1. (Title) Name(s) of presenter(s) Organizational Affiliation Welcome Fee-for-Service, Level I January 2012 Project Funded by CSAT

2. Welcome Housekeeping Overview Add a slide of your choice and a story

3. Overview What to expect in the next two days? Housekeeping Information to assist you with your comfort

4. 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?

5. Health Care Reform 5 Janet Zwick JBS and NIATx Coach

6. Leading Change: A Plan for Substance Abuse and Mental Health Services Administration (SAMHSA) Roles and Actions 2011 - 2014 Behavioral health is an essential part of health. Individuals and families cannot be healthy without positive mental health and freedom from addictions and abuse of substances. Behavioral health, prevention and treatment services are important parts of health service systems and community-wide strategies that work to improve health status 6

7. SAMHSA Strategic Initiatives Prevention of Substance Abuse and Mental Illness Trauma and Justice Military Families Recovery Support Health Reform Health Information Technology Data, Outcomes and Quality Public Awareness and Support 7 www.samhsa.gov

8. Drivers of Health Care Reform Greater attention to preventing illness and promoting wellness Primary focus is on the prevention of Chronic Illnesses Increased access to care Increased focus on the coordination/integration of services between primary care and specialty services Increased focus on quality and outcomes Increased provider accountability Greater emphasis on home and community based services and less reliance on institutional care (Adapted from SAMHSA, John O’Brien) 8

9. Aims of Health Care Reform Increase the number of individuals that have health insurance Increase accountability through the expansion of primary care, medical homes and accountable care organizations and financing structures Increase access to preventive services to improve health outcomes Combined with parity legislation 9

10. Aims of Health Care Reform (cont.) Expanded Populations –Newly Medicaid Eligible--133% of the Federal Poverty Level (FPL) –Health Insurance Exchange Participants- -Individuals and Families at or below 400% of the FPL 10

11. Implications of Health Care Reform Buy what is good and modern Focus on coordination between primary care and specialty care: –Significant enhancements to primary care Workforce enhancements Increased funding for Federally Qualified Health Centers –Bi-directional MH/SUD in primary care Primary care in MH/SUD settings 11

12. Implications of Health Care Reform (cont.)  More Incentives to identify MH/SUD - SBIRT—huge focus by SAMHSA and HRSA - Coverable service—enhanced Medicaid match More payment strategies Payment on successful episode of care 12

13. How Does Behavioral Health Fit? Become valuable partners with primary care or become one themselves Establish your niche Demonstrate value to insurers, medical providers and others Rapid effective access! Super Easy to work with!

14. Opportunities Opportunity to broaden your financial base Opportunity to have good data to fine tune and improve care Opportunity to partner with primary medical care and improve overall health of your target groups Opportunity to form new alliances and establish community supports for what you do Opportunity to invest in prevention

15. So What Does Health Care Look Like in New Jersey? 15

16. Geography is destiny…….. Why here? Why now? How does geography change your billing destiny? Pair up and share your expectations for the workshop. Add a wild prediction of the best possible outcome for the collaborative should your expectations be met.

17. (Title) Name(s) of presenter(s) Organizational Affiliation NIATx Model

18. "Never invest in any idea you can't illustrate with a crayon." – Peter Lynch

19. E x e c u t i v e S p o n s o r C h a n g e L e a d e r C h a n g e T e a m People W a l k - t h r o u g h F l o w c h a r t i n g N o m i n a l G r o u p T e c h n i q u e P D S A C y c l e Tools Rules Use existing resources Measure change I m p r o v e m e n t Process M o d e l Change Project aim Sustain the gains

20. (Title) Name(s) of presenter(s) Organizational Affiliation Who’s Who in Process Improvement?

21. Executive Sponsor Authority to Allocate Resources

22. Executive Sponsor Responsible for Communicating the Vision Martin Luther King

23. Executive Sponsor Sees change as a priority Barack Obama, President

24. Executive Sponsor Empowers the change leader

25. Change Leader Reggie White Someone who is comfortable providing day-to-day leadership, energy and enthusiasm Has the power and prestige to influence people at all levels of the organization

26. Change Leader Oprah Winfrey Michelle Obama Focuses the team on the change team objective Uses mandates

27. Change Leader Queen Rania of Jordan Challenges the status quo Reports directly to the Executive Sponsor Gets results mandated by data

28. Change Team Members Samaritan Village, Inc. Jamaica Outpatient Program Staff and supervisors in the work area where changes will be made Customers, family, caregivers People with special knowledge Others who are affected by the change

29. Change Team Responsibilities Identify possible changes that could meet the objective Decide how to implement the change Create and conduct rapid-cycle pilot tests until goal is achieved Collect data Study results to see if the change should be adopted, adapted or abandoned

30. Key Roles: Change Team AIM LOCATION POPULATION

31. What makes this approach to change different? Change is a big experiment No mistakes, no right or wrong Data tells you if the change was an improvement Customer guides change ideas

32. To often we design processes to meet the organization’s needs and not the needs of the customer.

33. Plan Do Study Act Using Rapid Cycle Testing Why? Evaluate the impact of potential changes on a given aim

34. Model for Improvement 3. What changes can we make that will result in an improvement? 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide P D S A

35. Learning Objectives Participants will: Understand the basic concepts of a rapid cycle change using the Plan-Do-Study-Act approach to process improvements. Practice entering information on the Change Project Form.

36. 1. CHANGE PROJECT TITLE Going the Distance 2. What AIM will the Change Project address? Choose one aim and indicate baseline measure and target. Increase flight distance of our plane Increase the distance the paper airplane flies by 25% over the baseline distance of _10_ feet. 4. START DATE and expected completion date 7. EXECUTIVE SPONSOR Mary Adams 8. CHANGE LEADER Jane Smith 9. CHANGE TEAM MEMBERS Carla, Sam, Terri, John (Jerry is our data coordinator) Name of Organization: Wing and a Prayer Airlines, Inc.

37. Rapid Cycle # Cycle Begin Date 2010 Cycle End Date 2010 Plan What is the idea/change to be tested? Do What steps are you specifically making to test this idea/change? Who is responsible? Study What were the results? How do they compare with baseline measure? Act What is your next step? Adopt? Adapt? Abandon? B 11/2 11/2 The team will design/build one paper airplane. Fly the plane to see how far it will go. Two pilots (Clara & John) will fly the airplane. Jerry will document the distance traveled for each flight and record it on the template. Distance traveled: flight #1 = 11 ft. flight #2 = 9 ft. Plane took an immediate nose dive so it was decided that more weight was needed in the back of the plane. Baseline data was established. Average distance =10 ft. We will now select a change to test. 1 11/2 11/2 Add masking tape to the wings. A 1” piece of masking tape was placed on both wings near the tail of the plane. Carla and John will test fly. Jerry will document data. Distance traveled: Carla’s flight = 4 ft. John’s flight = 6 ft. The wings sagged from the weight of the tape making the plane fall quickly. Abandon The tail of the plane seems too heavy and reduced the distance traveled. We will remove the tape. PDSA CYCLES

38. PDSA Cycle for Improvement Form Teams (4-6 members) Count off by _______________ Assign the following roles – Team Lead (NIATx = change leader) – Pilot 1 – Pilot 2 – Data collection/scribe – Designers Design and build a paper airplane for distance and accuracy Flight One - Pilot 1 and Pilot 2 will fly the plane, record the data this will be your baseline (the number you want to improve) Repeat Rapid Cycle: More cycles means more data means more chances to improve, means a better score Flight

39. PDSA Cycle for Improvement Rules Only one design change per PDSA cycle Each team designs and commits to flying only one plane All planes must have wings and be able to fly Each design is flown by each of the pilots In order to fly you must get clearance from the air traffic controller Flight

40. Have Fun & Fly Safe!!!

41. Discussion What did you learn about rapid cycle change projects?

42. Designing Change Projects Unfocused improvement efforts are a waste of time and resources

43. Designing Change Projects

44. (Title) Name(s) of presenter(s) Organizational Affiliation Flowcharting

45. Why Flowchart? Flowcharts force an organizational focus on process.

46. Why Flowchart? Flowcharting is useful for: 1.Providing a starting point to understand the process as it is today. 2.Identifying key problems/bottlenecks 3.Showing where to test ideas for most impact 4.Adding interactivity & fun - gets the team together 5.Creating a simple & succinct visual process overview

47. Setting up a flowchart Where does the process begin? Where does the process end? START END Verifying Coverage. Intake appt. Is scheduled Customer calls office Title the process you are flowcharting.

48. 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.

49. Sample Flowchart Process name: Customer 1 st Contact (phone call) to Agency Response Customer phones agency START END Customer routed to voicemail Receptionist answers phone? Receptionist able to help customer? Transfer customer to qualified staff person Receptionist books the appointment “thanks” customer Hang up phone Yes No Website Walk-in Referral Other 1 st Contact Options Checked 1x per day Staff not available 1 person to answer phone

50. Before You Start 1. Identify a Change Leader to lead the flowchart discussion. 2. Choose one person’s organization and complete the flowchart exercise. Change Team Assignment

51. Flowchart the billing process. Remember the steps to follow: 1.Define where the process begins and ends 2.Give your flowchart a title: e.g., “First Contact to Scheduling First Appointment” 3.Define process steps 4.Review/refine flowchart 5.Identify problems and bottlenecks 6.Customer barriers

52. Large Group Discussion 1.Useful? 2. How could you use your flowchart to help engage your organization in the change process?

53. Learning Objectives The importance of data in a change project. A six-step process for the effective measurement of the impact of change.

54. How will you know which changes worked and which did not? How will you know which changes resulted in an improvement? Which change(s) is the most important and resulted in the most significant improvement? Data answers three common change project questions…..

55. Data directs the action steps toward a change project improvement goal.

56. Keep data collection and reporting as simple as possible, but be specific.

57. A Step Process for Measuring the Impact of Change 6 6

58. 6 Steps for Measuring the Impact of Change Always ask why. 1 DEFINE YOUR AIM & MEASURES 1 DEFINE YOUR AIM & MEASURES 2 COLLECT BASELINE DATA 2 COLLECT BASELINE DATA 3 ESTABLISH A CLEAR GOAL 3 ESTABLISH A CLEAR GOAL 4 CONSISTENTLY COLLECT DATA 4 CONSISTENTLY COLLECT DATA 5 CHART YOUR PROGRESS 5 CHART YOUR PROGRESS 6 ASK QUESTIONS 6 ASK QUESTIONS

59. 1. Define your measures. This ensures that the results are interpretable and accepted within the organization. Clear definitions of your measures should: - Clarify project objectives - Be agreed upon by stakeholders

60. 2. Collect baseline data. QUESTIONS TO ASK: A.Was the data defined to ensure that we collect exactly the information needed? B.How accurate is the data? Does accuracy matter? C.Does the process ensure that the measures will be collected consistently? D.Do trade-offs exist? Is quality more important than the time required to collect data? Never start a change project without it.

61. 3. Establish a clear goal. This ensures that the results are interpretable and accepted within the organization. A goal should: - Be realistic yet ambitious - Be linked to project objectives - Avoid confusion

62. 4. Consistently collect data. Regular data collection is a crucial part of the change process. As a team, decide: Who will collect the data? How will they collect it? Where will the data be stored?

63. 5. Chart your progress. Use visual aids for sharing the data. Use visual aids for sharing the data. Share pre-change (baseline) and post-change data with: - Change Team - Executive Sponsor - Others in the organization Line graph

64. A simple line graph example Remember: One graph, one message.

65. 6. Ask questions. What is the information telling me about change in my organization? Why was one change successful and another unsuccessful? Always ask why.

66. Begin to fill out the measurement worksheet

67. (Title) Name(s) of presenter(s) Organizational Affiliation Collaboration Why?

68. "If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.“ George Bernard Shaw

69. Coach/NIATx/Convener Design this slide