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Capitol Region Learning Collaborative Kick-Off Workshop


Capitol Region Learning Collaborative Kick-Off Workshop Presented by: Beth Rutkowski, MPH, and Kimberly Johnson, MSEd, MBA April 21, 2009 Sacramento, California – PowerPoint PPT presentation

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Title: Capitol Region Learning Collaborative Kick-Off Workshop

Capitol Region Learning Collaborative Kick-Off
Presented by Beth Rutkowski, MPH, and Kimberly
Johnson, MSEd, MBA April 21, 2009 Sacramento,
Adopting Changes in Addiction Treatment
  • One year project funded by the California
  • A partnership of the Pacific Southwest Addiction
    Technology Transfer Center, the NIATx National
    Program Office, and CADPAAC
  • Development of five regional learning

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
  • Strategies to plan for change and implement rapid
    cycle improvement projects

What do we plan to cover today?
  • How to measuring the impact of change
  • How to brainstorm possible solutions and motivate
    a change team
  • Next steps and networking opportunities

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

  • 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
  • Provides for group problem-solving
  • Allows participants to choose what they want to
    learn and address

Motivate the Collaborative Members
  • Record and celebrate
  • success (need data)
  • Acknowledge performance of team
  • members, and whole change teams
  • Provide support and share experiences

The Reality
  • 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

SOURCE Natl 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
Laboratory University of Illinois Chicago,
March 2007.
Detox Retention Rate
Successful Transfer 4
Transfer, No Connect 12
Dont finish 23
Finish Detox, No Transfer 61
SOURCE Treatment Episode Data Set Admission
and Discharge Reports, SAMHSA, 2004.
Residential Retention Rate
Successful transfer 4
Transfer No connect 10
Finish Treatment No Transfer 51
Dont finish 34
Outpatient/IOP Retention Rate
Successful transfer 7
Finish Treatment, No transfer 36
Dont finish 51
Transfer, No Connect 7
When we add them together
  • 170,000 dont 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
NIATx Network for the Improvement of Addiction
  • 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

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
  • 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
  • Reduce No-Shows 41 reduction
  • (28 agencies reporting)
  • Increase Admissions 56 increase (23 agencies
  • Increase Continuation 39 increase (39 agencies

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
  • 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,
  • Empowers the change leader

Selecting a Change Leader
  • Person has sufficient power and respect to
    influence others at all levels of the
  • 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
  • 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

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
  • Addiction Technology Transfer Centers
  • Faces and Voices of Recovery
  • Join Together
  • Legal Action Center
  • National Association of Addiction Treatment
  • National Association of Alcohol and Drug Abuse

Our Growing List of Partners
  • National Association of State Alcohol and Drug
    Abuse Directors
  • National Council for Community Behavioral
  • Robert Wood Johnson Foundation
  • State Associations of Addiction Services
  • Substance Abuse and Mental Health Services
    Administration Center for Substance Abuse
  • 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

The ACTION Campaign
Join Today!

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Why a Walk-through?
  • The walk-through
  • Helps understand the customer and organizational
  • Provides a new perspective
  • Allows you to feel what its 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-Through
  1. Agency director or executive sponsor plays the
    role of client and or family member
  2. 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, observe
  5. Record observations and feelings
  6. Involve staff, get their feedback

The Walk-Through Write-Up
  • First contact
  • First Appointment
  • The Intake Process
  • Transition between level of service - The
  • 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

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
  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
  • Assures that critical steps in the process will
    not be skipped

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Quick Start Road Map Management responsibilities
  • Do a needs assessment and identify a problem
    important to management
  • Walk-Through
  • Focus Groups
  • Existing Data
  • Establish a target objective
  • Achievable
  • Specific
  • Measurable

Quick Start Road Map Management responsibilities
  • 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

Quick Start Road Map Management responsibilities
  • Who will be on the Change Team?
  • Change Leader
  • 3-5 Members
  • Work together until success is achieved
  • Instructions for the Team
  • Clear statement of problem with data
  • Clear objective
  • Priority for improvement
  • Promise of support and commitment

  • 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.

  • 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

  • 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

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
  • Whats it like to be our customer?
  • What are we trying to accomplish?
  • How will we know if a change is an improvement?
  • What changes can we test that may result in an
  • 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
Changes that Result in Improvement
Hunches Theories Ideas
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

The Importance of Data
Power of Two
How does that translate to measuring the impact
of change?
1. Number of First Contacts 2. Number of
Assessments 3. Elapsed Time 4. Assessment
1. Date of First Contact 2. Date of Assessment
How does that translate to measuring the impact
of change?
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
1. Date of First Treatment Session 2. Date of
Fourth Treatment Session
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

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

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
  • 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

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
  • The time period for the baseline will vary by
  • Measure
  • Agencys size
  • Ease of Collection
  • Preferred Sample Size is at least 40

Baseline Data Examples
  • Average time from 1st Contact to Assessment is 35
  • 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 agencys 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
  • No ? Assessment No-Shows by 40
  • Yes ? Assessment No-Shows from 60 to 36
  • No ? Time from 1st Contact to Assessment by 20
  • 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 agencys size. 
  • Devise ways to collect information but remember
  • 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

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Stay out of the Quicksand
  • Dont collect too much data
  • Dont focus on too many measures
  • Dont 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

Sample Chart
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 Kits
  • Provide 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
  • Make Connections with the Next Level of Care
  • Express Check-In and Check-Out
  • Introduce Clients to Ongoing Supports
  • Evaluate the Hand-Off

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Change Project Form
  • Details the project charter
  • Chosen aim, baseline, change team members, agency
    demographics, etc.
  • Helps to track progress with change project (PDSA
  • Provides space for lessons learned, business
    case, and sustainability plan

Quick Start Road Map Change Team responsibilities
  • 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 Map Change Team responsibilities
  • 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
  • Prioritize the ideas and select a strategy

Quick Start Road Map Change Team responsibilities
  • Outline the process to be used
  • What will be done?
  • Who will be responsible at each step?
  • What resources are needed to implement the
  • 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 Map Change Team responsibilities
  • How will progress be monitored?
  • Who will monitor fidelity with the planned
  • 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?
  • Who will maintain a record of Team deliberations,
    decisions and steps taken?

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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 Success
  1. Have a clear objective
  2. Implement only 1 new thing at a time
  3. Make sure everyone implements change as
  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

Capitol Region 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

Contact Us!
  • Beth Rutkowski
  • 310-388-7647
  • Kim Johnson
  • 207-252-9950

Thank you for coming!