Overview

1. Overview Making a business case for process improvement Andrew Quanbeck, M.S. NIATx 200 Scientific Manager

2. Previous experience NIATx 200 Business case research About me

3. NIATx Fundamentals – 20 minutes Case studies – 20 minutes Business case framework – 20 minutes What keeps you up at night? – 15 minutes Overview

4. Remember yesterday…

5. Program to Treatment One size for all Right treatment at right time for each Belief to Science Experience and tradition Peer reviewed, controlled studies Human Service to Health Social supports and change Restoration to well being Grant to reimbursement Charity Earned income Our Rotary Phone

6. 19 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 Statistics

7. Customers are served by processes. 85 percent of customer related problems are caused by organizational processes. To better serve customers, organizationsmust improveprocesses. Why Process Improvement?

8. Why Organizational Change? • Addiction is a population health issue • To serve a population we must organize resources • Well intentioned clinicians and practitioners working in isolation cannot solve addiction

9. A Framework for Change

10. Understand and Involve the Customer Focus on the Key Problems Pick a Powerful Change Leader Get Ideas from Outside the Organization Do Rapid-Cycle Testing Five Principles

11. Most important of the Five Principles What is it like to be a customer? Walk-through, focus groups… 1. Understand & Involve the Customer

12. The walk-through is useful for: Understanding the customer and organizational processes Providing a new perspective Allowing us to ‘feel’ what it’s like Letting us see the process for what it is Seeking out and identifying real problems Generating ideas for improvement Asking why?…and why? again Why Walk-through?

13. What keeps the CEO awake at night? What processes have been identified by staff and customers as barriers to excellent service? 2. Focus on Key Problems

14. Examples of Key Problems • Excessive paperwork • Initial and ongoing client no-shows for services • Length of the intake process • Creating successful handoffs across levels of care • Improving financial solvency • Staff turnover • Tailored treatment

15. Visionary Link to a strategic plan Set a clear aim Engagement Support the change leader Periodically attend change team meetings Personally invite change team participants Leadership Remove barriers Connect the dots Communicate Executive Sponsor Role

16. Who has: Influence, respect and authority across levels of the organization A direct line to the CEO Empathy for the staff Time devoted to leading change projects 3. Select a Powerful Change Leader

17. OverallPerspective Leadership Characteristics • Change Leader Characteristic Survey • 29 Categories, 99 responses - Change leaders (n = 40)/Executive sponsors (n=20)/Change teams members (n=39)

18. Regular meetings Ensure accountability Identify potential solutions using PI tools Nominal group technique Flowcharting Change Team Responsibilities

19. Provides a new way to look at the problem Real creativity in problem solving comes from looking beyond the familiar 4. Seek Ideas Outside the Organization and the Field

20. Airlines (Southwest, Delta, Midwest) Airline pilots Hy-Vee Etc. Examples of Outside Ideas

21. Start by asking three 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? 5. Do Rapid Cycle Testing • Model for ImprovementReference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

22. Collect baseline data Determine the target population and location Establish a clear aim Before Starting the Change

23. PDSA Cycles Plan the change Do the plan Study the results Act on the new knowledge Adapt Adopt Abandon Rapid-cycle changes should be doable in two weeks Make Changes

24. A P S D D S P A A P S D A P S D Change Cycles Changes That Result in Improvement DATA Hunches Theories Ideas Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide

25. Reduce waiting time Reduce no-shows Increase admissions Increase continuation Key: waiting time = waste NIATx Aims

27. A note on measurement…

28. Start tracking first request for service Do a walkthrough Recap- two things you should do if you haven’t done so already

29. Provider case examples…. Acadia Hosptial Perinatal Treatment Services Prairie Ridge Kentucky River Community Care Addiction Resource Center Adcare

30. Open Access to IOP- Acadia Hospital Bangor, Maine Clients who fit clinical profile over phone or at local ED offered an evaluation the following morning at 7:30 a.m. All evaluated clients invited to start program the same day IMMEDIATE RESULTS Time between initial contact and screening dropped from 16 days to 1.3 days More people were screened the first week than in the entire previous month

31. Results Open access has resulted in continued growth in the number of admissions (project implemented in March 2003)

32. Project #1 – Operating Results We serve more clients and the program operates more efficiently

33. Perinatal Treatment Services Problem:long-term residential treatment program was only four months into the fiscal year with a net loss of $140,000, 60% continuation rate through the first four units of service, and occupancy rates below 50% Goal: Increase continuation Strategy: seeing the program through the eyes of the customer

34. Impersonal admission process (done in public area, took two hours, interrupted several times) Changes: greeting customer by name, assigning peer mentors, giving bravery awards, creating private admission office Walkthrough experience

35. PTS Improvements

36. Business Case

37. Problem: no increases in state or federal appropriations for eight straight years, with ever-rising costs Goal: Increase admissions Strategy: focus on increasing admission among the 40% of clients who are fee-for-service Prairie Ridge Addiction Treatment Services

38. Doing more with current resources Found capacity by driving out inefficiency Outpatient direct service rates have gone from 40% pre-NIATx to 53% post-NIATx Effective increase of 3.12 new FTEs

39. 40% solution Pre-NIATx, variable and flat growth of third party, Medicaid, and client fees: 3rd Party – FY- 04 - $290,888 FY- 06 - $507,852 Medicaid - FY- 04 - $203,471 FY- 06 - $276,801 Client Fee - FY- 04 - $132,834 FY- 04 - $223,714

40. Improvements in staff retention and morale State eventually offered contract incentives in response to long-term performance Other benefits

41. Kentucky River Community Care Grant funded, indigent populations Applied PI approach to issue of staff retention (staff can be viewed as customers too) Baseline six-month retention rate: 40%

42. Kentucky River Community Care Approach: walkthrough as a new staff member Ideas: learn from another program with good staff retention (benchmarking) Results: new orientation and training procedures yield 90%+ staff retention after six months PI is part of job description

43. Addiction Resource Center – Brunswick Maine Wait Times Are Down 77% From Baseline

44. Addiction Resource Center - MaineIOP Volume Is Up 150% Over Baseline

45. Addiction Resource Ctr Business CaseMedicaid Net is up 53% Over Baseline 3’rd Party and Private Net Is Up 50% Over Baseline

46. Decrease Dependence on Grant Revenues Through using the basic principles of NIATx the Addiction Resource Center has been able to decrease the overall % the substance abuse dept is underwritten by State grants from 71% in 2007 to 46% by July 1, 2008 (grant amounts have remained flat for 5 years).

47. CASE STUDY: ADCARE OUTPATIENT SERVICES of WORCESTER Support for This Project Was Provided by NIATx Through a Grant From the National Institute on Drug Abuse.

48. Introduced OPEN ACCESS Pre Post Open Access Open Access Wait Time Ave 7.65/days 1.1/days Show Rates Ave 63% 85% Increase in volume of Assessments: 36%

49. Increased admissions by 36%. But we discovered that 35% did not show for their first session post assessment. Some of our assessments required a higher level of care. Many of our assessments presented with increased medical and psychiatric co-morbidities. AFTER OPEN ACCESS

50. QUANTIFY THE GAINS #1 Let’s say the increased admissions are 25/month and that the admission assessment results in average revenue of $65.00. New revenues/month are 25 x $65 = $1625. For a year 12 months x $1625 = $19,500. AND 300 more people being assessed for treatment. (25 people x 12 months)