Southern California Learning Collaborative Kick-Off Workshop

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Southern California Learning Collaborative
Kick-Off Workshop
Presented by Beth Rutkowski, MPH, and Kimberly
Johnson, MSEd, MBA April 2, 2009 Rialto,
California
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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

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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

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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

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What do we plan to cover today?

• How to measuring the impact of change
• How to brainstorm possible solutions and motivate
  a change team
• Next steps and networking opportunities

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Learning Collaboratives
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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

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The Culture of Learning Collaboratives

• Data Driven
• Dialogue and Discussion
• Celebrations

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Data-Driven

• Baseline Data
• Keep it simple/manageable
• Sustainability
• Use existing sources of data
• Real-time data

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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

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Celebrate!
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Motivate the Collaborative Members

• Record and celebrate
• success (need data)
• Acknowledge performance of team
• members, and whole change teams
• Provide support and share experiences

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The Reality

• 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

SOURCE Natl Survey on Drug Use Health,
SAMHSA, 2006.
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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.
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Detox Retention Rate
Successful Transfer 4
Transfer, No Connect 12
Dont finish 23
Finish Detox, No Transfer 61
SOURCE Treatment Episode Data Set Admission
andDischarge Reports, SAMHSA, 2004.
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Residential Retention Rate
Successful transfer 4
Transfer No connect 10
Finish Treatment No Transfer 51
Dont finish 34
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Outpatient/IOP Retention Rate
Successful transfer 7
Finish Treatment, No transfer 36
Dont finish 51
Transfer, No Connect 7
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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?

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Luckily, we know a few things about process
improvement!
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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.

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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

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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
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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.

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Small Changes, Big Impacts

• Small changes make a big difference
  for both clients and staff

• Effective changes
  do not have to be expensive

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• The NIATx Model
• An Introduction

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Four NIATx Project Aims

• Reduce Waiting Times
• Reduce No-Shows
• Increase Admissions
• Increase Continuation Rates

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NIATx Results

• Reduce Waiting Times 51 reduction (37 agencies
  reporting)
• Reduce No-Shows 41 reduction
• (28 agencies reporting)
• Increase Admissions 56 increase (23 agencies
  reporting)
• Increase Continuation 39 increase (39 agencies
  reporting)

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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

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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

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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

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2. Focus on Key Problems

• What keeps the CEO awake at night?
• What processes do staff and customers identify as
  barriers to excellent service?

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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

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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

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5. Rapid Cycle Changes

• Pilot tests or experiments
• Two-four week cycles
• Many small changes
• can quickly add up to make a big impact

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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

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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.

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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

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• The ACTION Campaign
• An Introduction

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What is the ACTION Campaign?

• The ACTION Campaign provides easily adoptable
  practices that NIATx members have tested in the
  field

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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

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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

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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

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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

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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

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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

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The ACTION Campaign
Join Today!

• www.actioncampaign.org

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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

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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

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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?

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E.T. Phone Home

• Here is your mission
• Call your agency to request an assessment
  appointment

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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?

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Sample Walk-Through Results

• Strengths
• No waiting
• Efficient intake process
• Positive group experience
• Friendly staff

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Sample Walk-Through Results

• Opportunities
• Long intake process
• Lots of paperwork
• No privacy
• No family services

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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

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Quick Start Road MapManagement responsibilities

• Do a needs assessment and identify a problem
  important to management
• Walk-Through
• Focus Groups
• Existing Data
• Establish a target objective
• Achievable
• Specific
• Measurable

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Quick Start Road MapManagement responsibilities

• 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

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Quick Start Road MapManagement responsibilities

• Who will be on the Change Team?
• Change Leader
• 3-5 Members
• Work together until success is achieved
• Instructions for the Team
• Clear statement of problem with data
• Clear objective
• Priority for improvement
• Promise of support and commitment

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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.

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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

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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

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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

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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.

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Rapid-cycle Testing

• Start by asking five questions
• Whats it like to be our customer?
• What are we trying to accomplish?
• How will we know if a change is an improvement?
• What changes can we test that may result in an
  improvement?
• How can we sustain the improvement?

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Making Changes

• PDSA Cycles
• Plan the change
• Do the plan
• Study the results
• Act on the new knowledge
• Adapt
• Adopt
• Abandon

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Process Improvement
Changes that Result in Improvement
DATA
Hunches Theories Ideas
SOURCE Langley, Nolan, Nolan, Norman, Provost.
The Improvement Guide, San Francisco, Jossey-Bass
Publishers, 1996
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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

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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).

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The Importance of Data
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Power of Two
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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
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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/1st Treatment Session
who get a 4th Treatment Session
1. Date of First Treatment Session 2. Date of
Fourth Treatment Session
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How does that translate to measuring the impact
of change?
1. Date of First Contact 2. Date of Assessment 3.
Date of Admissions

1. Three Counts
2. Two Conversion Numbers
3. Three Elapsed Time Figures

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Why Is Data So Important?
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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
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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

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Rule 1 Define Measures

• Establish clear definitions
• Clarify project aims
• Agreed upon by key stakeholders

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Establishing Clear Definitions

• Example suggested measures
• Time from First Contact to Assessment
• of clients attending assessment/intake
  appointment
• of clients attending their 1st four
  post-admission sessions
• Measure definition
• Elapsed Time from Date of Assessment () Date of
  1st 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

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Rule 2 Establish a Baseline

• Never start a project without it
• Define a clear starting point
• Use agreed-upon definition

Start
Finish
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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

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Baseline Data Examples

• Average time from 1st 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

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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

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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 1st Contact to Assessment by 20
  days
• Yes ? Time from 1st Contact to Assessment from
  28 to 7 days

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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

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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

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Stay out of the Quicksand

• Dont collect too much data
• Dont focus on too many measures
• Dont get trapped in analysis paralysis

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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

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Sample Chart
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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?

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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

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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

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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

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Quick Start Road MapChange Team responsibilities

• 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?

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Quick Start Road MapChange Team responsibilities

• 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
• Prioritize the ideas and select a strategy

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Quick Start Road MapChange Team responsibilities

• 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?
• 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?

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Quick Start Road MapChange Team responsibilities

• 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?
• Who will maintain a record of Team deliberations,
  decisions and steps taken?

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Nominal Group Technique

• Silent Writing
• Each person share one solution
• Are there any missing?
• Get out the vote!
• Top three
• Where do we begin?

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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

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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

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Southern California Learning Collaborative

• Discussion
• What are our goals?
• How do we want to accomplish them?
• What are the next steps?

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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

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Contact Us!

• Beth Rutkowski
• 310-388-7647 brutkowski_at_mednet.ucla.edu
• Kim Johnson
• 207-252-9950
• Kimberly.johnson_at_chess.wisc.edu

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Thank you for coming!