Capitol Region Learning Collaborative Kick-Off Workshop Presented by: Beth Rutkowski, MPH, and Kimberly Johnson, MSEd, MBA April 21, 2009 – Sacramento, California

Adopting Changes in Addiction Treatment One year project funded by the California Endowment A partnership of the Pacific Southwest Addiction Technology Transfer Center, the NIATx National Program Office, and CADPAAC Development of five regional learning collaboratives

Regional Learning Collaboratives: Key Activities One-day kick-off workshop in April/May 2009 Series of monthly conference calls commencing one month following kick-off workshop Ongoing data collection and periodic submission – to measure progress made with change projects

What do we plan to cover today? Key components of the ACTION Campaign and NIATx model of process improvement How to identify key problem areas within your agency Strategies to plan for change and implement rapid cycle improvement projects

How to measuring the impact of change How to brainstorm possible solutions and motivate a change team Next steps and networking opportunities What do we plan to cover today?

Learning Collaboratives

What is a Learning Collaborative? A data driven network of change teams that works collectively to enhance performance. Data Network Change Teams Collective Performance Process Improvement

The Culture of Learning Collaboratives Data Driven Dialogue and Discussion Celebrations

Data-Driven Baseline Data Keep it simple/manageable Sustainability Use existing sources of data Real-time data

Dialogue and Discussion Evidence is that this is how adults learn best Provides for sharing experience and celebrating success Provides for group problem-solving Allows participants to choose what they want to learn and address

Celebrate!

Motivate the Collaborative Members Record and celebrate success (need data) Acknowledge performance of team members, and whole change teams Provide support and share experiences

23 million Americans need treatment 25% are able to access treatment 50% of those in treatment do not complete The way services are delivered is a barrier to both access and retention The Reality SOURCE: Nat’l Survey on Drug Use & Health, SAMHSA, 2006.

At any one time… 110,000 individuals waiting for assessment 42,000 waiting for treatment 32 days from first contact to treatment No-show rates about 50% SOURCE: Survey conducted by Survey Research Laboratory University of Illinois – Chicago, March 2007.

Detox Retention Rate Successful Transfer: 4% Finish Detox, No Transfer: 61% Don’t finish: 23% Transfer, No Connect: 12% SOURCE: Treatment Episode Data Set Admission and Discharge Reports, SAMHSA, 2004.

Residential Retention Rate Finish Treatment No Transfer: 51% Successful transfer: 4% Transfer; No connect: 10% Don’t finish: 34%

Outpatient/IOP Retention Rate Finish Treatment, No transfer: 36% Don’t finish: 51% Successful transfer: 7% Transfer, No Connect: 7%

When we add them together… 170,000 don’t connect to next LOC in 14 days 250,000 not transferred from Detox to next LOC 770,000 leave treatment before goals met 1,190,000 opportunities for improvement?

Luckily, we know a few things about process improvement!

NIATx: Network for the Improvement of Addiction Treatment NIATx teaches behavioral health providers to use a simple process improvement model, developed under the leadership of Dr. Dave Gustafson, to improve access to and retention in treatment for all clients.

NIATx Mission To improve care delivery in order to help people live better lives To become the premier resource for systems and process improvement for behavioral health services

Why Process Improvement? Customers are served by processes. 85 percent of customer-related problems are caused by processes. You must improve your processes to better serve customers. CUSTOMERS = CLIENTS

Why Organizational Change? Small changes do increase client satisfaction. Satisfied clients are more likely to show up and continue their treatment. More clients in treatment make your work more rewarding. More admissions and fewer drop-outs improve the bottom line.

Small Changes, Big Impacts Small changes make a big difference for both clients and staff Effective changes do not have to be expensive

The NIATx Model: An Introduction

Four NIATx Project Aims Reduce Waiting Times Reduce No-Shows Increase Admissions Increase Continuation Rates

NIATx Results Reduce Waiting Times: 51% reduction (37 agencies reporting) Reduce No-Shows: 41% reduction (28 agencies reporting) Increase Admissions: 56% increase (23 agencies reporting) Increase Continuation: 39% increase (39 agencies reporting)

Five Key Principles Understand and involve the customer Fix key problems Pick a powerful Change Leader Get ideas from outside the organization Use rapid-cycle testing

The Business Case: The Sixth Principle Commitment to improving processes can help solve key problems fundamental to organizational performance The ability to operate at a positive margin The ability to attract funding The ability to attract & retain staff members

1. Understand & Involve the Customer Most important of the Five Principles What is it like to be a customer? Your staff can be considered customers, too. Conduct walk-throughs Hold focus groups and do surveys

2. Focus on Key Problems What keeps the CEO awake at night? What processes do staff and customers identify as barriers to excellent service?

3. Powerful Change Leader The Change Leader must have… –Influence, respect, and authority across levels of the organization –A direct line to the CEO –Empathy for all staff members –Time devoted to leading Change Projects

4. Ideas from Outside Organization Real creative problem-solving comes from looking beyond the familiar Provides a new way to look at the problem –Access Walk-in clinics in Wal-Mart –Client Engagement Hair Dressers Coffee Shops –Client Handoffs National Rental Car Hyatt Hotels

5. Rapid Cycle Changes Pilot tests or experiments Two-four week cycles Many small changes can quickly add up to make a big impact

Role of the Executive Sponsor Senior leader in the agency Must see change/improvement as a priority Identifies the problem and articulates the vision Demonstrates commitment to the process (time, resources) Empowers the change leader

Selecting a Change Leader Person has sufficient power and respect to influence others at all levels of the organization. Person has the ability to: instill optimism, has big-picture thinking, is focused and goal-oriented, and has a good sense of humor.

Change Leader Responsibilities Serves as a catalyst to develop ideas Successful communicator: facilitates change team meetings, is consistent, concise (data), creative, engaging (incentives), and a skilled listener. Minimizes resistance to change Keeps the Executive Sponsor updated on change team activities

The ACTION Campaign: An Introduction

What is the ACTION Campaign? The ACTION Campaign provides easily adoptable practices that NIATx members have tested in the field

Why this Campaign? The field is ready for a transformation The ACTION Campaign promotes a set of changes that many organizations in the addiction treatment field are ready to make

An Unprecedented Partnership Leading organizations join to reach the widest possible audience No single organization has ties to all the addiction treatment providers across the country

Our Growing List of Partners American Association for the Treatment of Opioid Dependence Addiction Technology Transfer Centers Faces and Voices of Recovery Join Together Legal Action Center National Association of Addiction Treatment Providers National Association of Alcohol and Drug Abuse Counselors

Our Growing List of Partners National Association of State Alcohol and Drug Abuse Directors National Council for Community Behavioral Healthcare Robert Wood Johnson Foundation State Associations of Addiction Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Treatment Research Institute

The Formula 500 treatment agencies implementing one intervention to increase access, engagement or level of care transition over 18 months will impact 55,000 lives affected by addiction

Three ACTIONs that Make a Difference 1.Provide rapid access to services 2.Improve client engagement 3.Create a seamless transition between levels of care

The ACTION Campaign Join Today!

Why a Walk-through? The walk-through… –Helps understand the customer and organizational processes –Provides a new perspective Allows you to feel what it’s like Lets you see the process for what it is –Seeks out and identifies real problems –Generates ideas for improvement –Keeps you asking why?…and why? again

How to Do a Walk-Through 1.Agency director or executive sponsor plays the role of client and or family member 2.Inform staff and clients if needed, in advance that you will be doing the walk through 3.Encourage staff to treat you as they would a client; no special treatment 4.Think, feel, observe 5.Record observations and feelings 6.Involve staff, get their feedback

The Walk-Through Write-Up First contact First Appointment The Intake Process Transition between level of service - “The Handoff.” What surprised you? What two things would you like to change most?

“E.T. Phone Home” Here is your mission: Call your agency to request an assessment appointment

“E.T. Phone Home” 1.What did you learn? 2.How easy was it to reach a live person? 3.How were you greeted? 4.What information was requested? 5.How long was the wait for the next available appointment? 6.What would you change?

Sample Walk-Through Results Strengths No waiting Efficient intake process Positive group experience Friendly staff

Sample Walk-Through Results Opportunities Long intake process Lots of paperwork No privacy No family services

Quick Start Road Map A graphic series of steps to make it easier to plan and implement a change Steps divided into management and change team responsibilities Assures that critical steps in the process will not be skipped

Quick Start Road Map Management responsibilities: 1.Do a needs assessment and identify a problem important to management Walk-Through Focus Groups Existing Data 2.Establish a target objective Achievable Specific Measurable

Quick Start Road Map Management responsibilities: 3.How will the change be measured? Simple Quick Accessible Who can record the data? How frequently can it be gathered and summarized? TIP: Data driven decisions are more objective and more readily accepted TIP: Without data you have no way to gauge the success or effectiveness of a new practice

4.Who will be on the Change Team? Change Leader 3-5 Members Work together until success is achieved 5.Instructions for the Team Clear statement of problem with data Clear objective Priority for improvement Promise of support and commitment Quick Start Road Map Management responsibilities:

Plan Define the change behaviorally… precisely what will be done? Who will implement the change? What preparation needs to be done before starting the change? Clarify who will measure the change and who will review the data regularly to share with the team.

Do Note the exact start date for the cycle How long will the initial test last? How often will the team meet to assess progress and review data? During the test, the team considers what improvements might need to be made to improve the results

Study After the agreed upon test period the team reviews the results Change leader (or designated change team member) assembles and graphs the data for the team The team deliberates what it has learned Based on the learning, the team considers whether a change in strategy is in order

Act (Adopt, Adapt, Abandon) In light of what has been learned, the team decides what to do next –Make an adjustment in the strategy to get closer to the objective –Increase the objective (adapt) if the initial target has been met and the team believes even more progress can be made –Combine another change (adapt) with the existing strategy to start a new cycle –Abandon the existing strategy and start a new cycle

It is important to remember… It often takes more than one cycle to achieve your objective. By changing only 1 thing at a time you know the impact of your change. Sometimes several changes are necessary to maximize the improvement you seek.

Rapid-cycle Testing Start by asking five questions: 1.What’s it like to be our customer? 2.What are we trying to accomplish? 3.How will we know if a change is an improvement? 4.What changes can we test that may result in an improvement? 5.How can we sustain the improvement?

Making Changes PDSA Cycles –Plan the change –Do the plan –Study the results –Act on the new knowledge Adapt Adopt Abandon

Process Improvement Hunches Theories Ideas Changes that Result in Improvement AP SD A P S D AP SD D S P A DATA SOURCE: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

The Airplane Exercise Description: A small group activity to demonstrate use of the PDSA cycle Objective: Learn how to use the PDSA approach with a team in order to achieve a specific aim

The Airplane Exercise – Instructions 1.PLAN: Design a paper plane using the materials provided. Set an aim and measure for your team – what do you want to accomplish? 2.DO: Choose one person to be the flier. Have them make three flights. 3.STUDY: After each test flight, the data coordinator should measure the distance the plane traveled down the runway and record this on the change project form. Calculate the average distance for the three flights. 4.ACT: Based on the measurements, review the design of your plane and look for improvements (what can we do that will result in an improvement). Make just ONE change to the design of the plane, and repeat steps 1-4 until you have collected data for 3 cycles (original design cycle + 2 change cycles).

The Importance of Data

Power of Two

How does that translate to measuring the impact of change? 1. Number of First Contacts 2. Number of Assessments 3. Elapsed Time 4. Assessment Conversion 1. Date of First Contact 2. Date of Assessment

How does that translate to measuring the impact of change? 1. Number of Clients w/First Treatment Session 2. Number of Clients w/Fourth Treatment Session 3. Elapsed Time between First and Fourth Treatment Sessions 4. % of Clients w/1 st Treatment Session who get a 4 th Treatment Session 1. Date of First Treatment Session 2. Date of Fourth Treatment Session

How does that translate to measuring the impact of change? 1.Three Counts 2.Two Conversion Numbers 3.Three Elapsed Time Figures 1. Date of First Contact 2. Date of Assessment 3. Date of Admissions

Why Is Data So Important?

Principle #5: Rapid-Cycle Testing Start by asking 3 questions –What are we trying to accomplish? –How will we know the change is an improvement? –What changes can we test that will result in an improvement? SOURCE: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

7 Simple Rules of the Road Define measures Collect baseline data Establish a clear aim Consistent collection Avoid common pitfalls Report and Chart progress Ask questions

Rule 1: Define Measures Establish clear definitions Clarify project aims Agreed upon by key stakeholders

Establishing Clear Definitions Example suggested measures –Time from First Contact to Assessment –# of clients attending assessment/intake appointment –% of clients attending their 1 st four post-admission sessions Measure definition –Elapsed Time from Date of Assessment (–) Date of 1 st Contact –# of clients with scheduled assessment/intake appointment (–) # of clients who actually attend assessment/intake appointment –# of clients with four post-admission sessions (/) # of admissions

Rule 2: Establish a Baseline Never start a project without it Define a clear starting point Use agreed-upon definition StartFinish

Baseline Data Serve as a meaningful “road map” Helps answer the question: “How will we know a change is an improvement?” Use tools to collect a adequate baseline information The time period for the baseline will vary by –Measure –Agency’s size –Ease of Collection Preferred Sample Size is at least 40

Baseline Data Examples Average time from 1 st Contact to Assessment is 35 Days 40% of our assessments are no-shows Only 30% of our clients receive four units of service in 30 days Only 25% of Detoxification Discharges connect with the next level of care

Rule 3: Establish an aim Be flexible –Information suggests changing the aim, change it –Aim is too ambitious, set a realistic aim that still challenges the agency to improve –Aim is easily achieved, set a more ambitious aim that stretches the agency’s capacity to improve

Defining Your Project Aim: The Good and the Bad No: ↑ % of RES Discharges to OP by 20% Yes: ↑ Successful RES Discharges to OP from 40 to 48% No: ↓ Assessment No-Shows by 40% Yes: ↓ Assessment No-Shows from 60 to 36% No: ↓ Time from 1 st Contact to Assessment by 20 days Yes: ↓ Time from 1 st Contact to Assessment from 28 to 7 days

Rule 4: Consistently Collect Data The length of time necessary to test a change will vary depending on an agency’s size. Devise ways to collect information but remember KEEP IT SIMPLE Collect small samples over short time periods –Next 10 clients –Next 15 phone calls –Measure impact in days not weeks or months –Preferred sample size is at least 40 –Pilots should not last more than a month Once change is successful, collect larger samples to verify progress –Track clients admitted next week –Examine data for one month

Rule 5: Avoid Common Pitfalls 1.Events occurring before their time 2.Sequential events occurring in order but with long lag times 3.Sequential events occurring out of order 4.Missing dates 5.Cell contains characters 6.Incorrect recording of dates

Dates before their time Dates out of sequence Long lag times

Stay out of the Quicksand Don’t collect too much data Don’t focus on too many measures Don’t get trapped in analysis paralysis

Rule 6: Report and Chart Progress A Simple Axiom: One chart, one message Charts can be used to: –Highlight the baseline (pre-change) data –Identify when a change was introduced –Visually represent the impact of individual changes over time, and –Inform your agency about sustaining change over time

Sample Chart

Rule 7: Ask Questions Do not accept results at face value Do the results look right? What is the data telling us? Unsuccessful changes afford the opportunity to ask Why?

Data Summary Determine what you will measure Establish a system to collect key data elements Gather your baseline Define your aim Collect data often and consistently Evaluate the impact –One chart, one message –Ask questions

The 12 ACTION Kits Provide Rapid Access to Services Engage Potential Client on 1st Call Express Check-In Increase Efficiency and Capacity Where is the Front Door? Improve Client Engagement Make Clients Feel More Welcome What's In It For Me? Use Confirmation Systems That Work Counselor Feedback Create Seamless Transitions Between Levels of Care Make Connections with the Next Level of Care Express Check-In and Check-Out Introduce Clients to Ongoing Supports Evaluate the Hand-Off

Change Project Form Details the “project charter” –Chosen aim, baseline, change team members, agency demographics, etc. Helps to track progress with change project (PDSA cycles) Provides space for lessons learned, business case, and sustainability plan

Quick Start Road Map Change Team responsibilities: 6.Collaborate on what contributes to the maintenance of the problem Agency processes Variability in staff performance External situation or factors Service design Unclear expectations Lack of knowledge or skill Agency policy Others?

Quick Start Road Map Change Team responsibilities: 7.What changes might achieve the objective? Be creative, think “outside the box” Brainstorm/Nominal Group Technique Gather information from other treatment agencies Assess how other industries deal with this problem 8.Prioritize the ideas and select a strategy

Quick Start Road Map Change Team responsibilities: 9.Outline the process to be used What will be done? Who will be responsible at each step? What resources are needed to implement the change? 10.What data will be gathered to assess progress? What measures will be used? Who will gather the data? Who will review and analyze the data?

Quick Start Road Map Change Team responsibilities: 11.How will progress be monitored? Who will monitor fidelity with the planned change? How will mid-course adjustments be made? Who will gather data and chart progress? How often will the Team meet to assess progress and determine need for modifications? 12.Who will maintain a record of Team deliberations, decisions and steps taken?

Nominal Group Technique Silent Writing Each person share one solution Are there any missing? Get out the vote! Top three Where do we begin?

Keys to Change Project Success 1.Have a clear objective 2.Implement only 1 new thing at a time 3.Make sure everyone implements change as planned 4.Start small 5.Study the results before making modifications 6.Do not hesitate to start a new cycle

So, making changes in service processes can improve your… Financial bottom line Organizational climate Relationship with referral sources Staff retention Client satisfaction Treatment outcome Other indicators important to agency

Capitol Region Learning Collaborative Discussion: What are our goals? How do we want to accomplish them? What are the next steps?

Next Steps Conducting agency walk-through Scheduling monthly learning collaborative conference calls Data submission via the ACTION Campaign website Participating in evaluation activities Opportunities for ongoing technical assistance

Contact Us! Beth Rutkowski ; Kim Johnson

Thank you for coming!