1. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Rapid Cycle Process Improvement (PI 101) Lynn Madden, MPA, CHE Scott O. Farnum, MS, MPA Thomas Zastowny, PhD Reduce Waiting & No-Shows  Increase Admissions & Continuation

2. www.NIATx.net NIATx was originally a partnership of two grant programs The Center for Substance Abuse Treatment 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 Improving the Quality of Health Care for Mental and Substance Use Conditions: Quality Chasm Series Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders Institute of Medicine of the National Academies November 1, 2005 http://www.nap.edu/catalog/11470.html

5. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Major Findings “Erroneous expectation that once patients have achieved insight they will be ready for discharge and continue as recovered for a substantial period of time.”

6. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Reality Most alcohol and drug dependent patients relapse following cessation of treatment. In general 50-60% begin reusing within 6 months of stopping treatment. “Scared straight” and “threats to safety” programs have been found to be potentially harmful. Accumulating evidence suggests best treatment is to follow the model of treating cardiovascular disease and diabetes (chronic disease management).

7. 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

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 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

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 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

12. 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

13. 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

14. 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

15. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Rapid-cycle Testing Start by asking five questions: 1. What’s it like to be our customer? 2. What are we trying to accomplish? 3. How will we know if a change is an improvement? 4. What changes can we test that may result in an improvement? 5. How can we sustain the improvement?

16. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net APT FOUNDATION – REDUCING TIME TO TREATMENT A series of 12 change projects over 2 years reduced time from initial contact to medication from 26 days to 2 days.

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

18. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net REDUCED WAIT TIME = INCREASED CENSUS

19. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Change Cycles Hunches Theories Ideas Changes that Result in Improvement AP SD A P S D AP SD D S P A DATA Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide

20. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Learnings  You really don’t know what you don’t know  Nothing replaces face to face “asking” - senior managers and senior clinical leaders are the best for this role  Stay focused on the big picture goals

21. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Day One – OP Services10/06 AIM: Decrease Wait Time between phone call and first appointment CHANGE MADE: At time of phone contact, offer client/referral next day appointment for first face to face with clinician Change Time Frame: October 30 to November 19. Pre-change Time Frame: October 9, 2006 to October 29

22. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Day One - Results

23. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Day One Outpatient August 2006 Change Project Aim: Improve Retention At conclusion of 1 st appointment offer a second appointment the next day Pre-Change Time Frame: July 24 to August 11, 2006 Change Time Frame: August 14 to September 1, 2006

24. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Change Period 19 first appointments occurred during the change period All 19 clients were offered a next day visit, only 2 were able to utilize this offer However, all 19 returned for a second visit 100% retention during this period

25. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Improving Retention Pre-change 23 returned out of 28 Change 19 returned out of 19 In August of 2007, retention to the 2 nd visit was 95% and to the third visit, 90%

26. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net AMHC - Small changes matter! A 3% improvement in no-show rate = 31 visits

27. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Small Changes Really Matter A 3% improvement in the no-show rate = $1100/month or $13,300/year This program is in a group of programs that together were intended to produce an operating margin of $15,123 This data helps answer the question – are we moving in the right direction?

28. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Aroostook Mental Health Center – decreasing no show rate

29. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Key Learnings When the program was open to them, the clients who needed it the most showed up – and they stayed in treatment. Quality Improvement methods can be an operational driver Clients who don’t have so many barriers to enter treatment are more likely to show up. Treatment must change to accommodate their needs. Improving access to treatment makes good clinical sense

30. 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

31. 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.

32. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Detours Change Project not related to strategic goals No feedback Leadership inadequate No business case Long change cycles

33. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Utilizing the NIATx Process to Develop a new Orientation Group

34. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net AIM: Increase Continuation NASC will increase client retention through the implementation of a comprehensive orientation group. Targeted Clients: Clients opened in program within 7 months of initial orientation session (54 clients on 1/28/2010). Measure: Comparison of retention rates for orientation group (those completing all sessions) and control group (remainder of target group)

35. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Change: Develop and implement a comprehensive orientation group curriculum. Four week group, topics to include facility rules, treatment planning and goal setting, development of a recovery environment and health issues. 54 clients were targeted based on intake date. Invitations to the orientation group were given to primary counselors to distribute to these clients. 16 clients attended at least one session, 9 of these completed all four sessions.

36. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Results Orientation: 9 clients who completed all orientation sessions Control: 45 clients who did not complete all orientation sessions Total: All targeted clients Active Clients: percentage of clients who are still open in NASC programs Last Tox Test Clean: percentage of clients whose most recent tox test was negative Data collected 9/12/2010

37. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Next Steps Orientation group has continued regularly since March. 45 clients have completed all sessions, over 60 have participated. Orientation was opened to all clients; new clients remain the priority. Outcomes for all who completed orientation group need to be collected and analyzed. Counselors need to be sold on the process. Long term data analysis should be completed quarterly. Impact on continued attendance in other groups is needed.

38. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Impact Involved counselors and staff recognize that new processes can lead to better outcomes. Involved counselors and staff empowered to be part of the change process. Clients have better outcomes, both in retention and abstinence from drug use. Results of this PDSA will be used to demonstrate effectiveness of the process, and as a motivator for change teams in new projects.