Transcript Sustainability

Making Changes LastSustainability
Thomas R Zastowny, PhD
NIATx Coach & Healthcare Consultant
Reduce Waiting & No-Shows  Increase Admissions & Continuation
www.NIATx.net
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Reduce
Waiting
& No-Shows
 Increase
Admissions & Continuation
Making Changes LastSustainabilityFeaturing a change project
from Racine Psychological
Services
Reduce Waiting & No-Shows  Increase Admissions & Continuation
www.NIATx.net
All
authors
share
equally
in this presentation
Reduce
Waiting
& No-Shows
 Increase
Admissions & Continuation
CONCEPTS
NIATx has
achieved
“first stage
validity”
www.NIATx.net
Reduce Waiting & No-Shows  Increase Admissions & Continuation
CONCEPTS
1.
2.
3.
4.
Diffusion, spread and
sustainability are interrelated and inter-dependent
A specific plan, customized to
organization, culture and
system, is required for
maximal stability &
portability
NIATx has achieved “first
stage validity”
Precise Definitions, Planning
and Methods are required for
sustainability
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Background
• As we have witnessed the significant and powerful performance
improvement changes associated with NIATx, our attention has
turned to sustainability of improvements. Webster has defined
sustainability in many ways but including these two succinct and
clear elements: “A characteristic of a process or state that can
be maintained indefinitely; to keep in existence, to maintain or
prolong” What family of strategies then
can help us maintain the important
changes we have made?
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Background
• Concept & Definition
Spread
Diffusion
Sustainability
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
METHOD
• Concept & Definition
Spread
Scatter
A P
Sustainability
Share
S D
Switch
Stretch
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Diffusion
Reduce Waiting & No-Shows  Increase Admissions & Continuation
Four NIATx Aims
Reduce Waiting Times
Reduce No-Shows
Increase Admissions
Increase Continuation Rates
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Sustain What?
The Projects PDSAs
The Culture of Improvement
Evidence Based Practice
Practice Based Evidence
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Madison in
Winter
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Evidence-Based Treatment Model
Induction
Motiv
Patient
Attributes
at Intake
Staff
Attributes
& Skills
Behavioral
Strategies
Family &
Friends
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Personal Health Services
Supportive
Networks
Sufficient
Retention
Crime
Therapeutic Psycho-Social
Relationship
Change
Social
Relations
Program
Characteristics
Posttreatment
Enhanced
Counseling
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Drug
Use
Social Skills
Training
Social Support Services
Simpson, 2001 (Addiction)
Reduce Waiting & No-Shows  Increase Admissions & Continuation
The importance of sustainability
• Important to not only implement a
change but also to see whether it
continues – Pluye, et al. 2004b
• Most implementation is able to be
sustained for at least a limited amount of
time - Porowski, et al. 2004; Scheirer, 2004
• Activities become routine when they
reflect the collective values and beliefs of
members – Capoccia, et al., 2007; Pluye, et al., 2004a
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
NIATx 200 - March 25, 2009
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Sustainability and Institutionalization
• Effectively maintaining an operation
that improves services
• Maintaining financial feasibility and
producing positive outcomes through
consistent interagency collaboration
• Programs ability to generate
continuation, growth, and support
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Research questions
• NIATx goals: Increase access and
retention
– Was this accomplished? Hoffman, et al. (2008)
• Were the NIATx components
sustained?
– Qualitative assessment to determine if this
was accomplished.
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Evaluation process
• Qualitative data collected from 38
agencies
– Quarterly calls – 302 interviews
– Site visits – 121 interviews + 119 focus
groups
– Evaluator observations – 111 summaries
• Time period
– Base grant funding – 18 mo. RWJ, R1 & R2;
36 mo. STAR (2003-2006)
– NIDA follow-up – additional 18 mo. (20062008)
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Which core components remained?
•
•
•
•
•
•
•
Change leader – 35 of 38 agencies
Top leadership support – 34 + 3 partial
Client focus – 34 +1 to some extent
Data collection – 33 + 3 some sources
Data review – 34 + 1 somewhat
Change teams – 28 agencies
PDSA’s – 22 agencies
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Qualitative & Quantitative
Not everything that
can be counted counts,
and not everything that
counts can be counted.
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-Albert Einstein
Reduce Waiting & No-Shows  Increase Admissions & Continuation
99
Other components still in use
• Strategy techniques:
– Walkthroughs – 8 + agencies
– Nominal group – 2
• NPO ongoing learning components:
– Website – 1
– Interest circle participation – 8 ~ others
– Learning collaboratives – well liked
– Monthly conference calls – mostly not mentioned
– Coaches – no longer under contract
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Change Initiatives
• Most were sustained - key influences:
• Roadblocks and barriers:
– Staffing turnover - 25 agencies
“Change team meetings have been suspended due to staffing difficulties
and the PDSA cycles are not being used.”
– Staff resistance – 18 agencies
“They abandoned the attempt to integrate the Session Rating Scale and the
Outcomes Rating Scale into clinical sessions. Counselors never were very
supportive. But, they have used the experience to make their treatment
planning process more client centered.”
– Unforeseen consequences – 11 agencies
– Too many changes at one time – 2 agencies
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Change Initiatives, cont.
• Wings beneath your feet
– Leadership support – 34 +3 partial
– Data review – 34 + 1 (ongoing monitoring)
– Internal coaching - 16
“I sent out emails to clinical staff, reminded them to give feedback. I didn’t
do that kind of stuff with the second team so staff just forgot.”
Another Change Leader said:
“We need to be refreshed, reminded, and then implement [changes] again.”
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Experience speaks
Monitoring prevents negative spirals:
“Participants noted that it is important to continue to monitor changes
after implementation. Otherwise, staff will tend to revert to old
practices. Participants provided examples of previous changes
undertaken in the outpatient programs that had not been
sustained.”
Regular meetings allow important data review:
“The agency was reminded of the importance of looking at data every single
month and having good indicators in place to flag problems.”
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Culture change?
• Implementation of policies and procedures;
another mechanism to change culture:
“Staffing changes give challenges to sustainability. One
good thing is that those changes that were working
became standard so new staff didn’t know anything but
the changed practices. It’s not extra; it’s just what we do!”
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Not every change is a keeper!
• Data revelations!
“We’ve sustained most of the changes but when something hasn’t worked, we
abandon it.”
• Client revelations!
“We tried [making reminder calls] for group [attendance] but it was too much:
clients didn’t like all of the phone calls—they could be getting 4 phone calls a
week. We amended the change because of their feedback.”
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Inquiry
(1) What organizational and
operational structures (e.g.,
policies, procedures, work guidelines for
providing service, ownership of the
process?) are in place to hold the gain?
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Inquiry
(2) What are the clinical, business and
oversight processes that assure
continuation? (e.g., stability, integration
into the organization culture, allowance of
fluctuations within statistical control,
sustain plans and staff ownership)
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Inquiry
(3) What are the outputs, impacts and
outcomes we continue to want to see
to know sustainability is working?
(e.g., definitions-, i.e. same day service,
continuation & client participation, and
intervals of measurement to gauge
stability, increases in access and
retention).
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
Inquiry
(4) What is the Business Case for the
Improvement and Sustainability? ( e.g.
cost benefit, dollars and sense, new
revenue)
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
One Story
▲One organization’s plan for sustainability for access
included the following…(a) two policy changes to
ensure same day treatment, (b) a mandate to revisit
the process if same day treatment was unsuccessful
for 2 contiguous days, (c) continuous measurement
in the first year after the improvement using a step
down approach (e.g., measure weekly, then monthly,
then quarterly ,then yearly). A well crafted plan for
sustainability is a must for longevity. Inclusion of these
dimensions can help improve the precision of the
sustainability plan and cover a wide reaching set of
strategies to “hold the gain” across the organization. This
strategy works equally as well within single and complex
organizations, and state wide collaboratives.
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
British National Health Services
Sustainability Model
1. Benefits Beyond Helping Patients
2. Credibility to Affected Staff of Benefits From
Improvement
3. Adaptability of Improved Process
4. Staff Involvement & Training to Sustain Process
5. Staff Attitude Toward Sustaining the Improved
Process
6. Senior Leadership Responsibility for the
Process
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
British National Health Services
Sustainability Model
7. Clinical Leadership responsibility for the Process
8. Effectiveness of the System to Monitor Progress
& Process
9. Fit with Organization’s Strategic Aims & Culture
10. Infra Structure to Sustain- e.g. Staff, Facilities,
Equipment,Time
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
WORKSHEET
(1) What organizational and operational structures (e.g., policies,
procedures, work guidelines for providing service, ownership of the
process?) are in place to hold the gain?
(2) What are the clinical, business and oversight processes that
assure continuation? (e.g., stability, integration into the organization
culture, allowance of fluctuations within statistical control, sustain
plans and staff ownership)
(3) What are the outputs, impacts and outcomes we continue to
want to see to know sustainability is working? (e.g., definitions, i.e. same day service, continuation & client participation, and intervals
of measurement to gauge stability, increases in access and retention).
(4) What is the Business Case for the Improvement and
Sustainability? ( e.g. cost benefit, dollars and sense, new revenue)
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Reduce Waiting & No-Shows  Increase Admissions & Continuation
WORKSHEET
Sustaining the Gains
Describe the change you want to sustain
What are the organizational structures that can
be put in place to help preserve the process
changes you have made?
What are the ongoing data needs that will help
the organization know if the desired change
is being sustained? Who will gather this
data? Who will review it and when? Is there
a standard meeting that could own this
responsibility?
What is the business case for the improvement
you want to sustain?
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References
Akerlund, K. M. (2000). Prevention program sustainability: The state’s perspective. Journal of Community Psychology,
28, 353–362.
. Backer, T.E. (2000). The Failure of Success: Challenges of Disseminating Effective Substance Abuse Prevention
Programs. Journal of Community Psychology, 28 (3), 363-373.
Capoccia, V.A., et al. (2007). Making “Stone Soup”: Improvement in Clinic Access and Retention in Addiction Treatment.
Journal on Quality and Patient Safety, 33 (2), 95-103.
Commons, M., McGuire, T.G., Riordan, M.H. (1997). Performance Contracting for Substance Abuse Treatment. HSR:
Health Services Research, 32 (5), 631- 650.
Fitzgerald, M. (2000). Operator assistance with process improvement. Addictions Management, 21-22.
Gustafson D.H.: Designing systems to improve addiction treatment: The foundation. Alcoholism and Drug Abuse Weekly
14, Nov. 4, 2002.
Hoffman, , K.A., Ford, J.H., Choi, D, Gustafson, D.H., McCarty, D (2008). Replication and sustainability of improved
access and retention within the Network for the Improvement of Addiction treatment, Drug and Alcohol Dependence
98 (1-2) 63-69.
Johnson, K., Hays, C., Center, H., Daley, C. (2004). Building Capacity and sustainable prevention innovations: a
sustainability planning model. Evaluation and Program Planning, 27, 135-149.
Lake, B., Walker R. (2005). Report on Sustainability and Expansion of North Carolina’s Drug Treatment Courts.
Administrative Office of the Courts, 1-57
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References
McCarty, D. et al. (2007). The Network for the Improvement of Addiction treatment (NIATx): Enhancing Access and
Retention. Drug Alcohol Depend, 88(2-3), 138-145
Porowski, A.W., Burgdorf, K., Herrell, J.M. (2004) Effectiveness and sustainability of residential substance abuse
programs for pregnant and parenting women. Evaluation and Program Planning, 27, 191
Pluye, P., Potvin, L., Denis, J. L.(2004). Making public health programs last: conceptualizing sustainability. Evaluation
and Program Planning, 27, 121-133
Pluye, P., Potvin, L. Denis, J.L., Pelletier, J. (2004). Program Sustainability: focus on organizational routines. Health
Promotion International. 19 (4), 489- 500
Scheirer, M.A., (2005). Is sustainability Possible? A review commentary on Empirical studies of program sustainably.
American Journal of Evaluation, 26, 3, 320- 347
Thompson, B., Lichtenstein, E., Corbett, K., Nettekoven, L., & Feng, Z. (2000). Durability of tobacco control efforts in the
22 Community Intervention Trial for Smoking Cessation (COMMIT) communities 2 years after the end of
interventions. Health Education Research, 15, 353–366.
Thompson, B., &Winner, C. (1999). Durability of community intervention programs: definitions, empirical studies, and
strategic planning. In N. Bracht (Ed.), Health promotion at the community level (pp. 137–154). Thousand Oaks:
Sage
Wisdom, J. P., Ford, J. H., Hayes, R. A., Edmondson, E., Hoffman, K., & McCarty, D. (2006). Addiction treatment
agencies' use of data: a qualitative assessment. Journal of Behavioral Health Services & Research, 33(4), 394-407.
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