1. Benefits of Process Improvement in Substance Abuse Treatment
Kevin Lewis Rick Hankey
Southwest Florida Addictions Services Lifestream Behavioral Health
Angie Maldonado Sheila Barbee
The Center for Drug Free Living Substance Abuse Program Office

2. Presentation Objectives
Provide information about rapid cycle process improvement
Describe how process improvement has been used to improve client access and retention in treatment – Sharing our story!
Identify benefits of using process improvement – What’s in it for me?
Demonstrate applications
Share plans for continuation

3. Background Began as joint initiative
CSAT, RWJ, NIATx
Provided grants to 39 treatment agencies
CFDFL
SWFAS
State Pilot Project
Promoted State Level Process Improvement
2006 STAR-SI
Kevin
The Network for the Improvement of Addiction Treatment (NIATx) began as a joint initiative of the Substance Abuse and Mental Health Services Administration” Center for Substance Abuse Treatment (CSAT) and the Robert Wood Johnson Foundation (RWJF)
In two rounds of funding CSAT and RWJ provided funding to 39 treatment agencies to implement process improvements
Since 2003, member agencies have participated in a learning collaborative network that, by providing training and peer support, has helped them to implement process improvement in their tx programs.
As a part of the NIATx initiative, CSAT and RWJF later funded six states under the STATE Pilot Project to establish payer-provider partnerships to identify haw states can provide leadership to improve treatment quality, use demonstrated process improvement methods to test way that states/payers and providers can more efficiently work together, and document and disseminate innovative practices in collaboration with treatment providers to improve performance quality.
In 2006, expanded upon results to state pilot to establish the Strengthening Treatment Access and Retention – State Implementation (STAR-SI) grand – to fund 7 state provider partnerships over a three year period to use process improvement methods to improve state and provider level organizational processes that affect client access to and retention in treatment.

4. Florida STAR-SI ParticipantsM M C
CFBHN M C
CFDFL C M
Florida STAR-SI Participants C
SWFAS M
Kevin
Elaborate on the geographic approach – in conjunctions with managing entities.
Red Flags indicate managing entities throughout the state
The blue stars are Year 1 Providers
Yellow Stars are Year 2 Providers
Yellow Flags Indicate Original STAR sites – serve as Peer Mentors for the State
Green call out boxes indicate the areas that we have additional peer mentoring capacity – increased since grant
?? Could have something that includes non-star agencies that have received additional training such as PDSA, change team, road Map
SFPC

5. 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
Kevin

6. NIATx Four Project Aims
Fl-Substance Abuse Project Aims
Fl-Substance Abuse Project Aims
Increase the number of persons who complete detoxification and then enter outpatient services.
Reduce average time between initial screening/assessment and the delivery of first outpatient treatment service.
Reduce average time between an individual’s first contact for outpatient treatment and an initial screening/assessment.
Increase the number of persons who complete detoxification and then enter outpatient services.
Reduce average time between initial screening/assessment and the delivery of first outpatient treatment service.
Reduce average time between an individual’s first contact for outpatient treatment and an initial screening/assessment.
Reduce Waiting Times
Reduce No-Shows
Increase Admissions
Increase Continuation Rates
Rick

7. NIATx Results Reduced Waiting Times: 34.8% reduction
(68 change projects in 31 agencies reporting)
Reduced No-Shows: 33% reduction
(49 change projects in 27 agencies reporting)
Increased Admissions: 21.5% increase
(42 change projects, 22 agencies reporting)
Increased Continuation: 22.3% increase
(88 change projects in 31 agencies reporting)
Rick

8. Florida Access and Retention
Rick

9. Evidence-based predictors of change
Six Key Principles
Evidence-based predictors of change
Understand & Involve the Customer
Focus on Key Problems
Select the Right Change Agent
Seek Ideas from Outside the Field and Organization
Do Rapid-Cycle Testing
Establish a Business Case
Rick 9

10. Understand and Involve the Customer
Most important of all the Principles
What is it like to be a customer? Staff are customers, too!
Walk-through, focus groups…
Angie

11. Focus on Key Problems
What is keeping the executive director awake at night?
What processes have staff and customers identified as barriers to excellent service?
Angie
2. Carefully select problems to solve.
What is keeping the executive director awake at night? The research indicates that it is crucial to select a project that addresses a key organizational goal. If the project can help the executive director sleep better, they will actively support the project and do everything in their power to make the project a success.
What was found from the walk-thru? Problems in a process are discrepancies, or gaps, between actual and desired performance. Most staff can come together around improving services for the clients we serve.
What processes have staff identified as barriers to improved customer service? Recognizing staff needs improves buy-in, and increases the likelihood of sustainability.
What complaints have been received from referral sources? Responding to referral source concerns increases likelihood of improved relationships. 11

12. Select a Powerful Change Leader
Who has:
influence, respect and authority across levels of the organization
a direct line to the CEO
empathy for the staff
time available to lead change projects
no fear of data
Angie

13. Seek Ideas Outside the Organization and Field
Provides a new way to look at the problem
Real creativity in problem solving comes from looking outside the familiar
Angie

14. Do Rapid Cycle Testing: PDSA – What and How
Plan Do
Study
Act
Angie
Overview of the rapid change cycle process

15. Process Improvement: The “How” to Achieve the Aims
Process focused
There are opportunities to improve the way we do things
Processes are the problem, not the person
Customer oriented
Our customers know best what needs to be improved about our services
Data focused – on-going data sampling
We can’t know if a change is an improvement unless we have data
Angie

16. The Model for Improvement: 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?
Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996
Kevin
The 4th & 5th principles, Seeking change ideas outside the organization and Do Rapid-Cycle testing, are address thru the PDSA Process Improvement model.
Ask three fundamental questions:
1. What are we trying to accomplish?
2. How will we know if a change is an improvement?
3. What changes can we test that may result in an improvement?
This is where we engage in idea generation - use the Nominal Group technique, looking at customer suggestions, try looking outside the agency for ideas, etc.
And once a promising change has been identified, rapidly use the Plan-Do-Study-Act (PDSA) cycle to turn a change idea into action: 16

17. Rapid-Cycle Testing Rapid-Cycle changes PDSA cycles
Are quick; do-able in 2 weeks
PDSA cycles
Plan the change
Do the plan
Study the results
Act on the new knowledge
Kevin
Use the PDSA process to:
pilot test changes
implement further changes – spreading a change from one location or level to another, merge step into the whole process, etc.
sustain changes 17

18. Changes That Result in Improvement Hunches Theories Ideas
Repeated Use of Cycle
Changes That Result in Improvement A P S D
DATA D S P A A P S D
Kevin A P S D
Hunches Theories Ideas

19. Sample Aim and Change Cycles CFDFL
AIM: Decrease No Show rate for outpatient treatment appointments
Change Cycles:
Change appointment policies
Reminder phone calls
Put repetitive no-shows into a “pre-contemplation” group
Angie

20. CFDFL- Agency Example
Chg 3
Chg 1
Chg 2
Angie

21. SWFAS- Agency Example Aim: Reduce Wait Times
Target Population: Youth Outpatient
Baseline: 3-4 month wait for assessment
Change Cycles:
Reminder phone calls
Walk-in assessments
Results: Wait = No more than 3 days
Kevin

22. Creating Capacity for Process Improvement - Managing Entity
Monitoring Performance
State Performance Measures
Allocation and reallocation of funding
QA process
Development of a System of Care
Communication of best practices
To assist subcontractors in meeting the contractual requirements
Data reporting and correcting
Sheila
Larger scale implementation of PI – when individual agencies come together
Days Worked
Days in community
Percent completing treatment
Meeting goals
Employed at discharge 22

23. Agencies in the STAR-SI Grant Managing Entity
ACTS
Bay Care (Harbor Behavioral Health)
Center for Women
Coastal Behavioral Health
DACCO
First Step
Manatee Glens
Tri-County
Sheila
Geographic location part of original plan and further expansion
Perhaps developing capacity – expertise - through managing entities ---
or for agencies that are not members of ME - geographic proximity may be asset

24. Provider Successes Across the State
Reduced intake paperwork by 50%
Increased # of persons who enter outpatient treatment after detox from 43% to 67%
Reduced no-shows for from 41% to 11%.
Reduced wait time for first appointment from 3 weeks to 7 days
Increased the number of persons who complete detox and enter OP by 50%
Implemented electronic process for concurrent admissions
Increased revenues
Sheila
Reflects gains by DACCO – paperwork
Detox – manatee glens
No shows for apt. Meridian
Wait time for apoointment Meridian
Detox – the harbor
Increased revenues - Meridian

25. Executive Sponsor Plays Key Role
Vision
Engagement
Barrier removal
Connecting the dots
Rick

26. Vision Sees agency service issues clearly
Links improvement to strategic plan
Willing to define aims and establish attainable objectives
Rick

27. Is this a priority for my job?
Importance and business case
Exec sponsor interest and follow-up
Hold teams accountable:
Special invitation to each member
Specify level of responsibility
Regular reports
Remove barriers
Publicly recognize success
Rick

28. Change!
Inclusion rather than exclusion
Bottom up
Rick

29. How will it affect my job?
Paperwork reduction
Performance management
Job enhancement
“Work smarter, not harder”
Predictability
Improved feedback
Rick
Not the same old QI

30. Will the effort really result in improvement?
Model commitment to keep trying
Benchmark others
“Cheerlead”
It’s okay to make mistakes and learn from them
Data is our friend!

31. Establishing Capacity State-Wide STAR-SI
Utilize a Geographic Approach
Increase staff capacity to utilize rapid cycle performance improvement techniques
Engage local state staff
Establish Managing Entities and State Coaches as hub
Integrate a cadre of well trained state coaches and peer mentor to assist agencies in implementing performance improvement
Connect with established processes
Improve Data capacity to determine client outcomes (Crystal reporting)
Sheila
YES!!

32. Capacity to Sustain Progress
Through the Development of:
State Coaches/Managing Entities
Change Team Leaders (Academy)
Peer Mentors
Change Team Leaders
Change Team Members
ACTION Campaign – Tools
Basic Tools – PDSA-101
Sheila

33. What’s Next? Continuation Recruit participants Train staff
Provide technical assistance and support
Hold learning sessions/collaboratives
Next Meeting – June 23rd in Tampa
Sheila

34. Thank you!