1. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net A Quick Primer - Rapid Cycle Process Improvement (PI 101) Reduce Waiting & No-Shows  Increase Admissions & Continuation

2. www.NIATx.net NIATx was originally a partnership of two grant programs in 2003 SAMHSA/CSAT Strengthening Treatment Access and Retention and The Robert Wood Johnson Foundation Paths to Recovery

3. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Statistics 19 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 Substance Abuse and Mental Health Services Administration, 2002

4. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Co-Occurring Statistics 10 million Americans need co-occurring treatment in any given year Those with COD, approx. 70% do not receive treatment and those treated only 19% received treatment for both conditions COD is highly prevalent in MH & SA populations (30-80%)

5. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net A Systems Thinking Orientation Starting Assumptions Everyone is acting as they should, given the system they are in Your current system is perfectly designed to produce the results it is currently producing –To produce different results you must change the system We all contribute to the system that we are a part of, both positively and negatively W. Edwards Deming

6. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

7. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Process, Process, Process A Major Focus Of the NIATX Approach is to identify processes that can be improved and not “bad” people. Emphasis on this point is helpful in mitigating anxiety about change.

8. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net NIATx Aims Reduce Waiting Times Reduce No-Shows Increase Admissions Increase Continuation Rates

9. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Five Key Principles Evidence-based predictors of change Understand and involve the customer Focus on key problems Select the right change agent Seek ideas from outside the field and organization Do rapid-cycle testing

10. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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 3 weeks

11. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Conducting a Walk-through  Play the role of a client and a client’s family member seeking treatment at your agency  Try to think and feel as the client/family member would, and think about what they would want changed  Ask staff what changes would make the process better for clients and for staff  Compile a list of client and staff needs and possible improvements that could address these needs

12. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net NIATx – Breakthrough Innovations Rapid Cycle Change – appeals to both the rider and the elephant The Walk-through – an opening experience Business case – tying change to strategic advantage – right now

13. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Select the right 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

14. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net CORE IDEAS Change is not an event, it is a process. Leadership starts from within, and requires a commitment to change. Beliefs and values matter.

15. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Starting a Change Project Select a change team – name a change leader, an executive sponsor, and data person Conduct a walk-through Collect baseline data Review data and walk-through Suggest a process change that might change access or retention

16. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Real Change “Years of study and experience show that the things that sustain change are not bold strokes but long marches – the independent, discretionary, and on-going efforts of people throughout the organization….. In difficult situation, leaders who have neglected the long march often fall back on the bold stroke.” - Rosabeth Moss Kanter, 1999

17. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Assignment – Discuss a core belief that you bring to your work with your colleagues. How does this belief inform your ideas about coaching change?

18. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Teach me – Rapid Cycle Style Coach Academy Madison, WI March 2011 Pauley Johnson

19. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Practice elements of coaching –Teaching basic concepts –Role Playing initial meetings with key players Exercise Objective

20. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net People don’t mind change, but don’t like to BE CHANGED Employee Involvement in Process Matters! –Involvement is an inherently messy process Change is messy –There are ways to help you through the messy parts –But we can’t avoid getting a little dirty in the process Coaching for Change

21. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Help create a path to avoid chaos through: –5 Principles –Walk Through –PDSA –Forming a Change Team –Description of Roles Some chaos is good, coach to help through Key NIATx Elements

22. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Tips for Preparing Your Presentation

23. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Involvement with plans Learn by doing Successive attempts result in competence Principles of Adult Learning

24. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Provide different avenues for learning material Hearing, Seeing, Touching/Doing Repeat message in different ways Keep it simple People Learn in Different Ways

25. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What is the objective? What will hold interest? What will be done to reinforce and provide opportunities for practice? Plan to teach

26. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Repeat main message Pictures are worth a thousand words Hands on How will you involve audience? Practice Sincerity counts Elements of presentation

27. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What can be improved? What would you do differently next time? Feedback from audience Review and Evaluate

28. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Groups of 6 Plan to present the basics of the topic you have been given Practice in group ½ of group teach presentation to another group Bring back feedback from your students to the group Decide what changes you would make based on feedback Report out Your Job

29. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Can You Hear Me Now? Using Appreciative Inquiry for Developing Change Projects Pauley Johnson and Lynn Madden Coach Academy, Madison, WI March, 2011

30. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Used to generate positive change in widely varying settings ( Cooperrider DL, Sorensen PF, Yaeger TF, and Whitney D eds., Appreciative Inquiry, Stipes Publishing, 2001) Utilizes past event recall in the form “storytelling” and “event report out” of positive past experiences that furthered a specific goal. Positive energy generated through these stories helps build enthusiasm and momentum for current project AI Background

31. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net TO START: A clear and specific goal that is important to the organization PHASE 1: Discovery –Event recall and report out of past instances of success re goal –Individuals pair up and interview each other about their past positive experiences with the goal. –Avon of Mexico, diversity. Three Phases

32. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Utilizing info from Discovery, participants specify what their organization might look like a year from now if it fully met the goal Specific details elicited for all levels of the organization Phase 2: Dreaming

33. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Utilizing information from Discovery and Dreaming phases, participants come up with ideas for change cycles. Phase 3: Design

34. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Remember you will be the one reporting on the story told to you so: Ask clarifying questions, go for details Who, what, when, where, why Instructions for reporters

35. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Tables of 6, pair up, pick a recorder for table 5 min. -- silently brainstorm re positive past experiences that have led to increased revenue (either increased revenue or decreased costs). 6 min.( 3 min. p/interview) – tell your story to your partner 10 min. – Reporters tell story they have heard to group, reportee may amend or clarify elements of story as reporter tells it to group. Recorder lists important elements 2 min. – Group votes on top story 5 min. – Report out to whole group Exercise:

36. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net The Coaching Toolbox Coach Academy Madison, WI March 29. 2011 Pauley Johnson

37. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Starting out doing rapid cycle improvement doesn’t always go smoothly…. What do we do then?? When teaching PDSA isn’t enough…

38. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Prep for initial visit with Site Visit Roadmap Initial conversation with executive sponsor –Roles of exec sponsor, change leader, change team –Role play Motivational message Meeting with change team –Exec Sponsor checklist Picking a change leader – important attributes Change team member – important attributes Starting Out Right

39. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Understanding the customer –Walk Through –Convenience Samples –Phone Sampling –Alternative “walk throughs” – e.g. billing guide Understanding processes –Flow charting –Root Cause Analysis Deciding on a Change Project

40. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Exec Sponsor special invitations Exec Sponsor spells out –Project and it’s importance –Level of responsibility, accountability –Reporting requirements –Time frame Change leader and team –Develop ground rules for: attendance, conflict resolution, participation, meeting etiquette, task completion, etc. –Time line Getting a Change Team Started

41. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Nominal Group Technique Change leader monitors and regularly asks for participation Change leader and exec sponsor model okay to make mistakes Change leader monitors possible group conflicts Encouraging team member participation

42. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Nominal Group Technique Appreciative Inquiry Creativity Techniques Ideas outside Agency -- benchmarking Developing Change Cycles

43. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Regular data report outs Meeting Agendas –Allow but limit time for expression of concerns PDSA –Knowing “when to hold ‘em and when to fold ‘em” –Use of huddles when meetings can’t happen or aren’t necessary –Simple data collection Timeline Keeping a Change Team Moving

44. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net DeBono’s 6 Thinking Hats PDSA as a pilot –Many different ideas can be tried for short time frames –Data determines whether to maintain –Allowance for unintended consequences Mechanisms established in ground rules: –Open expression –Disagreement is desirable “reasonable minds may differ” Resolving Team Conflicts

45. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Overview Out of Site…Out of Mind Planning an Introductory Site Visit

46. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Site Visits… Sometimes we are surprised by what we find. 2

47. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Why Do a Site Visit? Connect with staff and the facility Reinforce key roles Review progress and answer questions Introduce forms/NIATx website Troubleshoot potential problems Help the team get on track 3

48. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Typical Site Visit Agenda 1.Tour the facility and meet staff 2.Meet with Exec. Sponsor and Change Leader to clarify their roles 3.Learn about agency priorities 4.Review PDSA Cycle progress 5.Clarify change team meeting frequency and typical agenda 6.Introduce and walk-through progress report form 7.Note project timeline and next steps 4

49. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 1. Seeing the Facility & Meeting Staff 5 You may find pleasant surprises or encounter situations that need to be addressed in order for the agency to succeed in its improvement projects

50. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 2. Assess Key Roles Executive Sponsor commitment and understanding of role Change Leader potential for success Change Team membership and operating procedures 6

51. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net A Committed Executive Sponsor is Good to Find 7

52. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Every Change Leader has strengths and limitations 8

53. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 3. Agency Priorities Discuss what was learned in the Walk-Through Review management concerns What issue is being addressed first? Is objective a challenge yet achievable? Did management complete the 1 st page of the QSRM? 9

54. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 4. Review PDSA Cycle Progress Role of the Change Leader Change Team deliberations Documentation of key steps –Baseline data –Understanding of service problem –Start date for change cycle –Gathering of performance data Overall understanding of the PI methodology 10

55. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 5. Progress Reporting Review data measures and collection procedures Discuss how to chart progress Introduce and walk-through the Change Project Report form Be prepared to provide regular on going TA for at least three months 10

56. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 6. Project Timeline Review key dates on the timeline and clarify when next contacts will take place 11

57. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net In Summary With a site visit you will have a better “feel” for the agency or the staff No matter how clear the instructions have been, there will be a need for coaching Issues around data and reporting are universal. Patience and structure are your friends! 12

58. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net The Ideal Coach

59. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Airplane Game Team Change Package

60. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Your Aim & Measures AIM –Improve the performance of a paper airplane to maximize the distance it flies and the accuracy of the flight Measures –Distance in feet –Accuracy of the landing (total landing points)

61. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 6 Simple Rules 1.Only one design change per PDSA cycle 2.All planes must have wings and be able to glide 3.Teams must have their PDSA sheet checked by air traffic control before they do a test flight 4.Each design must be flown by three different test pilots 5.A flight is in the runway band if it touches the tape

62. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Getting Started Form into teams Designate: –Team leader –Data person to track and record the PDSA cycles –3 test pilots –Additional people can help and take turns as pilots Each team should have: –Change package –2 PDSA worksheets –Paper for your first, baseline plane –Graphs for measuring distance & accuracy

63. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What to DO at Each Step 1. Plan 1.Record what theory or hunch you are going to test 2.Record what you are going to do and how 3.Predict your results (not just accuracy and distance, also consider other characteristics) 2. Do 1.Create the plane 2.Fly it 3 times, with 3 different pilots 3.Record the distance of each flight 4.Record the runway band that each flight landed in 3. Study 1.Compute the average distance and plot it on the graph 2.Compute the total runway landing band points and plot it on the accuracy graph 3.Discuss the results and what you have learned 4. Act 1.Decide what to do for the next PDSA cycle 2.What will you abandon, what will you adapt, what will you adopt

64. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net PDSA Worksheet PLAN DO STUDY ACT Theory you want to test: What and How: Predicted Results: Results: # Distance (feet) On Runway 1 2 3 Total Average What happened? What worked? What didn’t? What did you Learn? What will you keep doing? What will you stop doing? What will you change, do more of or do less of?

65. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net PDSA Worksheet PLAN DO STUDY ACT Theory you want to test: What and How: Predicted Results: Results: # Distance (feet) On Runway 1 2 3 Total Average What happened? What worked? What didn’t? What did you Learn? What will you keep doing? What will you stop doing? What will you change, do more of or do less of?

66. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net PDSA Worksheet PLAN DO STUDY ACT Theory you want to test: What and How: Predicted Results: Results: # Distance (feet) On Runway 1 2 3 Total Average What happened? What worked? What didn’t? What did you Learn? What will you keep doing? What will you stop doing? What will you change, do more of or do less of?

67. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Distance Data Paper Plane Distance Team: _____________________________

68. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Accuracy Data Paper Plane Accuracy Team: _____________________________

69. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Airplane Change Package & Measures ProblemChangesMeasures Short Flight DistancesUse heavier paper Change launch Flight distance on straight line Nose DivesAdd tape weight to rear to prevent Percent nose dives Wanders Off-TargetReinforce plane body with staple Distance from straight path

70. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net THE NIATx WAY – START UP

71. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 1) Are any of the NIATx Aims and outcomes important to the Executive Sponsor? NIATx Aims: ☐ Reduce waiting time ☐ Reduce no ‐ shows ☐ Increase continuation ☐ Increase admissions Financial Impact ☐ Increase revenue ☐ Reduce costs ☐ Increase staff retention

72. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 2) Define Project ☐ What level of care? ☐ Which location (if more than one)? ☐ What is the targeted population?

73. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 3) Who has been appointed Change Leader ?

74. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 4) Who else has been appointed to the Change Team? Send formal invitation. 2. 3. 4. 5. 6. 7.

75. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 5) Has the Executive Sponsor allocated sufficient resources? ☐ Of Change Leader’s time ☐ Coverage for counselors’ billable hours ☐ Change Team members’ time ☐ Other ___________________________

76. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 6) How will the Executive Sponsor monitor progress? ☐ Read minutes ☐ Meet with Change Leader weekly ☐ Follow tracking measure ☐ Other ______________________

77. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 7) Walk ‐ through: What’s it like to be your client? Walk through the process you are improving as if you were a client. List two salient observations from the walk through: 1. 2. ☐ How many days until the next available appointment for assessment? _____ for the first treatment session?________ ☐ What percent of appointments were no ‐ shows for assessments? _____ for treatment ?______

78. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 8) Confirm project aim: Which aim are you trying to accomplish in this project? Recommended sequence: ☐ Reduce waiting time ☐ Reduce no ‐ shows ☐ Increase continuation ☐ Increase admissions Each aim contributes to accomplishing the next.

79. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 9) Measure baseline for selected aim, (if not done in 7): How will you know if a change is an improvement? What will you measure? What is baseline measurement? __________ What is target? __________

80. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 10) What practices hold promise for accomplishing the selected aim in your setting? Refer to list of promising practices. Add to the list. 1. 2. 3. 4. 5.

81. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 11. PLAN (P) What promising practice is to be tested? DO (D) What steps are you specifically taking to test this promising practice? Who is responsible to do what, when? STUDY (S) What are the results? How do they compare with the baseline measure? Was the promising practice tested as planned? ACT (A) WHAT IS YOUR NEXT STEP? ☐ Adapt-- Repeat PDSA cycles until this promising practice can be abandoned or adopted. ☐ If abandoned – Select another promising practice to test. ☐ If adopted -- Has the aim been accomplished yet? If YES- Move to Sustained Gain If NO– Test Another Practice

82. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 12) How did these promising practices improve the bottom ‐ line? ☐ Reduce costs? ☐ Increase revenue? ☐ Increase staff retention?

83. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 13) How can you sustain the gains? ☐ Appoint Sustain Leader ☐ Select target sustain measure ☐ Plan for relapse ☐ Plan for staff turnover ☐ Other _____________________________

84. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 14) How can you tell your story? ☐ Storyboard ☐ PowerPoint ☐ Elevator Speech ☐ Other ________________

85. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 15) What project is next? Go back to 1.

86. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Techniques for Jumpstarting Creative Thinking 1 1 See Joel Saltzman, Shake That Brain, 2006, John Wiley, for further ideas

87. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Start with a Creative “Attitude” Treat Problem Solving as a game – have fun! –“The supreme accomplishment is to blur the line between work and play” -- Arnold Toynbee Be Daring –“If at first an idea is not absurd, then there is no hope for it.” -- Albert Einstein Be optimistic and persistent –“Whether you think you can or think you can’t, you are absolutely right.” – Henry Ford

88. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Challenge Assumptions Clear deck of old ideas Consider everything you “know” to be true about a current service or process Examine each assumption in turn (no matter how logical) and ask yourself – “What if it’s not necessarily the case?” –Boston Standup Stapler –KB Homes (people want basements)

89. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Change/Adapt – Don’t Throw Out Warner Bros, Looney Tunes development –Held “yes” meetings – ideas could be changed but not thrown out Reid Hastings – Netflix –Step 1: rent dvd’s over Internet –Step 2: subscription service –Step 3: download dvd’s directly off Internet

90. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Present Problem Clearly Write out problem in as clear and concise a manner as possible – no more than 2-3 sentences Test on others – do they get it?

91. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Restate Problem from Multiple Views Clients not getting from detox to 1 st OP Appt. – Examples: –Clients have more immediate needs to handle, e.g. housing –Clients fear starting a new group –Clients perceptions of treatment are inaccurate

92. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Opposites Approach Tom Sawyer is classic example: –How am I going to do all this WORK? –How are YOU going to do all this FUN? Wait Time example: –What can we do to reduce wait time to treatment –What can client do to make use of wait time

93. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Look for Worst Possible Solution A real solution, not an “anti” solution Tweak it to make good Woolmark’s summer weight wool promo: –Sheep in Central Park in Aug –Models w/ sheep on leash Madison Ave –8 million media impressions (not BAAAAD)

94. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Summary Clearly restate problem from different perspectives: –Lack of transportation creates a barrier to treatment –Clients concerns for adequate housing after detox discharge swamps efforts to attend OP treatment Try to find “worst possible solution” and tweak it Take a specific process and challenge ALL assumptions about it Restate problem in terms of opposites (e.g. Tom Sawyer) Have fun, be daring, mistakes can be goldmine

95. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Small Group Exercise Form groups of 6 people – Your charge is to develop a change cycle around the aim of increasing the transfer rate from detox to outpatient using the following method: 15 min. – use Nominal Group to come up with the “worst possible solution” 10 min. – Pick one of these and rework to make a good change cycle 5 min. – Discuss what you learned about developing new change ideas

96. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Overview A Spoonful of Sugar makes the Medicine go Down- Or is it a Cup

97. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Some is not a number, soon is not a time. -- Don Berwick, MD

98. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Overview Power of 2 Big A vs. Little A Seven Simple Rules

99. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Who uses data? Decision Makers –State (e.g., SSA or Legislature) –Funding Agency(e.g., State or Managed Care) –Provider (e.g., Executive Director, Board) Consumers –Clients –Employers –Employees

100. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Data is important to …. … show that treatment is working (state) … examine $ vs. quality (legislators/managed care and employers) … managed care companies who are interested in quality care

101. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Data is important to …. … help effectively and efficiently run the treatment agencies (ES) … receive quality care via immediate access (consumers) … understand impact of change for clients (employees)

102. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Using data to make decisions

103. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net WHY IS THIS IMPORTANT?

104. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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? Model for Improvement Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

105. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What do I need to Know?

106. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Today’s Session is brought to you by the

107. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Power of Two

108. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net (Title) Name(s) of presenter(s) Organizational Affiliation What do you need to know? 2 Categories –Deposits –Expenditures

109. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net How does this knowledge help? Deposits Number of Deposits Total Amount In Expenditures Number of Checks Written Total Amount Out

110. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What can you do with the knowledge? Net Profit = Deposits - Expenditures Hit Jackpot Broke the Bank

111. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What can you do with the knowledge? Ask Questions –What type of expenditures? –When do they occur? –Why did I experience a loss? Profit? –What happened that was different this month?

112. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What is the rest of the story? 1. Deposits 2. Expenditures 1. Total Deposits 2. Number of Deposits 3. Total Expenditures 4. Number of Expenditures 5. Net Profit or Loss

113. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

114. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

115. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

116. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net … And by the

117. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What are your aims? Big A (for aim) Reduce readmissions Little A (for aim) Intermediate measure

118. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Making Changes PDSA Cycles –Plan the change –Do the plan –Study the results –Act on the new knowledge Adapt Adopt Abandon Two-week-long cycles

119. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Sample “Little A Data” Admission: In addiction treatment? Medication adherence In treatment: Engagement/participation Post Level: Successful Transition

120. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Cycle Measures Cycle Measures: examine incremental impact of the PDSA change cycle Three scenarios –No shows –Transitions between levels of care –Time to treatment

121. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Cycle Measures If the process measure is no-shows, what might be examples of a cycle measure –Number of Missing Phone Numbers –Number of Connected Calls –Number of calls required –% of persons called who come the next day

122. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Cycle Measures  If the process measure is the percent of successful transfers from OP from Detox, what might be examples of a cycle measure  Scheduled appointment within 48 hours of discharge  Number of Calls required  Number of Days between Discharge and Admission  Number of clients offer to attend pre-discharge OP session  Number of clients actually attending

123. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Getting the numbers right

124. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net SEVEN SIMPLE RULES FOR MEASURING THE IMPACT OF CHANGE

125. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Rule 1: Define Measures Establish clear definitions Clarify project aims Agreed upon by key stakeholders

126. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Rule 2: Establish a Baseline Never start a project without it Define a clear starting point Use agreed-upon definition StartFinish

127. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

128. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net WHAT ARE EXAMPLES OF A GOOD AIM?

129. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Examples – Defining the Aims 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 1st Contact to Assessment from 28 to 7 days

130. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

131. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net How to encourage consistenty? What steps can you take? What advise might you offer to another agency having trouble with data collection?

132. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net WHAT ARE DATA CHALLENGES YOU HAVE ENCOUNTERED AND HOW DID YOU DEAL WITH THEM?

133. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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

134. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net EXAMPLE SPREADSHEET

135. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Stay out of the Quicksand Don’t collect to much data Don’t focus on too many measures Don’t get trapped in analysis paralysis Ask a “yes or no” question of your data

136. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Measuring Change Impact HOW DO YOU MEASURE CHANGE PROGRESS? WHAT HAS BEEN THE MOST EFFECTIVE TOOL? HOW COULD YOU USE CHARTS TO MEASURE CHANGE PROGRESS?

137. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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.

138. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example Chart

139. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net

140. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Use Trendlines

141. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net

142. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net CHANGES MAY HAVE MULTIPLE IMPACTS

143. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net HOW DO YOU THINK A CHANGE IN ONE AREA MIGHT IMPACT ANOTHER AREA? WHAT ADVICE MIGHT YOU GIVE AN AGENCY IN THIS SITUATION? WHAT IS THE MOST COMMON SITUATION YOU’VE ENCOUNTERED?

144. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Impact of Change on Other Areas

145. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net

146. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net

147. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net No-Show Exercise

148. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Scenario: starting a new OP program You identify 5 “classes” of clients (e.g., criminal justice referrals, Medicaid, etc.) Each “class” averages 1 request for service per week Hence, it seems logical to set up a schedule with one “slot” each week for each class of client What do you think average waiting time will be given this situation?

149. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Time for a game Roles: caller, receptionist, scheduler Red clients, blue clients, yellow clients, green clients, purple clients One roll of the die each day to simulate a request for service

150. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net 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?

151. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Exercise in Helping Providers Understand Data Issues

152. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Data Scenario 1 During a morning conversation with the change team, it became clear the measure definition for to identify clients who were being transferred from one level of care to another and subsequently how to tracking a successful engagement in the next level of care had changed over time. You also learned that these definitional changes are not being adequately communicated to staff involved in the change process and that this is not the first time that the definitions have been changed. What advise would you offer the change team?

153. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Data Scenario 2 The change team is working to reduce mental health detentions, which result in an admission. The number of detentions is expected to be around 500 for the year, but the change leader is finding fairly significant change in volume from one month to the next. For example, in January our total volume would suggest we expect to have around 40 detentions and instead had only 20. The team is a bit nervous about tracking and conclusions if monthly volume varies naturally right in the midst of seeing if a change has made a difference. What advice would you offer the change team to help them best watch for changes in an environment like this.

154. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Data Scenario 3 The change team is getting ready to implement changes in their OP program to improve retention and you receive an e-mail asking the following question - Do you have any statistics regarding the % of clients receiving substance abuse treatment that manage to complete 4 or more sessions of treatment? We are trying to figure out a benchmark. For the past two quarters we have 43%, but we do not know how this compares to other programs in our catchment. How would you answer this question?

155. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Summary You do not have to be the expert Understand how to measure the impact of change Remember to keep it simple (Power of 2) No baseline, no change project Clearly help sites define their AIM vs. aim Evaluate the impact –One chart, one message –Ask questions

156. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Sustaining the Gains It takes a plan - What family of strategies can help us maintain the important changes we have made?

157. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What organizational and operational structures and processes (e.g., policies, procedures, training, work guidelines for providing service, ownership of the process?) are in place to hold the gain?

158. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What are the data points we continue to want to see to know sustainability is working? And who gathers it? Looks at it? And when does this happen?

159. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What is the procedure for communicating results and sustainability progress? How often will the results be shared with organizational leadership? What actions will be taken to inform staff?

160. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What performance threshold will trigger action? How long must performance be below the threshold before action is taken? What are the first two action steps that will be undertaken when this threshold is meet?

161. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What is the general stage of adoption of your organization? How can understanding where your team/organization is help you move forward?

162. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What is the Business Case/strategic advantage and/or clinical gain for the Improvement and Sustainability?

163. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net How about executive focus – how can we keep it on performance improvement? What culture shifts occur as PI becomes more common?