southern california learning collaborative kick-off workshop
DESCRIPTION
Southern California Learning Collaborative Kick-Off Workshop. Presented by: Beth Rutkowski, MPH, and Kimberly Johnson, MSEd, MBA April 2, 2009 – Rialto, California. Adopting Changes in Addiction Treatment. One year project funded by the California Endowment - PowerPoint PPT PresentationTRANSCRIPT
Southern California Learning Collaborative Kick-Off Workshop
Presented by: Beth Rutkowski, MPH, and Kimberly Johnson, MSEd, MBA
April 2, 2009 – Rialto, California
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
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
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
• 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?
Learning Collaboratives
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
The Culture of Learning Collaboratives
• Data Driven
• Dialogue and Discussion
• Celebrations
Data-Driven
• Baseline Data
• Keep it simple/manageable
• Sustainability
• Use existing sources of data
• Real-time data
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
Celebrate!
Motivate the Collaborative Members
• Record and celebrate
success (need data)
• Acknowledge performance of team
members, and whole change teams
• Provide support and share experiences
• 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: Nat’l Survey on Drug Use & Health, SAMHSA, 2006.
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 LaboratoryUniversity of Illinois – Chicago, March 2007.
When we add them together…
• 170,000 don’t 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?
Luckily, we know a few things about process improvement!
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.
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
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
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.
Small Changes, Big Impacts
• Small changes make a big difference for both clients and staff
• Effective changes do not have to be expensive
The NIATx Model:
An Introduction
Four NIATx Project Aims
Reduce Waiting Times
Reduce No-Shows
Increase Admissions
Increase Continuation Rates
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)
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
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
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
2. Focus on Key Problems
• What keeps the CEO awake at night?
• What processes do staff and customers identify as barriers to excellent service?
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
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
5. Rapid Cycle Changes
• Pilot tests or experiments
• Two-four week cycles
• Many small changes
can quickly add up to make a big impact
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
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.
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
The ACTION Campaign:
An Introduction
What is the ACTION Campaign?
The ACTION Campaign provides easily adoptable practices that NIATx
members have tested in the field
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
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
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
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
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
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
The ACTION Campaign
www.actioncampaign.org
Join Today!
Why a Walk-through?
The walk-through…– Helps understand the customer and
organizational processes– Provides a new perspective
• Allows you to feel what it’s 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
How to Do a Walk-Through1. Agency director or executive sponsor plays
the role of client and or family member2. 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, observe5. Record observations and feelings6. Involve staff, get their feedback
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?
“E.T. Phone Home”
Here is your mission:
Call your agency to request an assessment appointment
“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?
Sample Walk-Through Results
Strengths
• No waiting
• Efficient intake process
• Positive group experience
• Friendly staff
Sample Walk-Through Results
Opportunities
• Long intake process
• Lots of paperwork
• No privacy
• No family services
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
Process Improvement Planning Guide
Identify problem important to management
wait-time - engagement - no-shows - retention
Target Objective
measurable - specific
How will you measure the change?
simple - quick - accessible
Who will be on the Change Team?
Instructions for the Change Team:
Quick Start Road MapManagement 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
Quick Start Road MapManagement 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
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 MapManagement responsibilities:
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.
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
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
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
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.
Rapid-cycle Testing
Start by asking five questions:
1.What’s 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?
Making Changes• PDSA Cycles
– Plan the change– Do the plan– Study the results– Act on the new knowledge
• Adapt• Adopt• Abandon
Process Improvement
Hunches Theories
Ideas
Changes that Result in
Improvement
A P
S D
APS
D
A P
S DD S
P A
DATA
SOURCE: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996
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
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).
The Importance of Data
Power of Two
How does that translate to measuring the impact of
change?
1. Number of First Contacts2. Number of Assessments3. Elapsed Time4. Assessment Conversion
1. Date of First Contact2. Date of Assessment
How does that translate to measuring the impact of
change?
1. Number of Clients w/First Treatment Session2. Number of Clients w/Fourth Treatment Session3. Elapsed Time between First and Fourth Treatment Sessions4. % of Clients w/1st Treatment Session who get a 4th Treatment Session
1. Date of First Treatment Session2. Date of Fourth Treatment Session
How does that translate to measuring the impact of
change?
1. Three Counts2. Two Conversion Numbers3. Three Elapsed Time Figures
1. Date of First Contact2. Date of Assessment3. Date of Admissions
Why Is Data So Important?
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
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
Rule 1: Define Measures
• Establish clear definitions
• Clarify project aims
• Agreed upon by key stakeholders
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
Rule 2: Establish a Baseline
• Never start a project without it
• Define a clear starting point
• Use agreed-upon definition
Start Finish
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– Agency’s size– Ease of Collection
• Preferred Sample Size is at least 40
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
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 agency’s capacity to improve
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
Rule 4: Consistently Collect Data• The length of time necessary to test a change will vary
depending on an agency’s 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
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
Client #
Date of 1st
Contact
Date of clinical
assessmentDate of
ISPISP
completedclient called
Date of orientation
Client called
Date of admission
(a) (b) ( d) ( e) ( f) (g) (h) (i)9 01/23/07 1/1/29/07 02/05/07 A/M N/S L/M
24 03/21/14 02/06/07 02/09/07 seen MBK 02/12/07 01/01/0054 04/10/14 02/19/07 02/20/07 seen 01/02/00 02/22/07 02/22/07
102 01/18/07 03/07/07 04/24/07 seen ok 03/12/07164 03/24/07 03/29/07 04/03/07 left by 4 ok 04/02/07 phone off N/S4/3/07169 01/06/07 01/08/07 no ISP 03/28/07 03/28/07196 04/09/07 04/11/07 ?264 04/30/08 05/09/07 05/17/07 ok 5/25/2006 ok/ns289 11/09/06 11/13/06 ? ? ? 05/16/07 OK 05/16/07
Dates before their time Dates out of sequence
Long lag times
Stay out of the Quicksand
• Don’t collect too much data
• Don’t focus on too many measures
• Don’t get trapped in analysis paralysis
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
Sample 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?
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
The 12 ACTION KitsProvide 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
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
Quick Start Road MapChange 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?
Quick Start Road MapChange 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
Quick Start Road MapChange 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?
Quick Start Road MapChange 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?
Change Team Deliberations
What situations or processes contribute to the problem?
What possible changes might help achieve the objective?
1 2 3 4 5
Prioritize the changes most likely to succeed and select one
Outline the implementation process you will use
What will be done? Who will Resources (Plan) do it? Needed (Do) 1 2 3 4 5
What data will be gathered? (Study) What? Who? How often?
How will progress be monitored to determine success and to assess need for further change? How? Who will do it? How often?
What is the next step? (Action):
Nominal Group Technique
• Silent Writing
• Each person share one solution
• Are there any missing?
• Get out the vote!
• Top three
• Where do we begin?
Keys to Change Project Success1. 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
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
Southern California Learning Collaborative
Discussion:
• What are our goals?
• How do we want to accomplish them?
• What are the next steps?
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
Thank you for coming!