Capitol Region Learning Collaborative Kick-Off Workshop
Presented by: Beth Rutkowski, MPH, and Kimberly Johnson, MSEd, MBA
April 21, 2009 Sacramento, California
Slide 3
Adopting Changes in Addiction Treatment One year project funded
by the California Endowment A partnership of the Pacific Southwest
Addiction Technology Transfer Center, the NIATx National Program
Office, and CADPAAC Development of five regional learning
collaboratives
Slide 4
Regional Learning Collaboratives: Key Activities One-day
kick-off workshop in April/May 2009 Series of monthly conference
calls commencing one month following kick-off workshop Ongoing data
collection and periodic submission to measure progress made with
change projects
Slide 5
What do we plan to cover today? Key components of the ACTION
Campaign and NIATx model of process improvement How to identify key
problem areas within your agency Strategies to plan for change and
implement rapid cycle improvement projects
Slide 6
How to measuring the impact of change How to brainstorm
possible solutions and motivate a change team Next steps and
networking opportunities What do we plan to cover today?
Slide 7
Learning Collaboratives
Slide 8
What is a Learning Collaborative? A data driven network of
change teams that works collectively to enhance performance. Data
Network Change Teams Collective Performance Process
Improvement
Slide 9
The Culture of Learning Collaboratives Data Driven Dialogue and
Discussion Celebrations
Slide 10
Data-Driven Baseline Data Keep it simple/manageable
Sustainability Use existing sources of data Real-time data
Slide 11
Dialogue and Discussion Evidence is that this is how adults
learn best Provides for sharing experience and celebrating success
Provides for group problem-solving Allows participants to choose
what they want to learn and address
Slide 12
Celebrate!
Slide 13
Motivate the Collaborative Members Record and celebrate success
(need data) Acknowledge performance of team members, and whole
change teams Provide support and share experiences
Slide 14
23 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
The Reality SOURCE: Natl Survey on Drug Use & Health, SAMHSA,
2006.
Slide 15
At any one time 110,000 individuals waiting for assessment
42,000 waiting for treatment 32 days from first contact to
treatment No-show rates about 50% SOURCE: Survey conducted by
Survey Research Laboratory University of Illinois Chicago, March
2007.
Slide 16
Detox Retention Rate Successful Transfer: 4% Finish Detox, No
Transfer: 61% Dont finish: 23% Transfer, No Connect: 12% SOURCE:
Treatment Episode Data Set Admission and Discharge Reports, SAMHSA,
2004.
Slide 17
Residential Retention Rate Finish Treatment No Transfer: 51%
Successful transfer: 4% Transfer; No connect: 10% Dont finish:
34%
Slide 18
Outpatient/IOP Retention Rate Finish Treatment, No transfer:
36% Dont finish: 51% Successful transfer: 7% Transfer, No Connect:
7%
Slide 19
When we add them together 170,000 dont connect to next LOC in
14 days 250,000 not transferred from Detox to next LOC 770,000
leave treatment before goals met 1,190,000 opportunities for
improvement?
Slide 20
Luckily, we know a few things about process improvement!
Slide 21
NIATx: Network for the Improvement of Addiction Treatment NIATx
teaches behavioral health providers to use a simple process
improvement model, developed under the leadership of Dr. Dave
Gustafson, to improve access to and retention in treatment for all
clients.
Slide 22
NIATx Mission To improve care delivery in order to help people
live better lives To become the premier resource for systems and
process improvement for behavioral health services
Slide 23
Why Process Improvement? Customers are served by processes. 85
percent of customer-related problems are caused by processes. You
must improve your processes to better serve customers. CUSTOMERS =
CLIENTS
Slide 24
Why Organizational Change? Small changes do increase client
satisfaction. Satisfied clients are more likely to show up and
continue their treatment. More clients in treatment make your work
more rewarding. More admissions and fewer drop-outs improve the
bottom line.
Slide 25
Small Changes, Big Impacts Small changes make a big difference
for both clients and staff Effective changes do not have to be
expensive
Slide 26
The NIATx Model: An Introduction
Slide 27
Four NIATx Project Aims Reduce Waiting Times Reduce No-Shows
Increase Admissions Increase Continuation Rates
Five Key Principles Understand and involve the customer Fix key
problems Pick a powerful Change Leader Get ideas from outside the
organization Use rapid-cycle testing
Slide 30
The Business Case: The Sixth Principle Commitment to improving
processes can help solve key problems fundamental to organizational
performance The ability to operate at a positive margin The ability
to attract funding The ability to attract & retain staff
members
Slide 31
1. Understand & Involve the Customer Most important of the
Five Principles What is it like to be a customer? Your staff can be
considered customers, too. Conduct walk-throughs Hold focus groups
and do surveys
Slide 32
2. Focus on Key Problems What keeps the CEO awake at night?
What processes do staff and customers identify as barriers to
excellent service?
Slide 33
3. Powerful Change Leader The Change Leader must have
Influence, respect, and authority across levels of the organization
A direct line to the CEO Empathy for all staff members Time devoted
to leading Change Projects
Slide 34
4. Ideas from Outside Organization Real creative
problem-solving comes from looking beyond the familiar Provides a
new way to look at the problem Access Walk-in clinics in Wal-Mart
Client Engagement Hair Dressers Coffee Shops Client Handoffs
National Rental Car Hyatt Hotels
Slide 35
5. Rapid Cycle Changes Pilot tests or experiments Two-four week
cycles Many small changes can quickly add up to make a big
impact
Slide 36
Role of the Executive Sponsor Senior leader in the agency Must
see change/improvement as a priority Identifies the problem and
articulates the vision Demonstrates commitment to the process
(time, resources) Empowers the change leader
Slide 37
Selecting a Change Leader Person has sufficient power and
respect to influence others at all levels of the organization.
Person has the ability to: instill optimism, has big-picture
thinking, is focused and goal-oriented, and has a good sense of
humor.
Slide 38
Change Leader Responsibilities Serves as a catalyst to develop
ideas Successful communicator: facilitates change team meetings, is
consistent, concise (data), creative, engaging (incentives), and a
skilled listener. Minimizes resistance to change Keeps the
Executive Sponsor updated on change team activities
Slide 39
The ACTION Campaign: An Introduction
Slide 40
What is the ACTION Campaign? The ACTION Campaign provides
easily adoptable practices that NIATx members have tested in the
field
Slide 41
Why this Campaign? The field is ready for a transformation The
ACTION Campaign promotes a set of changes that many organizations
in the addiction treatment field are ready to make
Slide 42
An Unprecedented Partnership Leading organizations join to
reach the widest possible audience No single organization has ties
to all the addiction treatment providers across the country
Slide 43
Our Growing List of Partners American Association for the
Treatment of Opioid Dependence Addiction Technology Transfer
Centers Faces and Voices of Recovery Join Together Legal Action
Center National Association of Addiction Treatment Providers
National Association of Alcohol and Drug Abuse Counselors
Slide 44
Our Growing List of Partners National Association of State
Alcohol and Drug Abuse Directors National Council for Community
Behavioral Healthcare Robert Wood Johnson Foundation State
Associations of Addiction Services Substance Abuse and Mental
Health Services Administration Center for Substance Abuse Treatment
Treatment Research Institute
Slide 45
The Formula 500 treatment agencies implementing one
intervention to increase access, engagement or level of care
transition over 18 months will impact 55,000 lives affected by
addiction
Slide 46
Three ACTIONs that Make a Difference 1.Provide rapid access to
services 2.Improve client engagement 3.Create a seamless transition
between levels of care
Slide 47
The ACTION Campaign www.actioncampaign.org Join Today!
Slide 48
Slide 49
Slide 50
Why a Walk-through? The walk-through Helps understand the
customer and organizational processes Provides a new perspective
Allows you to feel what its like Lets you see the process for what
it is Seeks out and identifies real problems Generates ideas for
improvement Keeps you asking why?and why? again
Slide 51
How to Do a Walk-Through 1.Agency director or executive sponsor
plays the role of client and or family member 2.Inform staff and
clients if needed, in advance that you will be doing the walk
through 3.Encourage staff to treat you as they would a client; no
special treatment 4.Think, feel, observe 5.Record observations and
feelings 6.Involve staff, get their feedback
Slide 52
The Walk-Through Write-Up First contact First Appointment The
Intake Process Transition between level of service - The Handoff.
What surprised you? What two things would you like to change
most?
Slide 53
E.T. Phone Home Here is your mission: Call your agency to
request an assessment appointment
Slide 54
E.T. Phone Home 1.What did you learn? 2.How easy was it to
reach a live person? 3.How were you greeted? 4.What information was
requested? 5.How long was the wait for the next available
appointment? 6.What would you change?
Slide 55
Sample Walk-Through Results Strengths No waiting Efficient
intake process Positive group experience Friendly staff
Slide 56
Sample Walk-Through Results Opportunities Long intake process
Lots of paperwork No privacy No family services
Slide 57
Quick Start Road Map A graphic series of steps to make it
easier to plan and implement a change Steps divided into management
and change team responsibilities Assures that critical steps in the
process will not be skipped
Slide 58
Slide 59
Quick Start Road Map Management responsibilities: 1.Do a needs
assessment and identify a problem important to management
Walk-Through Focus Groups Existing Data 2.Establish a target
objective Achievable Specific Measurable
Slide 60
Quick Start Road Map Management responsibilities: 3.How will
the change be measured? Simple Quick Accessible Who can record the
data? How frequently can it be gathered and summarized? TIP: Data
driven decisions are more objective and more readily accepted TIP:
Without data you have no way to gauge the success or effectiveness
of a new practice
Slide 61
4.Who will be on the Change Team? Change Leader 3-5 Members
Work together until success is achieved 5.Instructions for the Team
Clear statement of problem with data Clear objective Priority for
improvement Promise of support and commitment Quick Start Road Map
Management responsibilities:
Slide 62
Plan Define the change behaviorally precisely what will be
done? Who will implement the change? What preparation needs to be
done before starting the change? Clarify who will measure the
change and who will review the data regularly to share with the
team.
Slide 63
Do Note the exact start date for the cycle How long will the
initial test last? How often will the team meet to assess progress
and review data? During the test, the team considers what
improvements might need to be made to improve the results
Slide 64
Study After the agreed upon test period the team reviews the
results Change leader (or designated change team member) assembles
and graphs the data for the team The team deliberates what it has
learned Based on the learning, the team considers whether a change
in strategy is in order
Slide 65
Act (Adopt, Adapt, Abandon) In light of what has been learned,
the team decides what to do next Make an adjustment in the strategy
to get closer to the objective Increase the objective (adapt) if
the initial target has been met and the team believes even more
progress can be made Combine another change (adapt) with the
existing strategy to start a new cycle Abandon the existing
strategy and start a new cycle
Slide 66
It is important to remember It often takes more than one cycle
to achieve your objective. By changing only 1 thing at a time you
know the impact of your change. Sometimes several changes are
necessary to maximize the improvement you seek.
Slide 67
Rapid-cycle Testing Start by asking five questions: 1.Whats 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?
Slide 68
Making Changes PDSA Cycles Plan the change Do the plan Study
the results Act on the new knowledge Adapt Adopt Abandon
Slide 69
Process Improvement Hunches Theories Ideas Changes that Result
in Improvement AP SD A P S D AP SD D S P A DATA SOURCE: Langley,
Nolan, Nolan, Norman, & Provost. The Improvement Guide, San
Francisco, Jossey-Bass Publishers, 1996
Slide 70
The Airplane Exercise Description: A small group activity to
demonstrate use of the PDSA cycle Objective: Learn how to use the
PDSA approach with a team in order to achieve a specific aim
Slide 71
The Airplane Exercise Instructions 1.PLAN: Design a paper plane
using the materials provided. Set an aim and measure for your team
what do you want to accomplish? 2.DO: Choose one person to be the
flier. Have them make three flights. 3.STUDY: After each test
flight, the data coordinator should measure the distance the plane
traveled down the runway and record this on the change project
form. Calculate the average distance for the three flights. 4.ACT:
Based on the measurements, review the design of your plane and look
for improvements (what can we do that will result in an
improvement). Make just ONE change to the design of the plane, and
repeat steps 1-4 until you have collected data for 3 cycles
(original design cycle + 2 change cycles).
Slide 72
The Importance of Data
Slide 73
Power of Two
Slide 74
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
Slide 75
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
Slide 76
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
Slide 77
Why Is Data So Important?
Slide 78
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? SOURCE: Langley, Nolan, Nolan, Norman, & Provost.
The Improvement Guide, San Francisco, Jossey-Bass Publishers,
1996
Slide 79
7 Simple Rules of the Road Define measures Collect baseline
data Establish a clear aim Consistent collection Avoid common
pitfalls Report and Chart progress Ask questions
Slide 80
Rule 1: Define Measures Establish clear definitions Clarify
project aims Agreed upon by key stakeholders
Slide 81
Establishing Clear Definitions Example suggested measures Time
from First Contact to Assessment # of clients attending
assessment/intake appointment % of clients attending their 1 st
four post-admission sessions Measure definition Elapsed Time from
Date of Assessment () Date of 1 st Contact # of clients with
scheduled assessment/intake appointment () # of clients who
actually attend assessment/intake appointment # of clients with
four post-admission sessions (/) # of admissions
Slide 82
Rule 2: Establish a Baseline Never start a project without it
Define a clear starting point Use agreed-upon definition
StartFinish
Slide 83
Baseline Data Serve as a meaningful road map Helps answer the
question: How will we know a change is an improvement? Use tools to
collect a adequate baseline information The time period for the
baseline will vary by Measure Agencys size Ease of Collection
Preferred Sample Size is at least 40
Slide 84
Baseline Data Examples Average time from 1 st Contact to
Assessment is 35 Days 40% of our assessments are no-shows Only 30%
of our clients receive four units of service in 30 days Only 25% of
Detoxification Discharges connect with the next level of care
Slide 85
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 agencys
capacity to improve
Slide 86
Defining Your Project Aim: The Good and the Bad 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 1 st Contact to Assessment from 28 to 7 days
Slide 87
Rule 4: Consistently Collect Data The length of time necessary
to test a change will vary depending on an agencys 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
Slide 88
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
Slide 89
Dates before their time Dates out of sequence Long lag
times
Slide 90
Stay out of the Quicksand Dont collect too much data Dont focus
on too many measures Dont get trapped in analysis paralysis
Slide 91
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
Slide 92
Sample Chart
Slide 93
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?
Slide 94
Data Summary Determine what you will measure Establish a system
to collect key data elements Gather your baseline Define your aim
Collect data often and consistently Evaluate the impact One chart,
one message Ask questions
Slide 95
The 12 ACTION Kits Provide Rapid Access to Services Engage
Potential Client on 1st Call Express Check-In Increase Efficiency
and Capacity Where is the Front Door? Improve Client Engagement
Make Clients Feel More Welcome What's In It For Me? Use
Confirmation Systems That Work Counselor Feedback Create Seamless
Transitions Between Levels of Care Make Connections with the Next
Level of Care Express Check-In and Check-Out Introduce Clients to
Ongoing Supports Evaluate the Hand-Off
Slide 96
Slide 97
Slide 98
Slide 99
Slide 100
Change Project Form Details the project charter Chosen aim,
baseline, change team members, agency demographics, etc. Helps to
track progress with change project (PDSA cycles) Provides space for
lessons learned, business case, and sustainability plan
Slide 101
Quick Start Road Map Change Team responsibilities:
6.Collaborate on what contributes to the maintenance of the problem
Agency processes Variability in staff performance External
situation or factors Service design Unclear expectations Lack of
knowledge or skill Agency policy Others?
Slide 102
Quick Start Road Map Change Team responsibilities: 7.What
changes might achieve the objective? Be creative, think outside the
box Brainstorm/Nominal Group Technique Gather information from
other treatment agencies Assess how other industries deal with this
problem 8.Prioritize the ideas and select a strategy
Slide 103
Quick Start Road Map Change Team responsibilities: 9.Outline
the process to be used What will be done? Who will be responsible
at each step? What resources are needed to implement the change?
10.What data will be gathered to assess progress? What measures
will be used? Who will gather the data? Who will review and analyze
the data?
Slide 104
Quick Start Road Map Change Team responsibilities: 11.How will
progress be monitored? Who will monitor fidelity with the planned
change? How will mid-course adjustments be made? Who will gather
data and chart progress? How often will the Team meet to assess
progress and determine need for modifications? 12.Who will maintain
a record of Team deliberations, decisions and steps taken?
Slide 105
Slide 106
Nominal Group Technique Silent Writing Each person share one
solution Are there any missing? Get out the vote! Top three Where
do we begin?
Slide 107
Keys to Change Project Success 1.Have a clear objective
2.Implement only 1 new thing at a time 3.Make sure everyone
implements change as planned 4.Start small 5.Study the results
before making modifications 6.Do not hesitate to start a new
cycle
Slide 108
So, making changes in service processes can improve your
Financial bottom line Organizational climate Relationship with
referral sources Staff retention Client satisfaction Treatment
outcome Other indicators important to agency
Slide 109
Capitol Region Learning Collaborative Discussion: What are our
goals? How do we want to accomplish them? What are the next
steps?
Slide 110
Next Steps Conducting agency walk-through Scheduling monthly
learning collaborative conference calls Data submission via the
ACTION Campaign website Participating in evaluation activities
Opportunities for ongoing technical assistance