improved compliance by 5%
Best Possible Care improve to a minimum of 95%
Joy and PrideSatisfaction improvement 25%
Value for Money Reduce drug expenditure 10%
a b
c d
8082848688
Compliance
Pre RIE
Target
Post RIE 0
50
100
NICE Compliance
%
Pre RIE
Target
Post RIE
7500
8000
8500
9000
9500
Drug Expenditure
Pre RIE
Target
Post RIE0
50
100
YP Inclusion in decision
% Pre RIE
Target
Post RIE
• STEP THREE:
Identify Team Membership:
1. Prescribing Clinicians• Nurse Consultant – Noreen Ryan • Consultant Psychiatrist – Dr Ian Dufton
2. Assessing Clinicians• Case Manager – Fiona Wood• [Consultant Psychologist – Dr Mark
Bowers]
3. Pharmacy • CAMHS Pharmacist – Rebecca Walker 4. Supporting Staff
• CAMHS Manager – Kate McNulty
5. “Fresh Eyes”• Member of the organisation who
doesn’t work in CAMHS
6. BICS team facilitator• Emma Broda
: A.D.H.D. Pathway
• STEP THREE:
Identify Team Membership:
1. Prescribing Clinicians• Nurse Consultant – Noreen Ryan • Consultant Psychiatrist – Dr Ian Dufton
2. Assessing Clinicians• Case Manager – Fiona Wood• [Consultant Psychologist – Dr Mark
Bowers]
3. Pharmacy • CAMHS Pharmacist – Rebecca Walker 4. Supporting Staff
• CAMHS Manager – Kate McNulty
5. “Fresh Eyes”• Member of the organisation who
doesn’t work in CAMHS
6. BICS team facilitator• Emma Broda
Essential Points –
•Multi-disciplinary & Multi-professional
•Cross section of the service and shared ownership of any improvements
: A.D.H.D. Pathway
So what’s a Rapid Improvement Event (RIE)?
• STEP FOUR:
Create Timetable for the EVENT:
Day 1:
Scene Setting Review of dataMapping aprescribing journeyof a patient with ADHDYoung People / CarerForum
Day 2:
Feedback from DayOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
Day 3:
Detail SolutionsCompleteAction /ImplementationPlanComplete ‘Just Do It’actions
: A.D.H.D. Pathway
So what’s a Rapid Improvement Event (RIE)?
• STEP FOUR:
Create Timetable for the EVENT:
Day 1:
Scene Setting Review of dataMapping aprescribing journeyof a patient with ADHDYoung People / CarerForum
Day 2:
Feedback from DayOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
Day 3:
Detail SolutionsCompleteAction /ImplementationPlanComplete ‘Just Do It’actions
Part Two of ‘meaningful’ service user involvement
Create Timetable for the EVENT:
ing data
g journeyyyyyyyyt withh
ple / Carer
Day 2:
FFeeeeeeeeeeeeeeeeddddddddbback from DayOOOOOOOOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
s
: A.D.H.D. Pathway
So what’s a Rapid Improvement Event (RIE)?
• STEP FOUR:
Create Timetable for the EVENT:
Day 1:
Scene Setting Review of dataMapping aprescribing journeyof a patient with ADHDYoung People / CarerForum
Day 2:
Feedback from DayOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
Day 3:
Detail SolutionsCompleteAction /ImplementationPlanComplete ‘Just Do It’actions
Part Two of ‘meaningful’ service user involvement
Creation of a semi-structured interview based on
prescribing journey map
Create Timetable for the EVENT:
ing data
g journeyt with
ple / Carer
Day 2:
Feedback from DaOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
s
Cre
p
: A.D.H.D. Pathway
So what’s a Rapid Improvement Event (RIE)?
• STEP FOUR:
Create Timetable for the EVENT:
Day 1:
Scene Setting Review of dataMapping aprescribing journeyof a patient with ADHDYoung People / CarerForum
Day 2:
Feedback from DayOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
Day 3:
Detail SolutionsCompleteAction /ImplementationPlanComplete ‘Just Do It’actions
Part Two of ‘meaningful’ service user involvement
Creation of a semi-structured interview based on
prescribing journey map
Parent / Carer interviewsYoung People (Under 16 (5)
and aged 16 &17 (2) interviews
Create Timetable for the EVENT:
ing data
g journeyt with
ple / Carer
Day 2:
Feedback from DaOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving
s
Cre
p
PYo
: A.D.H.D. Pathway
Patient driven, user involvement or simply asking young people and families what they think?
Brief main themes from user questionnaires & semi structured interviews
60% of families and young people thought the discussion helpful or very helpful
80% felt involved in the decision to start medication, the remainder in some or most of it.
The majority reported that they felt listened to, that we had helpful conversations about the bad effects as well as the possible benefits of medication
Along with the need to improve inclusion the main complaints focussed on the experience at pharmacy, the ability to use local chemists, better information, resources to help children and young people remember to take medication
: A.D.H.D. Pathway
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people receive effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people recieve effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
benefit from medication (and to do so in a timely
hetoe
erd
ke
e kild dic
): to y
f
timlls afamcat
1)thbe
to 5%
guidelines around the use of medication
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people recieve effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
ceed
mcoe in
d w
sm c
o in a timely
8) No mechanism to determine whether we are prescribing in a cost effective manner
benefit from medication (and to do so
hetoe
erd
keo in a timely a t e y
e kild dic
): to y 5
id li d th f di ti
timls afamcat
1)thbe
to 5%
guidelines around the use of medication
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people recieve effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
mcoce
ede ind w
sm c
o in a timely
8) No mechanism to determine whether we are prescribing in a cost effective manner
benefit from medication (and to do so
hetoe
erd
keo in a timely y
e kild dic
): to y 5
id li d th f di ti
timls afamcat
1)thbe
to 5%
guidelines around the use of medication
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
young perso
support the compliance / concordance with
oen
n (ent c
10) No method to identify / challenge “novel” prescriptions
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people recieve effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
mcoce
ede ind w
sm c
o in a timely
8) No mechanism to determine whether we are prescribing in a cost effective manner
benefit from medication (and to do so
hetoe
erd
keo in a timely y
e kild dic
): to y 5
id li d th f di ti
timls afamcat
1)thbe
to 5%
guidelines around the use of medication
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
young perso
support the compliance / concordance with
onen
n (ent c
10) No method to identify / challenge “novel” prescriptions
n spen
pp pmedication
staeopnt
11) Non standard titrations of medication, query young people receive effective and timely treatment
4. Gap Analysis No GoGo
Reflections:
12) No mechanism for regular and robust child, young person and parent / carer input
a b
c d
0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication
1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)
2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.
6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
8) No mechanism to determine whether we are prescribing in a cost effective manner
3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)
4) Lack of quality materials to support prescribing
5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe
9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication
10) No method to identify / challenge “novel” prescriptions
11) Non standard titrations of medication, query young people recieve effective and timely treatment
Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%
Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication
Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%
Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%
8) No mechanism to determine whether we are prescribing in a cost effective manner
hetoe
e kild dic
): to y 5
id li d th f di ti
timls afamcat
to 5%
guidelines around the use of medication
7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines
support the compliance / concordance with
10) No method to identify / challenge “novel” prescriptions
n spen
pp pmedication
staeopt
11) Non standard titrations of medication, query young people receive effective and timely treatment
about meddiccat clinicians and not linked to NICE
11) Non standard titrations of medication, query young people receive effective and timely treatment
5. Solution Approach
Reflections:
No GoGo
Cause Solution Idea Effecting Themes
Ease Impact Cost
7, 8, 11 Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
A,b,c,d EASY HIGH LOW
5, 8 Write shared care policies for all five classes of medication
MEDIUM HIGH MEDIUM
0, 1 Develop clinician ‘medication packs’ for all five classes of medication to allow non prescribers to adequately inform young people and families
A,d EASY MEDIUM MEDIUM
9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and mandatory)
A,d MEDIUM HIGH HIGH
4,8 Review service relationship with pharmaceutical companies
d MEDIUM MEDIUM LOW
10, 11, 7 Develop clinician psychopharmacology forum including all prescribers (medical and non medical) and pharmacy
A,b,c,d EASY HIGH LOW
Key 0 Easy/High/Cheap ∆ Medium X Hard/low/expensive
a b c d
5. Solution Approach
Reflections:
No GoGo
Cause Solution Idea Effecting Themes
Ease Impact Cost
7, 8, 11 Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
A,b,c,d EASY HIGH LOW
5, 8 Write shared care policies for all five classes of medication
MEDIUM HIGH MEDIUM
0, 1 Develop clinician ‘medication packs’ for all five classes of medication to allow non prescribers to adequately inform young people and families
A,d EASY MEDIUM MEDIUM
9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and manadatory)
A,d MEDIUM HIGH HIGH
4,8 Review service relationship with pharmaceutical companies
d MEDIUM MEDIUM LOW
10, 11, 7 Develop clinician psychopharmacology forum including all prescribers (medical and non medical) and pharmacy
A,b,c,d EASY HIGH LOW
Key 0 Easy/High/Cheap ∆ Medium X Hard/low/expensive
a b c d
e Solution Idea Effee
stimulants and Melatonin)
d
Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
5. Solution Approach
Reflections:
No GoGo
Cause Solution Idea Effecting Themes
Ease Impact Cost
7, 8, 11 Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
A,b,c,d EASY HIGH LOW
5, 8 Write shared care policies for all five classes of medication
MEDIUM HIGH MEDIUM
0, 1 Develop clinician ‘medication packs’ for all five classes of medication to allow non prescribers to adequately inform young people and families
A,d EASY MEDIUM MEDIUM
9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and manadatory)
A,d MEDIUM HIGH HIGH
4,8 Review service relationship with pharmaceutical companies
d MEDIUM MEDIUM LOW
10, 11, 7 Develop clinician psychopharmacology forum including all prescribers (medical and non medical) and pharmacy
A,b,c,d EASY HIGH LOW
Key 0 Easy/High/Cheap ∆ Medium X Hard/low/expensive
a b c d
d
e Sol tion Idea EffeeRewrite protocols for all five
classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
Include Fixed Method Incremental methodologies
5. Solution Approach
Reflections:
No GoGo
Cause Solution Idea Effecting Themes
Ease Impact Cost
7, 8, 11 Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
A,b,c,d EASY HIGH LOW
5, 8 Write shared care policies for all five classes of medication
MEDIUM HIGH MEDIUM
0, 1 Develop clinician ‘medication packs’ for all five classes of medication to allow non prescribers to adequately inform young people and families
A,d EASY MEDIUM MEDIUM
9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and manadatory)
A,d MEDIUM HIGH HIGH
4,8 Review service relationship with pharmaceutical companies
d MEDIUM MEDIUM LOW
10, 11, 7 Develop clinician psychopharmacology forum including all prescribers (medical and non medical) and pharmacy
A,b,c,d EASY HIGH LOW
Key 0 Easy/High/Cheap ∆ Medium X Hard/low/expensive
a b c d
e Sol tion Idea Effee
d
Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)
i
Develop clinician medication packs for all five classes A d
1
y
Week Dosage of methylphenidate (M/R)
Method of Contact and evaluation
1 10mg daily PRN phone adviceshort Conners and side-effect questionnaire
2 20mg daily PRN phone adviceshort Conners and side-effect questionnaire
3 30mg daily PRN phone adviceshort Conners and side-effect questionnaire
The regimes for modified release methylphenidate are as follows: Weightunder 25 Kg
Include Fixed Method Incremental methodologies
: A.D.H.D. Pathway
Example of Standard
Treatment Algorithm
Target State No GoGoImproved Health
improved compliance by 20%Best Possible Care
improve to a minimum of 95%
Joy and PrideSatisfaction improvement 50%
Value for Money Reduce drug expenditure 10%
a b
c d
808284868890
Compliance
Baseline
Target
Repeat 70
80
90
100
NICE Compliance
%
Baseline
Target
Repeat
02000400060008000
10000
Drug Expenditure
10% target0
50
100
YP Inclusion in decision
% Pre RIE
Target
Post RIE
A3 – boxes 1 - 3Re-designing the service along LEAN principles
Other Pathways that have demonstrated improvements in Patient Flow and / or improved
Quality