HIV-STICNovember 8, 2011

NIATx Tools for Effective Change

Reduce Waiting & No-Shows Increase Admissions & Continuation

NIATx opportunities for tomorrow

NIATx opportunities for tomorrow

Over 13,000 Over 13,000 substance abuse substance abuse

treatment providers treatment providers nationwide.nationwide.

Reduce Waiting & No-Shows Increase Admissions & Continuation

Conducting a Walk Through

How does the client experience services?

The walk-through is a cornerstone of NIATx process. A walk-through is an exercise that allows you to experience your services exactly as your customers do.

Why do a walk-through?

• Value in seeing your services from a new perspective.

• We make assumptions about how services are being delivered that may not reflect what actually happens.

• The walk-through can identify low-cost opportunities for improvement that can make a big difference in engaging and retaining clients

How to do a walk-through

• Plan – let staff know, client and recorder

• Do – try to think and act as client would

• Do – ask staff what changes @ each step, record your own ideas (no cost improvements)

• Study – make a list of changes to discuss with team, share results with Executive Sponsor

Act on the Results

• Discuss how to incorporate relevant change ideas into your project

• Have the ES decide how to handle ideas not directly related to your project

• Use PDSA to implement any change that the ES wants to implement immediately

• Share your lessons learned about doing walk-throughs in your organization

Results of Walkthrough: “low hanging fruit” – Update magazines in waiting room– Inexpensive radio for “tasteful” music– On sale “décor” within budget– Refill cups for water bubbler– “low maintenance” flowers– Bulletin board with program information– Seating for paperwork– Local Commuter Rail & community – How do we give directions to our office?– Get clients involved

Ayer MA DC Process Problems with Admissions

• Identified “front door problems” = calls for intakes going to voicemail leading to a delay in services:– phone system needed upgrade– Vacant admin staff position– Under-utilization of centralized scheduling system– Clinicians with low productivity– Missed opportunity to increase business which could

help sustain grant funded drug court

NIATx opportunities for tomorrow

NIATx opportunities for tomorrow

Over 13,000 Over 13,000 substance abuse substance abuse

treatment providers treatment providers nationwide.nationwide.

Reduce Waiting & No-Shows Increase Admissions & Continuation

Flowcharting

Why Flowchart?

Flowcharting is useful for:– Providing a starting point/baseline view– Understanding the process – Identifying key problems/bottlenecks– Showing where to test ideas for most impact– Stimulating thinking - results in brilliant ideas– Adding interactivity & fun - gets the team together– Creating a simple & succinct visual process overview

Key Questions for Flowcharts

• Is the name of process clear?

• Where does the process begin?

• Where does the process stop?

• What does the process include/not include?

Process Change

Process Change

Identify Processes to Change

Nominal Group Technique

Nominal Group Technique

• Designed to promote group participation in the decision making process

• Used by small groups to – Reach consensus on the identification of key

problems (NIATx Key Principle 2) or

– Develop solutions that can be tested using rapid- change cycles (NIATx Key Principle 5).

Generating Solutions

• We have done a walk-through

• We have created a flowchart

• We have started to identify bottlenecks

• NOW we need to identify PROBLEMS & SOLUTIONS– NGT can help!!

Seven Steps

• Preparation (e.g., room and question)

• Silent idea generation

• Recording of ideas

• Idea discussion

• Preliminary voting

• Discussion of preliminary voting

• Final voting on ideas

HIV-STICNovember 8, 2011

NIATx Progress TrackingBaseline Data & Measuring Results

Reduce Waiting & No-Shows Increase Admissions & Continuation

Before Making Changes

• Collect baseline data

• Determine the target population and location

• Establish a clear aim

• Select a Change Leader and the Change Team

Model for Improvement

Start by asking three questions:

1. What are we trying to accomplish?

2. How will we know a change is an improvement?

3. What changes can we test? (next Tuesday!)

• Model for ImprovementLangley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

Executive Sponsor

• Articulates vision, linking PI efforts to grant goals, strategic plan and the bottom line

• Engages and empowers Change Leader and Change Team

• Removes barriers to change

Change Leader

• Motivates and leads Change Team• Catalyst for developing ideas for rapid cycles• Sets agenda and facilitates change team

meetings• Oversees changes and helps team with

implementation issues• Supervises measurement, compilation and

interpretation of data• Keeps Executive Sponsor aware of change

team activities

Change Team

• Focuses on one Change Project (1 aim, 1 LOC, 1 location, 1 population)

• Meets at least every other week

• Generates ideas for rapid cycle changes

Change Team cont’d

• Prioritizes, plans and carries-out change cycles until the goal is achieved

• Collects simple, timely data related to the cycle

• Decides if the change should be adopted, adapted or abandoned

What do Change Team Members look like?

• A small group of (~ 5-7) people invited by the Executive Sponsor

• Court administrators, front line workers, clinicians, judges, supervisors whose work “touches” the process

• People with special knowledge about the change, e.g. alumni, family members, IT staff, attorneys, police

• METHODS OF COLLECTING DATA FOR DECIDING WHAT CHANGE YOU WANT TO MAKE

Model for Improvement

Start by asking three questions:

1. What are we trying to accomplish?

2. How will we know a change is an improvement?

3. What changes can we test? (next Tuesday!)

• Model for ImprovementLangley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

Measuring Change7 Simple Rules of the Road

• Define measures

• Collect baseline data

• Establish a clear goal

• Consistent collection

• Avoid common pitfalls

• Report and Chart progress

• Ask questions

Rule 1: Define Measures

• Establish clear definitions– Continuation or

admissions may mean many things

• Clarify project aim &

goal• Agreed upon by key

stakeholders

Rule 2: Establish a Baseline

• Never start a project without it

• Define a clear starting point

• Use agreed-upon definition

Start Finish

Rule 3: Establish a Goal

– A realistic goal still challenges the agency to improve

– Set a goal that stretches the agency’s capacity to improve

– If information suggests changing the goal, change it

Rule 4: Consistently Collect Data

• 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– Cycles rarely last more than a month

• The length of time necessary to test a change will vary depending on an agency’s size. 

• Once change is successful, continue data collection to verify progress– Track clients admitted next week– Examine data for one month

Rule 5: Avoid Common Pitfalls

• Collect only the data you NEED

• Focus only on measures that relate to your aim

• Keep collection process as simple as possible

• Check that everyone understands the collection process --- early and often

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.

Example Chart

Time from First Contact to First Treatment

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Jun-03

Jul-03

Aug-03

Sep-03

Oct-03

Nov-03

Dec-03

Jan-04

Feb-04

Mar-04

Apr-04

May-04

Jun-04

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Changes Implemented ChangesSustained

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?

Track Change Cycle Data• Baseline Data

• Describe the Change

• Chart the Results – Post change

• Study Results

• Plan next change

Conducting a Change Exercise

PDSA cycles Plan the changeDo the planStudy the resultsAct on the new

knowledge

Rapid cycle changes Changes should be

doable in 2-3 weeks

 Aim: Access for incarcerated referrals – is difficult and time consuming. 

Change: Judge worked with jail personnel to arrange that clients referred to drug court be brought to the courthouse on the day of drug court. Jail staff always have prisoners to transport. Intake & screening done before and/or after drug court at the courthouse.

Results: Client seen sooner, intake person didn’t have to wait at the jail, and the drug court intake process faster.

Cooperation between jail, judge, and treatment improve process and client flow

Counseling Services, Inc. & York County Adult Drug Court, Maine

Ottumwa Iowa Family Drug Court

Aim: improve transfer of clients from Child Welfare to Family Drug Court

Change: Add dates to paperwork to track flow, provide training to case workers and identify one person to receives referral forms

Ottumwa Drug Court Results:

Total Number of

Client Referral Sheets

Number of Clients

starting Drug Court

Cases started prior

to adjudication

hearingBaseline Data 6 2 1

Change Data 17 5 3

MAINE STAR-SI: Learning Collaborative ID of the key focus areas using nominal group technique (NGT)

#1 Look at the practice of “giving appointments” to assess clients# 2 Paperwork issues – many – subset of concerns around time to DEEP treatment (OUI programming)

PROJECT DESCRIPTION # OF AGENCIES

REPORTING

# OF REQEUSTS

FOR SERVICE

# OF ASSESSMENTS

AVG TIME B/T 1ST PHONE CALL & ASSESSMENT

Pre-change:

12/19/06-1/15/07

Baseline 7 38 37

(Show rate=97%)

8.34 days

#1:

1/16/07-2/16/07

Faxing release forms & NEEDS or JASE vs. regular

mail

8 77 66

(Show rate=86%)

5.84 days

#2:

3/5/07-3/30/07

DEEP office notify providers of

process (vs. OSA notification)

8 64 52

(Show rate=81%)

7.08 days

#3:

8/6/07-8/24/07

Use multi-party release form,

signed by client at 1st face to face

session

8

(2 agencies had 0 clients)

45 40

(Unable to calculate show

rate)

4.91 days

Maine DEEP Change Cycle Data

ME Driver Education & Evaluation Program (DEEP) for OUI offenders

Aim: Increase AccessChange: OSA Fax paperwork (not mail)Results: • Time to treatment dropped 7+ days to 5• No show rates dropped 15%• Revenue rose by $24,146 or $313,898/year!

OSA began work to diffuse/spread project statewide for all OUI DEEP Program agencies