A Quick Primer - Rapid Cycle Process Improvement

1
A Quick Primer - Rapid Cycle Process Improvement
(PI 101)

Reduce Waiting  No-Shows ? Increase Admissions 
Continuation
2
NIATx was originally a partnership oftwo grant
programs in 2003

• SAMHSA/CSAT
• Strengthening Treatment Access and Retention
• and
• The Robert Wood Johnson Foundation
• Paths to Recovery

3
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
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
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
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
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
NIATx Aims

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

9
Five Key PrinciplesEvidence-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
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
Conducting a Walk-through

• Play the role of a client and a clients 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
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
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
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
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
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
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
Teach me Rapid Cycle Style

• Coach Academy
• Madison, WI March 2011
• Pauley Johnson

19
Exercise Objective

• Practice elements of coaching
• Teaching basic concepts
• Role Playing initial meetings with key players

20
Coaching for Change

• People dont mind change, but dont 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 cant avoid getting a little dirty in the
  process

21
Key NIATx Elements

• 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

22
Tips for Preparing Your Presentation
23
Principles of Adult Learning

• Involvement with plans
• Learn by doing
• Successive attempts result in competence

24
People Learn in Different Ways

• Provide different avenues for learning material
• Hearing, Seeing, Touching/Doing
• Repeat message in different ways
• Keep it simple

25
Plan to teach

• What is the objective?
• What will hold interest?
• What will be done to reinforce and provide
  opportunities for practice?

26
Elements of presentation

• Repeat main message
• Pictures are worth a thousand words
• Hands on
• How will you involve audience?
• Practice
• Sincerity counts

27
Review and Evaluate

• What can be improved?
• What would you do differently next time?
• Feedback from audience

28
Your Job

• 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

29
Can You Hear Me Now? Using Appreciative Inquiry
for Developing Change Projects

• Pauley Johnson and Lynn Madden
• Coach Academy,
• Madison, WI March, 2011

30
AI Background

• 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

31
Three Phases

• 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.

32
Phase 2 Dreaming

• 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

33
Phase 3 Design

• Utilizing information from Discovery and Dreaming
  phases, participants come up with ideas for
  change cycles.

34
Instructions for reporters

• 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

35
Exercise

• 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

36
The Coaching Toolbox

• Coach Academy
• Madison, WI March 29. 2011
• Pauley Johnson

37
When teaching PDSA isnt enough

• Starting out doing rapid cycle improvement
  doesnt always go smoothly.
• What do we do then??

38
Starting Out Right

• 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

39
Deciding on a Change Project

• Understanding the customer
• Walk Through
• Convenience Samples
• Phone Sampling
• Alternative walk throughs e.g. billing guide
• Understanding processes
• Flow charting
• Root Cause Analysis

40
Getting a Change Team Started

• Exec Sponsor special invitations
• Exec Sponsor spells out
• Project and its 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

41
Encouraging team member participation

• 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

42
Developing Change Cycles

• Nominal Group Technique
• Appreciative Inquiry
• Creativity Techniques
• Ideas outside Agency -- benchmarking

43
Keeping a Change Team Moving

• 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 cant happen or
  arent necessary
• Simple data collection
• Timeline

44
Resolving Team Conflicts

• DeBonos 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

45
Out of SiteOut of Mind Planning an Introductory
Site Visit
Overview
46
Site Visits
Sometimes we are surprised by what we find.
2
47
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
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
1. Seeing the Facility Meeting Staff
You may find pleasant surprises or encounter
situations that need to be addressed in order for
the agency to succeed in its improvement projects

5
50
2. Assess Key Roles

• Executive Sponsor commitment and understanding of
  role
• Change Leader potential for success
• Change Team membership and operating procedures

6
51
A Committed Executive Sponsor is Good to Find
7
52
Every Change Leader has strengths and limitations
8
53
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 1st page of the QSRM?

9
54
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
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
6. Project Timeline

• Review key dates on the timeline and clarify
  when next contacts will take place

11
57
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
The Ideal Coach
59
Airplane Game

• Team Change Package

60
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
6 Simple Rules

• Only one design change per PDSA cycle
• All planes must have wings and be able to glide
• Teams must have their PDSA sheet checked by air
  traffic control before they do a test flight
• Each design must be flown by three different test
  pilots
• A flight is in the runway band
• if it touches the tape

62
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
What to DO at Each Step

1. Plan
2. Record what theory or hunch you are going to test
3. Record what you are going to do and how
4. Predict your results (not just accuracy and
   distance, also consider other characteristics)
5. Do
6. Create the plane
7. Fly it 3 times, with 3 different pilots
8. Record the distance of each flight
9. Record the runway band that each flight landed in
10. Study
11. Compute the average distance and plot it on the
    graph
12. Compute the total runway landing band points and
    plot it on the accuracy graph
13. Discuss the results and what you have learned
14. Act
15. Decide what to do for the next PDSA cycle
16. What will you abandon, what will you adapt, what
    will you adopt

64
PDSA Worksheet
PLAN

DO

STUDY

ACT

Theory you want to
What happened?
Results

test

What worked? What didnt? What did you Learn?
Distance
On



(feet)

Runway



1




2




3



What and How

Total




Average






Predicted Results






65
PDSA Worksheet
PLAN

DO

STUDY

ACT

Theory you want to
What happened?
Results

test

What worked? What didnt? What did you Learn?
Distance
On



(feet)

Runway



1




2




3



What and How

Total




Average






Predicted Results






66
PDSA Worksheet
PLAN

DO

STUDY

ACT

Theory you want to
What happened?
Results

test

What worked? What didnt? What did you Learn?
Distance
On



(feet)

Runway



1




2




3



What and How

Total




Average






Predicted Results






67
Distance Data
68
Accuracy Data
69
Airplane Change Package Measures
Problem Changes Measures
Short Flight Distances Use heavier paper Change launch Flight distance on straight line
Nose Dives Add tape weight to rear to prevent Percent nose dives
Wanders Off-Target Reinforce plane body with staple Distance from straight path
70

• THE NIATx WAY START UP

71
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
2) Define Project

• ? What level of care?
• ? Which location (if more than one)?
• ? What is the targeted population?

73
3) Who has been appointed Change Leader ?
74
4) Who else has been appointed to the Change
Team? Send formal invitation.

• 2.
• 3.
• 4.
• 5.
• 6.
• 7.

75
5) Has the Executive Sponsor allocated sufficient
resources?

• ? Of Change Leaders time
• ? Coverage for counselors billable hours
• ? Change Team members time
• ? Other ___________________________

76
6) How will the Executive Sponsor monitor
progress?

• ? Read minutes
• ? Meet with Change Leader weekly
• ? Follow tracking measure
• ? Other ______________________

77
7) Walk-through Whats 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
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
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
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
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?
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
STUDY (S) What are the results? How do they
compare with the baseline measure? Was the
promising practice tested as planned?
82
12) How did these promising practices improve
the bottom-line?

• ? Reduce costs?
• ? Increase revenue?
• ? Increase staff retention?

83
13) How can you sustain the gains?

• ? Appoint Sustain Leader
• ? Select target sustain measure
• ? Plan for relapse
• ? Plan for staff turnover
• ? Other _____________________________

84
14) How can you tell your story?

• ? Storyboard
• ? PowerPoint
• ? Elevator Speech
• ? Other ________________

85
15) What project is next?

• Go back to 1.

86
Techniques for Jumpstarting Creative Thinking1

• 1 See Joel Saltzman, Shake That Brain, 2006, John
  Wiley, for further ideas

87
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 cant,
  you are absolutely right. Henry Ford

88
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 its not
  necessarily the case?
• Boston Standup Stapler
• KB Homes (people want basements)

89
Change/Adapt Dont Throw Out

• Warner Bros, Looney Tunes development
• Held yes meetings ideas could be changed but
  not thrown out
• Reid Hastings Netflix
• Step 1 rent dvds over Internet
• Step 2 subscription service
• Step 3 download dvds directly off Internet

90
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
Restate Problem from Multiple Views

• Clients not getting from detox to 1st 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
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
Look for Worst Possible Solution

• A real solution, not an anti solution
• Tweak it to make good
• Woolmarks summer weight wool promo
• Sheep in Central Park in Aug
• Models w/ sheep on leash Madison Ave
• 8 million media impressions (not BAAAAD)

94
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
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
A Spoonful of Sugar makes the Medicine go Down-
Or is it a Cup
Overview
97
Some is not a number, soon is not a time. --
Don Berwick, MD
98
Overview

• Overview
• Power of 2
• Big A vs. Little A
• Seven Simple Rules

99
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
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
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
Using data to make decisions
Impact
Comparisons
Gaps
Direction
Problems
Cost Effective
103
WHY IS THIS IMPORTANT?
104
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 ImprovementReference Langley, Nolan,
Nolan, Norman, Provost. The Improvement Guide,
San Francisco, Jossey-Bass Publishers, 1996
105
What do I need to Know?
106
Todays Session is brought to you by the
107
Power of Two
108
What do you need to know?

• 2 Categories
• Deposits
• Expenditures

(Title)
Name(s) of presenter(s) Organizational Affiliation
109
How does this knowledge help?

• Deposits
• Number of Deposits
• Total Amount In
• Expenditures
• Number of Checks Written
• Total Amount Out

110
What can you do with the knowledge?

• Net Profit Deposits - Expenditures

111
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
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
How does that translate to measuring the impact
of change?
1. Date of First Contact 2. Date of Assessment
1. Number of First Contacts 2. Number of
Assessments 3. Elapsed Time 4. Assessment
Conversion
114
How does that translate to measuring the impact
of change?
1. Date of First Treatment Session 2. Date of
Fourth Treatment Session
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
115
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

116
And by the
117
What are your aims?

• Big A (for aim)
• Reduce readmissions
• Little A (for aim)
• Intermediate measure

118
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
Sample Little A Data

• Admission
• In addiction treatment?
• Medication adherence
• In treatment
• Engagement/participation
• Post Level
• Successful Transition

120
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
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
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
Getting the numbers right
124
SEVEN SIMPLE RULES FOR MEASURING THE IMPACT OF
CHANGE
125
Rule 1 Define Measures

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

126
Rule 2 Establish a Baseline

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

Start
Finish
127
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

128
WHAT ARE EXAMPLES OF A GOOD AIM?
129
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 1st Contact to Assessment by 20
  days
• Yes ? Time from 1st Contact to Assessment from
  28 to 7 days

130
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

131
How to encourage consistenty?

• What steps can you take?
• What advise might you offer to another agency
  having trouble with data collection?

132
WHAT ARE DATA CHALLENGES YOU HAVE ENCOUNTERED AND
HOW DID YOU DEAL WITH THEM?
133
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
EXAMPLE SPREADSHEET
135
Stay out of the Quicksand

• Dont collect to much data
• Dont focus on too many measures
• Dont get trapped in analysis paralysis
• Ask a yes or no question of your data

136
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
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
Example Chart
139
(No Transcript)
140
Use Trendlines
141
(No Transcript)
142
CHANGES MAY HAVE MULTIPLE IMPACTS
143
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 YOUVE ENCOUNTERED?
144
Impact of Change on Other Areas
145
(No Transcript)
146
(No Transcript)
147
No-Show Exercise
148
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
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
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
Exercise in Helping Providers Understand Data
Issues
152
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
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
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
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
Sustaining the Gains It takes a plan - What
family of strategies can help us maintain the
important changes we have made?
157

• 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

• 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

• 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

• 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

• What is the general stage of adoption of your
  organization? How can understanding where your
  team/organization is help you move forward?

162

• What is the Business Case/strategic advantage
  and/or clinical gain for the Improvement and
  Sustainability?

163

• How about executive focus how can we keep it on
  performance improvement? What culture shifts
  occur as PI becomes more common?