HIV-STIC November 8, 2011 NIATx Tools for Effective Change Reduce Waiting & No-Shows  Increase Admissions & Continuation

NIATx opportunities for tomorrow Over 13,000 substance abuse treatment providers nationwide. Reduce Waiting & No-Shows  Increase Admissions & Continuation Conducting a Walk Through How does the client experience services?

The walk-through is a cornerstone of NIATx process. A walk-through is an exercise that allows you to experience your services exactly as your customers do.

Why do a walk-through? Value in seeing your services from a new perspective. We make assumptions about how services are being delivered that may not reflect what actually happens. The walk-through can identify low-cost opportunities for improvement that can make a big difference in engaging and retaining clients

How to do a walk-through Plan – let staff know, client and recorder Do – try to think and act as client would Do – ask staff what each step, record your own ideas (no cost improvements) Study – make a list of changes to discuss with team, share results with Executive Sponsor

Act on the Results Discuss how to incorporate relevant change ideas into your project Have the ES decide how to handle ideas not directly related to your project Use PDSA to implement any change that the ES wants to implement immediately Share your lessons learned about doing walk-throughs in your organization

Results of Walkthrough: “low hanging fruit” –Update magazines in waiting room –Inexpensive radio for “tasteful” music –On sale “décor” within budget –Refill cups for water bubbler –“low maintenance” flowers –Bulletin board with program information –Seating for paperwork –Local Commuter Rail & community –How do we give directions to our office? –Get clients involved

Ayer MA DC Process Problems with Admissions Identified “front door problems” = calls for intakes going to voic leading to a delay in services: –phone system needed upgrade –Vacant admin staff position –Under-utilization of centralized scheduling system –Clinicians with low productivity –Missed opportunity to increase business which could help sustain grant funded drug court

NIATx opportunities for tomorrow Over 13,000 substance abuse treatment providers nationwide. Reduce Waiting & No-Shows  Increase Admissions & Continuation Flowcharting

Why Flowchart? Flowcharting is useful for: –Providing a starting point/baseline view –Understanding the process –Identifying key problems/bottlenecks –Showing where to test ideas for most impact –Stimulating thinking - results in brilliant ideas –Adding interactivity & fun - gets the team together –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 stop? What does the process include/not include?

Process Change

Identify Processes to Change Nominal Group Technique

Designed to promote group participation in the decision making process Used by small groups to –Reach consensus on the identification of key problems (NIATx Key Principle 2) or –Develop solutions that can be tested using rapid- change cycles (NIATx Key Principle 5).

Generating Solutions We have done a walk-through We have created a flowchart We have started to identify bottlenecks NOW we need to identify PROBLEMS & SOLUTIONS –NGT can help!!

Seven Steps Preparation (e.g., room and question) Silent idea generation Recording of ideas Idea discussion Preliminary voting Discussion of preliminary voting Final voting on ideas

HIV-STIC November 8, 2011 NIATx Progress Tracking Baseline Data & Measuring Results Reduce Waiting & No-Shows  Increase Admissions & Continuation

Before Making Changes Collect baseline data Determine the target population and location Establish a clear aim Select a Change Leader and the Change Team

Model for Improvement Start by asking three questions: 1.What are we trying to accomplish? 2.How will we know a change is an improvement? 3.What changes can we test? (next Tuesday!) Model for Improvement Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

Executive Sponsor Articulates vision, linking PI efforts to grant goals, strategic plan and the bottom line Engages and empowers Change Leader and Change Team Removes barriers to change

Change Leader Motivates and leads Change Team Catalyst for developing ideas for rapid cycles Sets agenda and facilitates change team meetings Oversees changes and helps team with implementation issues Supervises measurement, compilation and interpretation of data Keeps Executive Sponsor aware of change team activities

Change Team Focuses on one Change Project (1 aim, 1 LOC, 1 location, 1 population) Meets at least every other week Generates ideas for rapid cycle changes

Change Team cont’d Prioritizes, plans and carries-out change cycles until the goal is achieved Collects simple, timely data related to the cycle Decides if the change should be adopted, adapted or abandoned

What do Change Team Members look like? A small group of (~ 5-7) people invited by the Executive Sponsor Court administrators, front line workers, clinicians, judges, supervisors whose work “touches” the process People with special knowledge about the change, e.g. alumni, family members, IT staff, attorneys, police

METHODS OF COLLECTING DATA FOR DECIDING WHAT CHANGE YOU WANT TO MAKE

Model for Improvement Start by asking three questions: 1.What are we trying to accomplish? 2.How will we know a change is an improvement? 3.What changes can we test? (next Tuesday!) Model for Improvement Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

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

Rule 1: Define Measures Establish clear definitions –Continuation or admissions may mean many things Clarify project aim & goal Agreed upon by key stakeholders

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

Rule 3: Establish a Goal –A realistic goal still challenges the agency to improve –Set a goal that stretches the agency’s capacity to improve –If information suggests changing the goal, change it

Rule 4: Consistently Collect Data 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 –Cycles rarely last more than a month The length of time necessary to test a change will vary depending on an agency’s size. Once change is successful, continue data collection to verify progress –Track clients admitted next week –Examine data for one month

Rule 5: Avoid Common Pitfalls Collect only the data you NEED Focus only on measures that relate to your aim Keep collection process as simple as possible Check that everyone understands the collection process --- early and often

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.

Example 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?

Track Change Cycle Data Baseline Data Describe the Change Chart the Results – Post change Study Results Plan next change

Conducting a Change Exercise PDSA cycles  Plan the change  Do the plan  Study the results  Act on the new knowledge Rapid cycle changes  Changes should be doable in 2-3 weeks

Aim: Access for incarcerated referrals – is difficult and time consuming. Change: Judge worked with jail personnel to arrange that clients referred to drug court be brought to the courthouse on the day of drug court. Jail staff always have prisoners to transport. Intake & screening done before and/or after drug court at the courthouse. Results: Client seen sooner, intake person didn’t have to wait at the jail, and the drug court intake process faster. Cooperation between jail, judge, and treatment improve process and client flow Counseling Services, Inc. & York County Adult Drug Court, Maine

Ottumwa Iowa Family Drug Court Aim: improve transfer of clients from Child Welfare to Family Drug Court Change: Add dates to paperwork to track flow, provide training to case workers and identify one person to receives referral forms

Ottumwa Drug Court Results: Total Number of Client Referral Sheets Number of Clients starting Drug Court Cases started prior to adjudication hearing Baseline Data 621 Change Data 1753

MAINE STAR-SI: Learning Collaborative ID of the key focus areas using nominal group technique (NGT) #1 Look at the practice of “giving appointments” to assess clients # 2 Paperwork issues – many – subset of concerns around time to DEEP treatment (OUI programming)

PROJECTDESCRIPTION# OF AGENCIES REPORTING # OF REQEUSTS FOR SERVICE # OF ASSESSMENTS AVG TIME B/T 1 ST PHONE CALL & ASSESSMENT Pre- change: 12/19/06- 1/15/07 Baseline73837 (Show rate=97%) 8.34 days #1: 1/16/07- 2/16/07 Faxing release forms & NEEDS or JASE vs. regular mail (Show rate=86%) 5.84 days #2: 3/5/07- 3/30/07 DEEP office notify providers of process (vs. OSA notification) (Show rate=81%) 7.08 days #3: 8/6/07- 8/24/07 Use multi-party release form, signed by client at 1 st face to face session 8 (2 agencies had 0 clients) 4540 (Unable to calculate show rate) 4.91 days Maine DEEP Change Cycle Data

ME Driver Education & Evaluation Program (DEEP) for OUI offenders Aim: Increase Access Change: OSA Fax paperwork (not mail) Results: Time to treatment dropped 7+ days to 5 No show rates dropped 15% Revenue rose by $24,146 or $313,898/year! OSA began work to diffuse/spread project statewide for all OUI DEEP Program agencies