Improving Performance in Behavioral Health using the NIATx Model

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Improving Performance in Behavioral Health
using the NIATx Model

• Nancy Paull, CEO Executive Sponsor
• Patricia Emsellem, COO Change Team Leader

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• 1) Fall River, MA 2) North Kingston RI 3)
  Cranston RI

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• Providing addiction treatment since 1977
• Opened an outpatient mental health clinic in 1987
• Has provided integrated behavioral health since
  the early nineties
• Opened inpatient dual diagnosis unit in 1999

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Fall River Inpatient Services
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Inpatient Services Was Losing Money at Alarming
Rate. Year End Net
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SSTAR Inpatient Department

• Total beds 66
• Detox. Capacity 20 beds
• Dual Diagnosis Detox 17 beds
• Male Step-Down Unit (SOAP) 20
• Female SOAP Unit 9 beds

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Dual Diagnosis (DDS) Unit

• Dual Diagnosis Enhanced Level III Detox
• Psychiatric assessment and medication management
• Staff trained in co-occurring disorders
• Staffed by counselors, milieu therapists, RNs.
• Program Director is a psychiatric nurse clinician
• Medical Director is a psychiatrist

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NIATX Five Key Principles

• Understand the Customer
• Pick a project that keeps the CEO awake at night
• Pick a powerful change leader
• Get ideas from outside the organization/field
• Use Rapid Cycle Testing

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Project AimIncrease Average Daily Census on DDS
by One Bed Day.

• One bed day 116,000 per year revenue
• ADC in year before project 13.77
• Goal 14.77

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The Change Team

• Includes leadership and front-line workers

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Rapid Cycle Process Improvement

• PDSA Cycles

Changes That Result in Improvement
DATA
Hunches Theories Ideas
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4 primary PDSA cycles in this change project with
2 contingent change projects

• Fill Admission Nurse Slot
• Offer transportation to incoming referrals
• Streamline admission approval process
• Dedicated admission phone line for select
  psychiatric hospitals

Reduce Forced OT for Nurses
Improve Nurse Retention
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Increase Nurse Retention Improve the Nursing
Orientation

• Understand the customer
• Interview one of the newly-recruited nurses who
  left before the orientation period
• Include her on the change team

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Reduce Forced OT

• Collect baseline data
• Consult with customer nurses
• Design intervention
• Halo effect ? - significant improvement took
  place before change was implemented

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1. Fill Admission Nurse Slot

• Admission nurse available Monday through Friday
  10-6
• ADC that week 12

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Data did not support a direct correlation between
filling Admission Nurse slot and of admissions
or average daily census.
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Just because something doesn't do what you
planned it to do doesn't mean it's
useless.-Thomas Edison
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Nursing OT reduced staffing stabilized
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Changes to Orientation contributed to reduced
drop-out and reduced orientation costs
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2. Offer Transportation

• Psychiatric hospitals notified that SSTAR would
  have driver available to pick up referred
  patients at their facility two afternoons a week.
• Added Admission Nurse coverage on those two
  evenings
• ADC 13.86

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3. Streamline Admission Approval Process

• Know your customer delay in admission decision
  did not meet their needs.
• For preferred psychiatric hospitals no need for
  DDS nurse to review case first. If theres a bed,
  the admission request is yes.
• Daily fax to these preferred psychiatric
  hospitals
• ADC 14.43

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4. Dedicated Phone Line for preferred referring
hospitals

• Special admission phone line for preferred
  hospitals
• Number included on daily fax to these hospitals
  announcing bed availability
• Rings on portable phone kept with admission
  person at all times.
• No voice mail, always live person, with yes
  response to request for admission as long as
  theres a bed.

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Inpatient Department Operates in the Black
SSTAR Inpatient Services Year End Net
250,000
200,000
150,000
100,000
50,000
0
(50,000)
FY 2004
FY 2005
FY 2006
30-Mar-
(100,000)
07
(150,000)
(200,000)
(250,000)
Dual Diagnosis Unit
Inpatient Department
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Other change projects at SSTAR

• Increased treatment continuation on inpatient
  detox, reduced AMAs, increased the of
  patients who completed treatment
• Improved access for Ambulatory Behavioral health
  and financial position of that department with an
  open access Intensive Outpatient program.

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Walkthrough

• Staff person, Mary, experienced admission to
  detox as though she were a client.
• Admission and Detox staff were informed of
  project.
• Mary called for admission, went through the
  admission process, was given a bed, and
  participated in treatment on the unit.
• Wrote up her experiences and made a presentation
  to staff.

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Understand the customer Why do they leave
inpatient AMA ?

• Asking the customer doesnt always yield usable
  information
• Exit interviews
• Post discharge phone interviews
• Client satisfaction surveys
• These client inquiries revealed no trends.

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Open Access IOP Has Positive Impact on Net for
Ambulatory Behavioral Health Department
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Understand the customer

• Meeting the client where they are
• Admission and participation in IOP same day or
  next day of request
• Clients who show up that day select the group
  content for that day depending on where they are
  at the time what will be most helpful

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NIATx model of process improvement

• Small changes can yield significant improvements
  in
• Treatment access
• Treatment outcomes
• Customer-client,referring organizations,staff -
  satisfaction
• Financial position of the organization
• Staff recruitment retention
• CEO sleeps better.