HIV-STIC November 8, 2011 NIATx Tools for Effective Change

1. HIV-STIC November 8, 2011 NIATx Tools for Effective Change Reduce Waiting & No-Shows  Increase Admissions & Continuation

2. NIATx opportunities for tomorrow Over 13,000 substance abuse treatment providers nationwide. Conducting a Walk Through How does the client experience services? Reduce Waiting & No-Shows  Increase Admissions & Continuation

3. 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.

4. 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 Why do a walk-through?

5. 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

6. 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

7. 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 Results of Walkthrough: “low hanging fruit”

8. 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

9. NIATx opportunities for tomorrow Over 13,000 substance abuse treatment providers nationwide. Flowcharting Reduce Waiting & No-Shows  Increase Admissions & Continuation

10. 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 Why Flowchart?

11. • Is the name of process clear? • Where does the process begin? • Where does the process stop? • What does the process include/not include? Key Questions for Flowcharts

13. Process Change

14. Process Change

15. Nominal Group Technique Identify Processes to Change

16. 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). Nominal Group Technique

17. 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!! Generating Solutions

18. 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

19. HIV-STIC November 8, 2011 NIATx Progress Tracking Baseline Data & Measuring Results Reduce Waiting & No-Shows  Increase Admissions & Continuation

20. Collect baseline data Determine the target population and location Establish a clear aim Select a Change Leader and the Change Team Before Making Changes

21. Model for Improvement Start by asking three questions: • What are we trying to accomplish? • How will we know a change is an improvement? • What changes can we test? (next Tuesday!) • Model for ImprovementLangley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

22. 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

23. 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

24. 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

25. 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 Change Team cont’d

26. 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

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

28. Model for Improvement Start by asking three questions: • What are we trying to accomplish? • How will we know a change is an improvement? • What changes can we test? (next Tuesday!) • Model for ImprovementLangley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

29. 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

30. Rule 1: Define Measures • Establish clear definitions • Continuation or admissions may mean many things • Clarify project aim & goal • Agreed upon by key stakeholders

31. Rule 2: Establish a Baseline • Never start a project without it • Define a clear starting point • Use agreed-upon definition Start Finish

32. 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

33. 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 4: Consistently Collect Data

34. 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 5: Avoid Common Pitfalls

35. 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. Rule 6: Report and Chart Progress

36. Example Chart

37. 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? ?

38. Track Change Cycle Data • Baseline Data • Describe the Change • Chart the Results – Post change • Study Results • Plan next change

39. 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 2-3 weeks

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

41. 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

42. Ottumwa Drug Court Results:

43. 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)

44. Maine DEEP Change Cycle Data

45. ME Driver Education & Evaluation Program (DEEP) for OUI offenders • Aim: Increase Access • Change: 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