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

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

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

Recipe for Success

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

Important Utensils

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

“Where it all started…”

Los Angeles County, California

Phase I Los Angeles County Process Improvement Pilot Project

November 2005-September 2006

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

Phase I Pilot Project Timeline

Nov ‘05

Orientation

Jan ‘06

Kick-Off

Workshop

Pre-Work

Nov ‘05-Jan ‘06

Feb ‘06

Site Visits

Mar ‘06

Monthly

Conference

Calls

Jun ‘06

Mid-Way

Change

Leader

Meeting

Sept ‘06

Completion

Conference

Phase I Aggregate Results

83% reduction in assessment/intake no-shows (2 agencies reporting)

39% increase in 30-day continuation (3 agencies reporting).

California Addiction Training and Education Series

November 2007-May 2009

**1,430 participants

***50 counties

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)

Sample Agenda

Case study - from an agency’s perspective Process Improvement 101 How to get started Measuring impact of change Promising practices

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

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)

Target Areas of Call Participation

= 10+ callers

= 5-9 callers

Phase II Los Angeles County Process Improvement Pilot Project

November 2007-October 2008

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)

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

6

2.6 2.5

44.3

1.9

4.6

3.5

1.2

6.9

0

1

2

3

4

5

6

7

Basel

ine

Mar

chApril

May

June

July

AugSep Oct

Avg

Day

sWait Time from First Contact to Admission

42% Average Improvement in Wait Time

43.5

2521.2

26.628.4

36.4

28.2

12.7

24.618.6

05

101520253035404550

Basel

ine

Mar

chApril

May

June

July

AugSep Oct

Avg

%

43% Average Improvement in No-Shows

No-Shows

70.677.4

84.8 86.680.5 84.3 87.5 84.6 87

84.1

0102030405060708090

100

Basel

ine

AprilM

ayJu

neJu

lyAug

Sept

Oct

NovAvg

% 19% Average Increase in Session-by-Session Attendance

Session-by-Session Attendance

68.5

73.9

68.9

73.975.1

72.9

70.7

75.172.9

64

66

68

70

72

74

76

Basel

ine

AprilM

ayJu

neJu

lyAug

Sept

Oct

Avg

%

30-Day Continuation

6% Average Improvement in 30-Day Continuation

California NIATx Coach Pilot Project

July 2008-April 2009

Infrastructure Development

Coach Academy Change Leader Academy Building local coaching and change leader

expertise within California – essential for spread to occur

Local Learning Collaboratives

July 2008-Present

“Local” Learning Collaboratives

Regional Learning Collaboratives – California Endowment

April 2009-Present

Target Areas of Call Participation

= 10+ callers

= 5-9 callers

Regional Learning Collaboratives – Like-Size County Structure

6

1 1

5

1

3

2

4

1

3

5

1

2

14

1

8

0%

20%

40%

60%

80%

100%

So Cal(n=8)

CentralValley (n-8)

CapitolRegion(n=12)

Bay Area(n=11)

Nor Cal(n=10)

Large Medium Small MBA*

*MBA = Minimum-Based Allocation (under 90K population)

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

“Nine Lessons Learned” Phase I and Phase II Pilot Projects

Strategies for Successful Change Project Implementation

Communicate

Brainstorm Multiple Ideas for Change

Be Creative

Work as a Team

Review Data Regularly!

Celebrate Early Successes

Keys Ingredients for Change Project Success

1. Choose the right Change Leader

2. Establish a clear objective

3. Implement only 1 new change at a time

4. Make sure everyone implements change project as planned

5. Start small

6. Study the results before making modifications

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

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?

Small Changes, Big Impacts

Small changes make a big difference for both clients and staff

Effective changes do not have to be costly

Sustainability is Possible…

What Does the Future Hold?

• Beth Rutkowski, MPH

• (310) 388-7647; brutkowski@mednet.ucla.edu

• Steve Gallon, PhD

• (503) 378-3537; sgallon@aol.com

• Alex Bruehl, MA

• (626) 299-4502; abruehl@ph.lacounty.gov

Thank you for your time!