Improving Quality of Care in SubstanceAbuse Treatment Using Five key ProcessImprovement Principles

Kim A. Hoffman, PhDCarla A. Green, PhDJames H. Ford II, PhDJennifer P. Wisdom, PhD, MPHDavid H. Gustafson, PhDDennis McCarty, PhD

Abstract

Process and quality improvement techniques have been successfully applied in health care arenas, butefforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for theImprovement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies touse process improvement strategies to increase client access to, and retention in, treatment. NIATxrecommends five principles to promote organizational change: (1) understand and involve the customer,(2) fix key problems, (3) pick a powerful change leader, (4) get ideas from outside the organization, and (5)use rapid cycle testing. Using case studies, supplemented with cross-agency analyses of interview data,this paper profiles participating NIATx treatment agencies that illustrate successful applications of eachprinciple. Results suggest that organizations can successfully integrate and apply the five principles as theydevelop and test change strategies, improving access and retention in treatment, and agencies’ financialstatus. Upcoming changes requiring increased provision of behavioral health care will result in greaterdemand for services. Treatment organizations, already struggling to meet demand and client needs, willneed strategies that improve the quality of care they provide without significantly increasing costs. The fiveNIATx principles have potential for helping agencies achieve these goals.

Address correspondence to Kim A. Hoffman, PhD, Department of Public Health and Preventive Medicine, OregonHealth & Science University, 3181 SW Sam Jackson Park Rd., CB 669, Portland, OR 97239, USA. Phone: +1-503-4940016;Fax: +1-503-4944981; Email: hoffmaki@ohsu.edu.Dennis McCarty, PhD, Department of Public Health and Preventive Medicine, Oregon Health & Science University,

CB 669, Portland, OR, USA.Carla A. Green, PhD, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.James H. Ford II, PhD, Department of Industrial Engineering, University of Wisconsin – Madison, Madison, WI, USA.David H. Gustafson, PhD, Department of Industrial Engineering, University of Wisconsin – Madison, Madison, WI, USA.Jennifer P.Wisdom, PhD,MPH, Department of Psychiatry, New York State Psychiatric Institute, Columbia University,

New York, NY, USA.

Journal of Behavioral Health Services & Research, 2012. 234–244. c) 2012 National Council for Community BehavioralHealthcare. DOI 10.1007/s11414-011-9270-y

234 The Journal of Behavioral Health Services & Research 39:3 July 2012

Introduction

Clinicians are increasingly under pressure to implement evidence-based decision making andreduce inefficiency in medical care.1,2 The Institute of Medicine’s Crossing the Quality Chasmcalled for health care organizations to improve quality of care through system redesign.1 Theserecommendations were recently extended to services for alcohol, substance, and mental healthproblems3; many substance abuse treatment agencies have weak organizational structure.4

Incorporating process improvement approaches into addiction treatment services managementmay address this problem, allowing agencies to modify service delivery and enhance accessand retention with only marginal expansions of infrastructure and resources.5–7 Demand fortreatment services exceeds service capacity, and with current funding limitations, dramaticincreases in treatment resources are unlikely. Thus, efficiency and effectiveness of existingservice systems must improve if goals are to be met, particularly for admission processes andearly engagement.6

Network for the Improvement of Addiction Treatment

The Robert Wood Johnson Foundation (RWJF) and the Substance Abuse and Mental HealthServices Administration’s Center for Substance Abuse Treatment (CSAT) combined resources tosupport a demonstration project that used process improvement techniques within drug and alcoholtreatment organizations. The project, entitled The Network for the Improvement of AddictionTreatment (NIATx), was developed and based at the University of Wisconsin – Madison andfocused on five principles supported by a review of process improvement research8: understandand involve the customer, fix key problems, pick a powerful change leader, get ideas from theoutside, and use rapid cycle testing.

The NIATx protocol begins with a “walk-through,” wherein a staffperson assumes the role of acustomer to experience and record the organization’s treatment processes.9 The facilitators andbarriers to treatment access and engagement are shared with a group of 3–6 staff who have agreedto play a role in process improvements. These groups, known as “change teams” are convened by achange leader to identify solutions and enact change projects designed to address problemsidentified in the walk-through. A cross-site evaluation of NIATx agencies found significantimprovements including a 37% decline in days to admission, an 18% gain in retention in carebetween the first and second treatment session, and a 17% gain in retention between the first andthird treatment session.6 A second NIATx cohort replicated these improvements.7

This paper elucidates the story behind these statistics, providing qualitative analyses andexamples of processes adopted by agencies that successfully implemented NIATx principles. Thefollowing section reviews theoretical underpinnings behind the five principles.

The NIATx five principles of change

Principle 1: Understand and involve the customer

Successful organizational innovations are customer-oriented.10–13 The first principle calls for“continued commitment to understand the needs and expectations of people who can benefit fromthe products and/or services produced by the organization.”8 These organizations involvecustomers when developing organizational changes and assessing improvements.14 This principlecan pose significant challenges resulting from clients’ disparate needs (e.g., co-occurring mentalhealth disorders, criminal justice involvement, homelessness, domestic abuse, and child care) thatrequire comprehensive, client-focused approaches.15–19

Improving Quality of Care in Substance Abuse Treatment HOFFMAN et al. 235

Principle 2: Fix key problems

Principle 2 directs change agents to focus on processes critical to the organization’s viability.Participants are encouraged to focus on the problems “that keep the Chief Operating Officer (CEO)up at night” because problems that are important to leaders are likely to have support necessary tolead to successful implementation. Specific targets can vary, but agencies are counseled to linkchanges to organizational objectives like reducing staff turnover or improving retention and agencyfinancial status. One method is to reduce no-show rates; more clients showing up to treatmentequate to more billable hours thus increasing revenue.14

Principle 3: Pick a powerful change leader

Principle 3 states that change leaders should have adequate authority and respect to assemble andmotivate groups,8 have enough power and social capital to lead change efforts,20 are able to increase“buy-in” by winning the “hearts and minds” of staff,21 and provide teams with a clear, attractivevision.22 Change leaders must have access to and the support of the CEO, be able to allocate resourcesto the change effort, and be committed to change processes and goals.8 Staff resistance to change, acommon barrier, can be mitigated by strong leaders who bridge “organizational segmentalism” (whendepartments do not engage or communicate well with each other) and barriers that prevent or slowchange processes.23 Leaders who use consistent communication create a vision for change, promoteengagement, and help overcome resistance.20,24

Principle 4: Get ideas from outside the organization

Process improvement’s emphasis on effectiveness and efficiency draws heavily on continuousimprovement models developed to improve manufacturing processes.25,26 Applications in businessmanagement and health care processes have demonstrated the capacity of organizational change toenhance operational efficiency27 and strengthen patient outcomes.28,29 Change teams areencouraged to seek out and capitalize on other organizations’ successful improvements includingproduction and business practices in other domains (e.g., transportation, hospitality, etc.).14

Principle 5: Use rapid cycle testing

NIATx promotes rapid cycle Plan–Do–Study–Act (PDSA) methods to identify problems andgenerate solutions (Plan), implement new processes (Do), measure and assess outcomes (Study),and institutionalize the change or make additional changes (Act).30,31 In a PDSA cycle, changes arepiloted with a small sample of staff and patients to assess feasibility and effectiveness. If effective,the intervention is institutionalized. If partially or wholly ineffective, the initiative is modified andtested until successful, or until a decision is made to abandon the approach. The PDSA methodinvolves paying attention to data, confirming the existence of problems, identifying opportunitiesfor improvement, and evaluating the effects of any changes.8

Although a substantial body of theoretical knowledge about the application of these principlescan be found for other settings (e.g., business and management literature),32 few clear examplesexist in behavioral health. Consistent with Fernandopulle and colleagues33 (p. 182) suggestion that“case studies provide essential qualitative insight into attributes associated with quality perform-ance”, this paper uses case studies of NIATx agencies, with cross-agency qualitative analyses, toillustrate successful applications of the principles and identify common pitfalls. Case studymethods have become important tools in the study of health care delivery.34 For example,organizational improvement case studies within behavioral health include a benchmark study of thesuccessful application of total quality management (TQM) in mental health settings,35 the use of

236 The Journal of Behavioral Health Services & Research 39:3 July 2012

program specification and accountability evaluation to monitor service delivery,36 and a multisiteintervention to improve access to care for chronic drug users.37

Methods

Participant selection and characteristics

The sample includes agencies chosen to participate in NIATx. Eligibility was limited to nonprofitagencies with at least 100 admissions/year and serving at least 50% publicly funded clients. RWJFmade ten awards in August 2003 and 15 more awards in January 2005 (awards were for18 months). CSAT awarded funds to 13 grantees in September 2003, providing them each with36 months of support. Further details about the initial round of applications and awards can befound elsewhere.9 Treatment agencies were located in rural and urban settings in 17 states, variedby size and services provided, and included multiple levels of care. Annual revenues ranged fromless than $300,000 to over $11 million. (For additional information, see Ford and colleagues,9 andMcCarty and colleagues6).

Procedures

Site visits and interviews

Annual site visits and quarterly telephone interviews were completed with 38 participatingNIATx agencies between October 2003 and May 2006. Individual interviews were conducted withchange leaders, executive directors, and a variety of staffpersons; focus group interviews wereconducted with front line staff, managers and therapeutic staff. Quarterly telephone interviews werecompleted with change leaders except when the annual site visit occurred. Executive directors andchange leaders agreed to participate in interviews as part of the project. Staff were invited but notrequired to participate; participation or nonparticipation was kept confidential. All intervieweeswere informed about confidentiality, freedom to participate and the right to withdraw from thestudy at any point. The Oregon Health & Science University (OHSU) Institutional Review Boardfor the Protection of Human Subjects approved and monitored the study.

All interviews were conducted by the OHSU evaluation team and all interviewers held doctoralor masters level degrees. The qualitative interview guide was semistructured and covered thefollowing dimensions: change initiatives and impacts, whether change initiatives were sustained,use of data to make decisions, change leader effectiveness, staff buy-in, staff empowerment,agency stability, effects on organizational culture, extent of customer focus, and learning fromothers. (Copies of interview guides are available upon request from the corresponding author.)

Each audio-recorded interview was about one hour. Interviewers summarized findings anddocumented reflections about interviews and site visits. After site visits, interviewers shared site-specific summaries of findings to programs, protecting confidentiality of interviewees, with thechange leader as a member check to increase validity38 and requested clarifications and additionalperspectives.

Coding and data analysis

The team began with initial read-throughs of a subset of interviews, making notes on possiblethemes for discussion at team meetings. Thematic codes were developed inductively and transcriptscontinually reviewed, allowing the data to dictate a majority of analytic categories.39 Through thisiterative process of coding, review, discussion, and revision, researchers documented thematiccodes and definitions in a codebook. This process was followed until no new categories emergedfrom the data and the codebook was finalized. Transcripts were then entered into ATLAS.ti 5.0

Improving Quality of Care in Substance Abuse Treatment HOFFMAN et al. 237

software,40 and the codes detailed in the code book were applied to the dataset. The contents ofeach coding category were reviewed to ensure agreement.

Evaluation staff took several steps to increase methodological rigor: multiple evaluatorsparticipated in data collection and analysis to ensure multiple viewpoints during code creation,evaluators considered rival explanations while analyzing data to validate the theoretical scheme,and agency representatives reviewed text to ensure clarity and provide additional detail (memberchecking). To ensure consistency across coders, we check-coded a 10% random selection ofinterviews using a subset of key codes, evaluating 526 coded passages. An additional coderreviewed inconsistencies between primary coders and check coders to resolve them; primarycoders’ were judged accurate for 89.3% of the 526 passages.

For cross-agency analyses, thematic content was extracted from the database by reviewing textrelevant to the five principles. A “best cases” case-study approach illustrates successful experiencesfrom participating agencies; cross-agency findings from thematic analyses provide informationabout common experiences and pitfalls. To select cases, investigators reexamined each principle (asdescribed in the “Introduction”), then collaboratively chose those with exemplary implementationof one or more principles. The type of case study approach used here allows researchers to exploreindividuals or organizations, simple or complex interventions, relationships, communities, orprograms.41

Results

Results are organized around the five NIATx principles. While agencies were encouraged toapply all five principles, each did so with varying degrees of success. As a result, it was impossibleto select a single agency representing the “best case” for all of the principles. Pseudonyms are usedin the following report of results to protect anonymity of agencies and individuals.

Principle 1: Understand and involve the customer

“Esperanza House” provides examples of how attention to client needs improves delivery ofcare. Esperanza House is located in an urban, southern city and serves about 100 homeless andindigent clients each year. It offers a full continuum of care for substance users and their families,including outpatient counseling, residential treatment and prevention, and community education.Esperanza House used NIATx principles to apply customer-focused changes after walk-throughssuggested they were not meeting client needs. The change leader incorporated clients into changeteams to brainstorm ideas about quality improvement:

The customer focus aspect has been a big part of our change projects and change teams. All the change teams havehad customers as part of their group — either current or former clients.

Esperanza House’s PDSA cycles included training administrative staff to answer client questionsand training intake coordinators to focus on treatment-related needs (e.g., making follow-upappointments). Lastly, a billing staffperson was trained to engage clients and perform individualfinancial consultations and payment planning. The change leader reported:

Results of this change cycle have been very positive: Client self-pay fees have increased from 22% per month toaround 90%. Support staff are less burned out, and the reorganization has allowed [Esperanza House] to reduce[staff] hours [at their request]…[increasing] revenue. We were just looking for better service—we didn’t anticipatethe increase in fee collections.

This agency also adjusted walk-in times to accommodate longer hours of operation, offeredadditional treatment modalities and techniques, including biofeedback, and restructured the

238 The Journal of Behavioral Health Services & Research 39:3 July 2012

orientation process to include sober peer support. They also trained staff to be more alert to clientdisengagement and implement motivational techniques to prevent early dropout.

Other NIATx agencies varied significantly on this dimension. Some made efforts to solicit clientfeedback and understand their needs, but most did little to involve customers directly in organizationalchanges or PDSA cycles. For example, clients were infrequently included as members of change teamsor invited to provide input when changes were planned. The most common approach to involving thecustomer tended to be collecting client response after a PDSA cycle was initiated, although this wasrarely institutionalized and often tended to be impromptu and informal.

Principle 2: Fix key problems

“New Life” is a mid-size, urban clinic that provides residential and outpatient substance abusetreatment. Most clients are indigent and unable to pay for treatment. New Life’s facility wasdevastated by a natural disaster. As clients returned, staff discovered clients had substantial mentalhealth needs as a result of their experiences related to the event. Additionally, New Lifeexperienced a dramatic reduction in resources, including staff who were displaced and did notreturn to work. The change leader felt that these changes were disorienting to the clients:

I am having to explain to people who want to come back that we are not the [New Life] we used to be. They arecoming back with the expectation of routine and normalcy like [predisaster] and when they come they are confusedand upset.

As a result, clients were leaving treatment prematurely. A PDSA cycle designed to facilitate amajor cultural shift was proposed. The director felt staff spent too much time “babysitting” andconducting “detective” work to root out banned activities such as smoking. The change cyclecalled for staff to emphasize that clients should be “responsible for their surroundings and eachother.” For instance, if a client was behaving disruptively, other clients were responsible for callinga community meeting so that all could discuss and resolve the problem. The goal of this changewas to encourage engagement in treatment, increase retention, and reduce the amount of staff timedevoted to enforcing rules.

In addition, a change team composed mostly of clients was charged with fostering engagementof new clients. The change leader reported:

[They] came up with a greetings system of their own and an orientation twice a week [for] new clients. Of the 50people who were here last Friday, 40 of the 50 had been here for more than 30 days. That shows great success ontheir part…

The change leader monitored the results by collecting and analyzing continuation rates. Shefound significant improvements:

When we started to involve the clients more in the change, there was a dramatic jump in continuation [retention intreatment]. We have also looked at our retention numbers for November [baseline] and December [2005] and theywere 60 and 69% respectively. About 75% have now [February 2006] been here more than 30 days.

New Life was exemplary, but some organizations did not progress beyond the stage of smallchanges. For example, a common pitfall was that initial change efforts targeted aesthetic issuessuch as cosmetic upgrades to waiting rooms, while more critical concerns, such as client retention,went unaddressed.

Principle 3: Pick a powerful change leader

Beth is director of program development at a large, urban, multisite treatment organization,“Sober Living.” Beth took the lead on change initiatives and, over time, encouraged change team

Improving Quality of Care in Substance Abuse Treatment HOFFMAN et al. 239

members to select their own targets. Her approach included: (a) attention to collecting andanalyzing data, (b) ability to communicate clearly about change cycles, (c) support from theagency’s CEO, and (d) unfailing enthusiasm.

Beth routinely incorporated the collection and analysis of data into the change team’s processimprovement strategy. Data-driven process improvements were based not only on quantitative datacollected from change cycles but also face-to-face interviews with clients. Beth encountered resistanceto process improvements, especially within the Sober Living’s detoxification unit. Staff described howoppositional the unit had initially been to Beth, given her outsider status, with comments like: “Who isshe coming in here and talking about possible changes? She doesn’t even work in this unit.” Bethgained acceptance and buy-in through effective communication: she engaged detoxification staff,explaining PDSAs and how the change teamworked. She elicited and addressed concerns, encouragingtwo-way communication. As a result, Beth was able to help the unit improve the quality of informationprovided to clients, streamline intake paperwork so that it was less burdensome, and cross-train staff toaddress all components of the intake process in order to avoid delays.

Other NIATx agencies indicated a wide range of leadership methods and styles. These were metwith varying levels of success. Primary pitfalls included unclear expectations for staff, lack of clearcommunication with change team members, turnover within the change leader position creatinginstability, and lack of adequate authority.

Principle 4: Get ideas from outside the organization

Two agencies illustrate how organizations can leverage knowledge gained from others. Theseagencies were from the same state but participated in different NIATx cohorts. “Step-Ahead,” anagency funded in the first RWJF cohort, had been engaged in process improvements for a longerperiod of time than “Choices” (an agency funded in the second RWJF cohort). Initially, the flow ofinformation was designed to be unidirectional—from the more experienced agency to the neweragency, but staff soon discovered the value of bidirectional exchanges.

Choices’ first PDSA activity was to improve procedures for assessing walk-in clients. Choiceslearned that Step-Ahead had already undertaken this as a change project, so scheduled a site visit tolearn how the project was implemented. After the site visit, Choices’ staff reflected on what theyhad learned and how to incorporate Step-Ahead’s recommendations. The change leadersummarized the team’s decision:

We decided at that point that we did not want to [manage walk-in clients] the same way that they did. But it was veryhelpful information and helped us make that decision. Shortly thereafter, we piloted our walk-in [procedures].

Likewise, Step-Ahead’s change leader reported:

We both exchanged ideas — they got more from us because we were in the process for over a year, but we got ideasfrom them…as far as efficiency. We loved having them. Later, I heard [Choices’ executive officer] speak of how muchthey were able to do so quickly because they were able to observe us and get peer-to-peer support; it helped themgrasp the [NIATx] concept quicker.

Step-Ahead and Choices continued to collaborate and share information with one another overthe course of their participation. Our cross-agency analyses suggested that “getting ideas from theoutside” was the least incorporated of NIATx’s five principles. This appeared to be due to lack oftime, staff shortages, and the concentration of effort on change projects within agencies.

Principle 5: Use PDSA rapid cycle change projects

“Transformations” treats several hundred patients a year in a northeastern city. It providesinpatient and outpatient treatment, methadone maintenance, and detoxification services to a mostly

240 The Journal of Behavioral Health Services & Research 39:3 July 2012

publicly funded population. Transformations used a series of PDSA cycles to improve retention.Baseline data showed early treatment dropout was a serious problem in their outpatient services:50% of the clients who completed intake appointments did not return for the first treatmentappointment. The team decided to train intake staff in Motivational Interviewing (MI)42 andimplement MI techniques during the intake appointment (Plan). The intervention was implemented(Do) and data were analyzed (Study). Over the following month, retention increased from 50% to90%. At that time, the change team agreed on an appropriate action (Act): They would adopt MItraining for all intake staff and make MI processes a standard procedure.

Staff initiated a second MI-based PDSA cycle in their residential facilities. In June 2005, thebaseline residential retention rate (the proportion of admitted clients who completed one week oftreatment) was 80%. By October, continuation rates had risen to 100%. The change was adopted asa standard procedure in the residential unit as well.

To increase staff interest and buy-in for the changes, the change team posted week-by-weektallies of change-related data for all staff to see. The progress through these initial successesincreased staff attention to customer needs and inspired new change cycles designed to furtherincrease retention in care including providing a tour of the facilities, creating a “health managementgroup” for clients on psychiatric medications, changing medication administration times to allowclients an extra hour of sleep, and instituting an “open door policy” to allow clients to expressconcerns to staff

Transformations’ change leader reported that the PDSA framework was a helpful tool:

[The PDSA cycles] have made a big difference in how we approach change. [They] provided a structure for us tomake changes and improvements [that are] measurable and…easy for people to use. The changes feel lessoverwhelming because of the process.

Cross-agency analyses showed a wide variety of responses to implementing PDSA cycles. Someagencies had difficulty implementing cycles, while others adopted the process quickly. Challengesincluded identifying appropriate outcome measures [Planning], accurately tracking pre- and post-change [Doing], interpreting differences in pre–post measures [Studying], and determiningappropriate next steps [Acting].

Discussion

Agencies’ experiences elucidate how simple strategies produce valuable improvements indelivery of substance abuse treatment. While agencies were encouraged to apply all five principles,each did so with varying degrees of success. As a result, it was impossible to select one singleagency as representing the “best case” for all of the principles. Each agency had its own strengthsand weaknesses related to the NIATx principles and for some, these strengths and weaknesseschanged over time. For instance, interviews suggest that agencies with changes in leadership orunstable financial environments went through periods where they were unable to engage fully inNIATx change efforts. Similarly, organizations encountering staffing, accreditation, or financialstress found it difficult to allocate staff time and energy to organizing changes around all fiveprinciples. We also found that smaller agencies had more difficulty implementing changes becausethey had fewer organizational resources of all kinds. Each agency, however, focused on theprinciples that were most important to its leadership and staff, taking into account their capacity forchange.

It is also noteworthy that successful process improvements are not without costs. Smalleragencies struggled with changes such as higher clinical caseloads when treatment access wasimproved. Similarly, increased workload or changes in hours of operation can put a strain onalready overburdened staff. Moreover, stress can result from simply working in an environmentwhere things are continually changing, even if those changes are improvements.

Improving Quality of Care in Substance Abuse Treatment HOFFMAN et al. 241

Limitations

The primary limitation of this study is that the findings are confined to NIATx agencies—agencies that recognized the value of process improvement prior to applying for funding from theRWJF or CSAT, successfully completed walk-through exercises, and submitted successful grantapplications. Thus, they likely represent agencies more amenable to process improvementstrategies from the outset. At the same time, the experiences reported across NIATx-participatingorganizations and as part of NIATx funding applications9 suggest that lessons learned from thesecase studies and cross-agency analyses may have broader applicability. Finally, we deliberatelyselected best example cases, which are not representative of all participating agencies. Nonetheless,they provide valuable opportunities to learn from successful change efforts. By improvingadministrative and clinical functions, agencies increase the likelihood that they will improve clientaccess to and retention in treatment, thus improving outcomes.

Implications for Behavioral Health

Improving the quality of behavioral health care is a challenge. Quality improvement techniqueshave been applied in various health care settings, but initiatives in drug and alcohol treatment lagbehind. Recent approaches emphasize continuously improved treatment processes as means ofimproving care quality. These efforts will be increasingly needed as the environment for behavioralhealth care changes. The Patient Protection and Affordable Care Act includes provisions formandated mental health and substance abuse treatments that will increase the level of servicesoffered and extend those services to a wider population.43 Systems of care are expected todocument the effectiveness of care delivery and use data to proactively manage care so thatprocesses are more efficient and more effective. Behavioral healthcare providers will faceimportant decisions in effectively designing benefits, service delivery, and outreach and enrollmentprograms to meet the needs of newly eligible adults. As demand for treatment services growsbeyond current service capacity and resources, process improvement becomes even more importantfor patients and staff in behavioral health care settings. NIATx principles offer innovative ways forprograms to meet demands while improving care and maintaining a client focus. Incrementalimprovements may seem modest but, when aggregated over time and across sites, can lead tosubstantive improvements. Modest gains can be a viable strategy for making large social problemsmore manageable.44 NIATx is an opportunity for treatment programs to learn process improve-ment. These case studies demonstrate that process improvement strategies can contribute toenhanced quality of care for alcohol and drug disorders.

Acknowledgments

We appreciate the support and participation of the treatment programs that have participated inNIATx. The Network for the Improvement of Addiction Treatment (NIATx) was funded by grantsfrom the Robert Wood Johnson Foundation and cooperative agreements from the Substance Abuseand Mental Health Services Administration, Center for Substance Abuse Treatment. The NationalEvaluation Team at Oregon Health and Science University was supported through awards from theRobert Wood Johnson Foundation (46876 and 50165), the Center for Substance Abuse Treatment(through subcontracts from Northrop Grumman—PIC-STAR-SC-03-044, SAMHSA SC-05-110),and the National Institute on Drug Abuse (R01 DA018282). National Program Office activities atthe University of Wisconsin were supported through awards from the Robert Wood JohnsonFoundation (48364), and the Center for Substance Abuse Treatment (through a subcontract fromNorthrop Grumman—PIC-STAR-SC-04-035). We are especially grateful for the cooperation andcollaboration from the 38 members of NIATx.

242 The Journal of Behavioral Health Services & Research 39:3 July 2012

Conflicts of interest The authors have declared that no conflict of interest exists.

References

1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. 1 ed. Washington, DC: National AcademyPress; 2001.

2. Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000.3. Institute of Medicine. Improving the quality of health care for mental and substance-use disorders: Quality chasm series. Washington,

DC: National Academy Press; 2006.4. McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public’s demand for quality care?

Journal of Substance Abuse Treatment 2003;25(2):117–121.5. Capoccia VA, Cotter F, Gustafson DH et al. Making “stone soup”: Improvements in clinic access and retention in addiction treatment.

Joint Commission Journal on Quality & Patient Safety 2007;33(2):95–103.6. McCarty D, Gustafson DH, Wisdom JP et al. The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and

retention. Drug & Alcohol Dependence 2007;88(2–3):138–145.7. Hoffman KA, Ford JH, Choi D et al. Replication and sustainability of improved access and retention within the Network for the

Improvement of Addiction Treatment. Drug & Alcohol Dependence 2008;98(1–2):63–69.8. Gustafson DH, Hundt AS. Findings of innovation research applied to quality management principles for health care. Health Care

Management Review 1995;20(2):16–33.9. Ford JH, Green CA, Hoffman KA et al. Process improvement needs in substance abuse treatment: Admissions walk-through results.

Journal of Substance Abuse Treatment 2007;33(4):379–389.10. Cooper R. Project NewProd: What Makes a New Product a Winner? An Empirical Study of Succesful Versus Unsuccesful Industrial

Innovation. Montreal, Quebec: Quebec Industrial Innovation Centre; 1980.11. Delbecq A, Mills P. Managerial Practices that Enhance Innovation. Organizational Dynamics 1985;14(1):24–34.12. Gerstenfled A. A study of successful projects, unsuccessful projects and projects in progress in West Germany. IEEE Transactions on

Engineering Management EM–23 1976;116–123.13. Maidique M, Zirger BJ. A study of success and failure in products innovation: The case of the US electronics industry. IEEE

Transactions on Engineering Management EM-31 1971;192–203.14. McCarty D, Gustafson D, Capoccia VA, et al. Improving care for the treatment of alcohol and drug disorders. Journal of Behavioral

Health Services & Research 2009;36(1):52–60.15. Oppenheimer E, Sheehan M, Taylor C. Letting the client speak: Drug misusers and the process of help seeking. British Journal of

Addiction 1988;83(6):635–647.16. Westermeyer J. Cross-cultural studies on alcoholism. Alcoholism: Biomedical and genetic aspects. Elmsford, NY: Pergamon; 1989.17. Mirin SM, Weiss RD, Michael J et al. Psychopathology in substance abusers: Diagnosis and treatment. American Journal of Drug &

Alcohol Abuse 1988;14(2):139–157.18. Substance Abuse and Mental Health Services Administration CSAT. Screening and assessment for alcohol and other drug abuse among

adults in the criminal justice system. Treatment Improvement Protocol (TIP) Series 7. Washington DC: US Government Printing Office;1994.

19. Substance Abuse and Mental Health Services Administration CSAT. Comprehensive Case Management for Substance Abuse Treatment:Treatment Improvement Protocol (TIP) Series 27. Rockville, MD; 1998.

20. Kotter JP. Leading change: Why transformational efforts fail. Harvard Business Review 1995;59–67.21. Hill S. How do you manage a flexible firm: The total quality model. Work, Employment and Society 1991;397–415.22. Kouzes J, Posner B. The leadership challenge. San Francisco: Jossey-Bass; 1988.23. Burns T, Stalker G. The management of innovation. New York: Oxford University Press; 1961.24. Kotter JP, Schlesinger L. Best of HBR: Choosing strategies for change. Harvard Business Review 2008;3–13.25. Deming WE. Out of the crisis. Cambridge, MA: MIT-CAES; 1986.26. Juran JM. Juran’s quality control handbook. New York: McGraw-Hill; 1988.27. Kaynak H. The relationship between the total quality management and practices and their effects on firm performance. Journal of

Operations Management 2003;21(4):405–435.28. O’Connor GT, Plume SK, Olmstead EM et al. A regional intervention to improve the hospital mortality associated with coronary artery

bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA 1996;275(11):841–846.29. Pearson ML, Wu S, Schaefer J et al. Assessing the implementation of the chronic care model in quality improvement collaboratives.

Health Services Research 2005;40(4):978–996.30. Gitlow H. Tools and methods for the improvement of quality. Homewood, IL: Irwin; 1989.31. Shewart W. Statistical method from the viewpoint of quality control. New York: Courier Dover Publications; 1986.32. Gustafson DH, Cats-Baril WL, Alemi F. Systems to support health policy analysis : Theory, models and uses. Ann Arbor, MI: Health

Administration Press; 1992.33. Fernandopulle R, Ferris T, Epstein A et al. A research agenda for bridging the ‘quality chasm.’ Health Affairs (Millwood) 2003;22

(2):178–190.34. Yin RK. Enhancing the quality of case studies in health services research. Health Services Research 1999;34(5 Pt 2):1209–1224.35. Sluyter GV, Barnette JE. Application of total quality management to mental health: A benchmark case study. Journal of Mental Health

Administration 1995;22(3):278–285.

Improving Quality of Care in Substance Abuse Treatment HOFFMAN et al. 243

36. Savas SA, Fleming WM, Bolig EE. Program specification: A precursor to program monitoring and quality improvement. A case studyfrom Boysville of Michigan. Journal of Behavioral Health Services & Research 1998;25(2):208–216.

37. McCoy HV, Messiah SE, Zhao W. Improving access to primary health care for chronic drug users: An innovative systemic interventionfor providers. Journal of Behavioral Health Services & Research 2002;29(4):445–457.

38. Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills, CA: Sage; 1985.39. Glaser BG, Strauss AL. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine; 1967.40. User’s manual for ATLAS.ti 5.0 [computer program]. Berlin: ATLAS.ti Scientific Software Development; 2004.41. Yin RK. Case study research: Design and methods. 3rd ed. 2003. Thousand Oaks, CA, Sage Publications. Applied Social Research

Methods Series42. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. 2nd ed. New York, NY: The Guilford

Press; 2002.43. Mental Health America. Fact sheet: Medicaid expansion. http://www.mentalhealthamerica.net 2011; Available at http://

mentalhealthamerica.net/go/action/policy-issues-a-z/healthcare-reform/fact-sheet-medicaid-expansion/fact-sheet-medicaid-expansion.Accessed August 8, 2011.

44. Weick KE. Small wins: Redefining the scale of social problems. American Psychologist 1984;39:40–49.

244 The Journal of Behavioral Health Services & Research 39:3 July 2012