Building Momentum for Process Improvement: The California Experience

1. Building Momentum for Process Improvement: The California Experience Presented by: Beth Rutkowski, MPH, Steve Gallon, Ph.D., and Alex Bruehl, MA 2009 NIATx Summit and SAAS National Conference, August 1, 2009

2. Workshop Overview LA County Phase I Process Improvement Pilot Project CATES Statewide Training Effort LA County Phase II Process Improvement Pilot Project CA NIATX Coach Pilot Project Local Learning Collaboratives Regional Learning Collaboratives Organic from the very beginning; the story begins before the phase I project � overview of NIATx to a small group � invited all county-contracted agency directors; from that determined interest; from there, the phase I pilot beganOrganic from the very beginning; the story begins before the phase I project � overview of NIATx to a small group � invited all county-contracted agency directors; from that determined interest; from there, the phase I pilot began

3. Key Partners UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center LA County Alcohol & Drug Program Administration NIATx National Program Office SAMHSA, Center for Substance Abuse Treatment Robert Wood Johnson Foundation County Alcohol and Drug Program Administrators Association of California

4. Recipe for Success It was about the people, not the money BR � glue to hold things together; catalytic, enthusiastic, vocal coordinator/leader for project Interest from a variety of sectors University-based training and technology transfer specialists, local government representatives, treatment agency personnel �Let�s do a little experiment� Money Expertise Back-up support/project management It was about the people, not the money BR � glue to hold things together; catalytic, enthusiastic, vocal coordinator/leader for project Interest from a variety of sectors University-based training and technology transfer specialists, local government representatives, treatment agency personnel �Let�s do a little experiment� Money Expertise Back-up support/project management

5. Key Ingredients Start small and demonstrate success Face-to-face learning sessions Individualized technical assistance/coaching Telephone-based technical assistance Data collection, submission, and review Availability of continuing education Change Leader Academy Coach Academy

6. Important Utensils Agency Walk-Through Change Team Agency Site Visits Quick Start Road Map Administrative Data Change Project Report Storyboarding Airplane Exercise

7. �Where it all started�� Los Angeles County, California

8. Phase I Los Angeles County Process Improvement Pilot Project November 2005-September 2006 Add logo; graphic � newspaper headlineAdd logo; graphic � newspaper headline

9. Participating Agencies Didi Hirsch CMHC, Via Avanta LA Centers for Alcohol and Drug Abuse Matrix Institute on Addictions (2) Social Model Recovery Systems Southern California Alcohol and Drug Programs Tarzana Treatment Centers

10. Phase I Pilot Project Timeline

11. Phase I Aggregate Results 83% reduction in assessment/intake no-shows (2 agencies reporting) 39% increase in 30-day continuation (3 agencies reporting).

12. California Addiction Training and Education Series November 2007-May 2009 Add logo; graphic � newspaper headlineAdd logo; graphic � newspaper headline

14. Where Were the Trainings and How Many People Did We Train? Nov 2007 San Francisco � 154 (18) San Diego � 137 (6) Bakersfield - 129 (10) May 2008 Redding � 77 (17) Santa Ana � 145 (6) Fresno � 78 (12) July 2008 San Jose � 341 (1) Sept 2008 San Rafael - 51 (2) Oct/Nov 2008 Concord � 114 (12) Rialto � 97 (8) Yuba City � 107 (18)

15. Sample Agenda Case study - from an agency�s perspective Process Improvement 101 How to get started Measuring impact of change Promising practices

16. Monthly Coaching/Follow-Up Conference Call Topics Month 1: Conducting a Walk-Through Month 2: Collecting Baseline Data Month 3: Establishing a Change Objective Month 4: Creating a Quick Start Road Map Month 5: Conducting a PDSA Change Cycle Month 6: Sustaining Change

17. Call Participation 60 hour-long conference calls held between Dec 2007 and May 2009 254 people from 35 counties Callers joined an average of 2-3 calls (mean=2.6) Targeted areas of participation (and implementation)

19. Phase II Los Angeles County Process Improvement Pilot Project November 2007-October 2008 Add logo; graphic � newspaper headlineAdd logo; graphic � newspaper headline

20. Participating Agencies Antelope Valley Rehabilitation Center (2) Behavioral Health Services (2) CA Hispanic Commission on Alcohol and Drug Abuse (2) Didi Hirsch Community Mental Health Center (2) House of Hope MELA Counseling Services Center SHIELDS for Families Tarzana Treatment Centers (2)

21. Project Enhancements Formal application process Greater focus on data More comprehensive data review and feedback 5th Change Leader monthly conference call 2nd Executive Sponsor conference call 12 individualized data coaching calls

22. Wait Time from First Contact to Admission Wait time from first contact to assessment or admission: Ranged from 3 to 9 days (based on data from 2 agencies) Average wait time across sites = 6 daysWait time from first contact to assessment or admission: Ranged from 3 to 9 days (based on data from 2 agencies) Average wait time across sites = 6 days

23. No-Shows No-show rate for assessment/intake Ranged from 24% to 65% (based on data from 4 agencies) Average assessment/intake no-show rate across sites = 43.5% No-show rate for assessment/intake Ranged from 24% to 65% (based on data from 4 agencies) Average assessment/intake no-show rate across sites = 43.5%

24. Session-by-Session Attendance Session-by-session attendance rates: Ranged from 65% to 75% (based on data from 3 agencies) Average treatment no-show rate across sites = 69.3% Session-by-session attendance rates: Ranged from 65% to 75% (based on data from 3 agencies) Average treatment no-show rate across sites = 69.3%

25. 30-Day Continuation 30-Day Continuation rates: Ranged from 67% to 70% (based on data from 2 agencies) Average continuation rates across sites = 68.5% 30-Day Continuation rates: Ranged from 67% to 70% (based on data from 2 agencies) Average continuation rates across sites = 68.5%

26. California NIATx Coach Pilot Project July 2008-April 2009 Add logo; graphic � newspaper headlineAdd logo; graphic � newspaper headline

27. Infrastructure Development Coach Academy Change Leader Academy Building local coaching and change leader expertise within California � essential for spread to occur

28. Local Learning Collaboratives July 2008-Present Add logo; graphic � newspaper headlineAdd logo; graphic � newspaper headline

30. Regional Learning Collaboratives � California Endowment April 2009-Present

33. Regional Learning Collaboratives � Like-Size County Structure

34. Regional ACTION Campaign/NIATx Learning Collaboratives CA-based ACTION Campaign membership more than doubled from 105 individuals in 82 agencies to 258 individuals from 204 agencies. Five day-long kick-off workshops were held in April-May 2009 386 treatment providers/administrative staff Staff from 156 agencies in 49 counties are now part of one of five collaboratives

35. �Nine Lessons Learned� Phase I and Phase II Pilot Projects

36. Seeing things from the client�s perspective can be helpfulSeeing things from the client�s perspective can be helpful

37. Multiple improvements can be made in a short period of timeMultiple improvements can be made in a short period of time

38. Process improvement can motivate staff and clients � they get excited when good things happen Process improvement can motivate staff and clients � they get excited when good things happen

39. The results surpassed the initial objectives/expectationsThe results surpassed the initial objectives/expectations

40. Simple improvements yield big dividendsSimple improvements yield big dividends

41. Using data can actually be helpfulUsing data can actually be helpful

42. There is a huge value to �sticking with it� (sustaining effort and keeping communication flowing) There is a huge value to �sticking with it� (sustaining effort and keeping communication flowing)

43. With any change comes resistanceWith any change comes resistance

44. One change may point to other changes that may improve servicesOne change may point to other changes that may improve services

45. Strategies for Successful Change Project Implementation

46. Communicate

49. Weekly or bi-weekly change team meetings Troubleshoot initial start-up problems early Provide management with updates on a frequent/as-needed basis Regular meetings Stay on Time Take minutes Keep roles clear Maintain a �parking lot� list Executive sponsor needs to show up (at least some of the time) Celebrate and communicateWeekly or bi-weekly change team meetings Troubleshoot initial start-up problems early Provide management with updates on a frequent/as-needed basis Regular meetings Stay on Time Take minutes Keep roles clear Maintain a �parking lot� list Executive sponsor needs to show up (at least some of the time) Celebrate and communicate

50. Establish a baseline Create a data collection plan � keep it simple! Review and analyze data frequently Provide feedback to change team Use data to inform next steps Establish a baseline Create a data collection plan � keep it simple! Review and analyze data frequently Provide feedback to change team Use data to inform next steps

51. Choose an initial change project with a high likelihood of success Discuss how management might formally acknowledge the success of the change team Post the results in a common area for all staff to see Choose an initial change project with a high likelihood of success Discuss how management might formally acknowledge the success of the change team Post the results in a common area for all staff to see

52. Keys Ingredients for Change Project Success Choose the right Change Leader Establish a clear objective Implement only 1 new change at a time Make sure everyone implements change project as planned Start small Study the results before making modifications

53. Lack of commitment Inexperience with process improvement tools Failure to define problem and objective clearly Difficulty creating simple measures Lack of familiarity with data graphing Failure to gather outside ideas Frequent Start-Up Issues Measuring the impact of change What measures to use Documenting the change process Recording data daily; reviewing data weekly Having the right people in key roles Executive Champion or Sponsor Change Leader with time to do the job Small enough Team to be effective Assuring key participants understand the service improvement model and process Lack of customer involvement in establishing a change objective Measuring the impact of change What measures to use Documenting the change process Recording data daily; reviewing data weekly Having the right people in key roles Executive Champion or Sponsor Change Leader with time to do the job Small enough Team to be effective Assuring key participants understand the service improvement model and process Lack of customer involvement in establishing a change objective

54. Diagnosing Potential Problems Management commitment? Agency walk-through? Issues targeted for improvement? Change Leader competency? Appropriate measures? Clear change project plan? Business case? Sustainability plan?

55. Small Changes, Big Impacts Small changes make a big difference for both clients and staff

56. Sustainability is Possible�

58. What Does the Future Hold? Function of vision, leadership, and commitment Built to last Function of vision, leadership, and commitment Built to last

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