WA HIV-STIC Kick-off February, 2012 Elizabeth Strauss, NIATx PI Coach Reduce Waiting & No-Shows  Increase Admissions & Continuation

Current State Desired Future The Change Process 1. Your Name/Organization/Role 2. If the bike represents your organization’s current “change process”, what part of the bike are you?

AGENDA Implementing SHIELD for HIV Prevention Introduction to Process Improvement Experience Rapid Cycle Testing How can the NIATx Way help with the implementation of SHIELD? NIATx Tools: –Nominal Group Process –Aim Measures and Cycle Measures –Change Project Form –Flowcharting What’s next? Closing

The Network for the Improvement of Addiction Treatment (NIATx) Started in 2003 with 13 substance abuse treatment provider organizations, funded by RWJF and SAMHSA/CSAT Today, nearly 1000 payers and providers participating in initiatives in 50 states

NIATx Provider Results Reduce Waiting Times: 23.6% reduction (82 change projects in 34 agencies) Reduce No-Shows: 32% reduction (51 change projects in 29 agencies) Increase Admissions: 25.3% increase (52 change projects in 25 agencies) Increase Continuation: 13.5% increase (102 change projects in 34 agencies) (As of November 2006)

SAMSHA Targeted Capacity Expansion/HIV Program AIM: Increase admissions, HIV testing, follow- up/continuation in HIV programs. (17 sites) RESULTS: Increase from 30% to 90% of clients attending next 4 sessions after intake (LA, CA). Increase from 10% to 80% of clients agreeing to HIV testing (Newark, NJ). Increase from 44% to 100% of clients completing intake/assessment (Detroit, MI).

Denver Public Health Infectious Disease Clinic Referral Process Increased the number of HIV+ patients referred to OP Behavioral Health Services from 1/month to 1- 2/week

Denver Public Health Infectious Disease Clinic Referral Process CHANGES: –Offered weekly groups for HIV+ patients, publicizing with flyers, posters, and tickets at the ID Clinic and Primary Care Clinic. –Did outreach to individuals. –Scheduled appointments rather than having walk-ins. –Social Workers from the ID Clinic held monthly meetings with ID Clinic, PCC, and OBHS staff to provide education about services available for HIV+ patients.

The Network for the Improvement of Addiction Treatment (NIATx) Applied the access and retention aims to Corrections Used the NIATx Way for Prevention Implemented Evidence-Based Practices using the NIATx model

HIV Services and Treatment Implementation in Corrections (HIV-STIC) NEW - Apply the NIATx Way to: –HIV Services in Corrections –HIV Prevention –Implementing an Evidence Based Practice -- SHIELD

11 1.Conduct implementation research on how to more effectively implement and sustain improvements in the HIV Services Continuum for offenders under correctional supervision 2.Evaluate relative effectiveness of a local change team process improvement approach for improving HIV service implementation in criminal justice settings Overall Research Goals

12 Randomized design (matched pairs of facilities) will compare HIV implementation and service outcomes in facilities using a local change team/process improvement approach to control sites receiving baseline training only 4 facilities/sites per Research Center; 36 facilities total Each agency (through Executive Sponsor) selects an area of HIV services continuum and instructs facilities to improve these services Control sites receive training and access to resources, and staff is charged with improving HIV services Experimental sites receive same training and resources as Controls PLUS local change team process improvement approach with a Coach

Why Process Improvement? Customers are served by processes 85% of customer related problems are caused by organizational processes To better serve customers, organizations must improve processes

What is Process Improvement? An experiment in change… using a structured process, guided by the customer, driven by data Based on the Model For Improvement in The Improvement Guide, by Langley, Nolan, Nolan, Norman, & Provost

Five Key Principles Evidence-based predictors of change Gustafson and Hundt, Understand & Involve the Customer 2.Focus on Key Problems 3.Appoint an Influential Change Leader 4.Seek Ideas from Outside the Organization 5.Do Rapid-Cycle Testing (PDSA cycles)

1. Understand and Involve the Customer Most important of the Five Principles

1. Understand and Involve the Customer What is it like to be our customer (inmate, patient, client, peer educator)?  Do a walk-through  Flowchart the process  Hold focus groups  Ask the customer

Walk-through Complete a walk-through of the area you are trying to improve 1.Select 2 people to play the roles of inmate and friend. 2.Let staff know in advance. 3.Act as if you were a typical inmate. 4.Observe and record your experiences and feelings. What barriers, discomfort, information gaps, positive experiences are there? Ask staff what changes would make their job easier or make it better for inmates. 5.Make a list of the areas that need improvement and specific changes you would want to make.

2. Focus on Key Problems –What keeps the Executive Sponsor awake at night? –What processes have staff and customers identified as barriers to prevention education?

3. Appoint an Influential Change Leader Who has:  Influence, respect and authority across levels of the organization  A direct line to the Executive Sponsor  Empathy for staff and customers  Time available to lead change projects  No fear of data  Enthusiasm

4. Seek Ideas from Outside the Organization To provide new ways of looking at the problem What can be learned from other organizations and businesses?

5. Do Rapid-Cycle Testing Rapid-Cycle changes  Are quick, small, do-able in 2 weeks PDSA cycles  Plan the change  Do the plan  Study the results  Act on the new knowledge (adapt, adopt or abandon) Plan Do Study Act

The role of data (and graphs) in decision-making Chg 1 Chg 2 Chg 3 Month

Model for Improvement 3. What CHANGES can we make that will result in an improvement? 1. What are we trying to accomplish? (AIM) 2. How will we know that a change is an improvement? (MEASURE) Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide Plan Do Study Act 4. How can we sustain the improvements?

What makes this approach to change different? The customer is involved Change is a big experiment No mistakes, no right or wrong Data tells you if the change was an improvement

Who’s Who in Process Improvement? The Executive Sponsor articulates the vision and removes barriers to change. The Change Leader provides day-to- day leadership with energy and enthusiasm to motivate and empower the Change Team. The Change Team plans and implements change cycles.

The Change Leader Facilitates change team meetings Supervises changes and helps team with implementation issues Is empowered to overcome barriers to implementation of change experiments Supervises measurement, compilation and interpretation of data Keeps executive sponsor aware of change team activities

The Change Team A small group of 5-7 people designated by the Executive Sponsor to work on a specific area for improvement (i.e. a change project focused on 1 aim)

The Change Team Plans and implements change cycles Identifies possible changes that could improve the aim Decides how to implement the change Creates and conducts rapid cycle pilot tests until the goal is achieved Collects data Studies results to see if the change should be adopted, adapted or abandoned

What Change Teams Say Rapid cycle testing has given us the opportunity to see that even small changes can have a large impact. Analyze your data - it can tell you what the problem is - it’s continuous - Turn to Data to Indicate Need for Change & Problem Solving. Successful collaboration leads to better client outcomes.

What Change Teams Say In addition to favorable results directly related to the change, we had an unintended positive side effect: Increased client return rate… from 76% to 85%, saving counselor time. Taking time to study the results and process how each member of the team felt about results helped to support decisions. “The walk-through opens your eyes to what a client goes through—invaluable.” Used “WALK THROUGH” for other processes.

Experience small scale, rapid PDSA cycles The Ball Pass Exercise

Model for Improvement 3. What CHANGES can we make that will result in an improvement? 1. What are we trying to accomplish? (AIM) 2. How will we know that a change is an improvement? (MEASURE) Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide Plan Do Study Act

The Ball Pass Exercise AIM: to pass the ball from person to person as quickly as possible. RULES: –Only one person may touch the ball at a time; each person must touch the ball with both hands. –The ball must be passed to a person who is not right next to you. –The cycle begins when the Change Leader passes the ball the first time and ends when the Change Leader has the ball at the end.

The Ball Pass Exercise Select a: –Change Leader –Data Recorder Cycle #1 (baseline): –Stand in a circle. –The Change Leader passes the ball to another person in the circle who is not next to them. –Each person passes the ball to another person who is not right next to them; when everyone has touched the ball, pass it back to the Change Leader. –The data recorder documents the time from the beginning to the end of the cycle (baseline data).

The Ball Pass Exercise Conduct at least 3 PDSA cycles –PLAN: What can we do to reduce the time required? –DO: Implement the change and measure how long it takes. –STUDY: Did we get the results we expected? Was the change implemented as planned? –ACT: Adopt, adapt or abandon this change idea and decide what the next cycle will be. –Repeat another PDSA cycle.

The Ball Pass Exercise Tell your story: Create a graph to show the data for each PDSA cycle, noting the change that was made for each cycle.

The Ball Pass Exercise Discussion Questions: How did you decide on a change? Were you able to implement one change at a time? Did you decrease the amount of time required? Why is it important to collect baseline data? What changes were most effective?

How can the NIATx Way help with the implementation of SHIELD?

 Recruitment  Intervention sessions  Participant retention  Maintenance/Sustaining SHIELD

Model for Improvement 3. What CHANGES can we make that will result in an improvement? 1. What are we trying to accomplish? (AIM) 2. How will we know that a change is an improvement? (MEASURE) Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide Plan Do Study Act

Nominal Group Process to brainstorm change ideas and assign priorities STEP 1: Preparation (clarify objective, prepare question, prepare meeting room) STEP 2: Silent idea generation STEP 3: Round-robin recording of ideas STEP 4: Serial discussion of ideas STEP 5: Preliminary voting STEP 6: Discussion of preliminary voting STEP 7: Final voting

Encourage creative thinking!

Nominal Group Process to brainstorm change ideas and assign priorities STEP 1: Preparation STEP 2: Silent idea generation STEP 3: Round-robin recording of ideas STEP 4: Serial discussion of ideas STEP 5: Preliminary voting STEP 6: Discussion of preliminary voting STEP 7: Final voting

Model for Improvement 3. What CHANGES can we make that will result in an improvement? 1. What are we trying to accomplish? (AIM) 2. How will we know that a change is an improvement? (MEASURE) Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide Plan Do Study Act

SHIELD AIM Measures SHIELD Pre-Post Assessment Form (Appendix 8) will measure: Communication Behaviors Knowledge Peer educator self-efficacy Social network

Aim Measures vs. Cycle Measures How will you know if a change is an improvement? Recruitment Participant retention

How to begin The Change Project Form Complete page 1, the Project Charter

Flowcharting Flowcharts force an organizational focus on process.

Why Flowchart? Flowcharting is useful for: 1.Providing a starting point/baseline view 2.Understanding the process 3.Identifying key problems/bottlenecks 4.Showing where to test ideas for most impact 5.Stimulating thinking - results in brilliant ideas 6.Adding interactivity & fun - gets the team together 7.Creating a simple & succinct visual process overview

Key Questions for Flowcharts Is the name of process clear? Where does the process begin? Where does the process end? What does the process include/not include?

Key Symbols for Flowcharts ? No Yes A square identifies a step in the process A diamond is a decision point in the process and asks a “yes or no” question or offers a choice of direction in the process. Action Post-It Notes are great for flowcharting.

What’s next? Do a walk-through Collect baseline data Set up a regular time for the Change Team to meet

For more information NIATx e-Learning Course: Process Improvement 101