In 2006, Iowa submitted an application to the SAMHSA Center for Substance Abuse Treatment to fund substance abuse services process improvement through the Strengthening Treatment Access and Retention-State Implementation (STAR-SI) grant. The STAR-SI initiative proposed to: 1) use data to reduce variation in processes and employ standards for performance monitoring; 2) focus on processes, not people, as the source of problems; and 3) pursue continuous, small improvements in access and retention, using techniques developed by Network for the Improvement of Addiction Treatment (NIATx).

In addition to improving basic client access and retention processes, STAR-SI presented Iowa the opportunity to create new ways for agencies to relate to both the Iowa Department of Public Health (IDPH) and to one another. The focus on collaborative partnership within STAR-SI not only presented opportunities for agencies to come together, share information and approaches to process improvement, but to share their successes with agencies from other states.

 

Before STAR-SI, some state-level progress had been made toward resolving client access and retention problems. Many structural and systemic barriers still existed, however, that challenged IDPH and Iowa’s substance abuse agencies as we tried to improve service delivery. Among a laundry list of barriers: a lack of childcare services and of transportation, excessive wait times, excessive paperwork, and lack of funding to provide needed recovery support services. These all colluded to muddy our vision of a more responsive delivery system.

Enter STAR-SI. While we originally saw STAR-SI as a means to reduce wait times and increase client retention in treatment, it soon became apparent that greater systemic benefits were accruing. The collaborative approach to learning improved our state’s providers’ abilities to broaden their fund of knowledge, while also increasing IDPH’s ability to create more collaborative working partnerships with these agencies.

 

Agencies quickly saw the benefit of sending staff to the semi-annual state learning collaboratives and the annual NIATx Change Leader Academy. As Eric Preuss, change leader at Community and Family Resources, remarked, “It’s been simply amazing what a little exercise like building a better paper airplane turns into!”  One change project to get clients in faster for evaluations caused a waterfall effect in the outpatient facility—decreasing wait times for evaluations from 25 to 7 days; decreasing no-shows from 25% to under 10%; increasing admission conversion rate by 10%; increasing retention to fourth session from 61% to 86%; and increasing customer satisfaction—all in the matter of weeks!

Learning to build and systematically “adapt a paper airplane” to enable it to fly farther at the Change Leader Academy might seem a minor exercise to the uninitiated. But it begins to gain relevance when one realizes that is essentially the process used to create a better client service system.

 
How did building a better paper airplane translate into better outcomes in Iowa? Iowa has decreased STAR-SI agencies’ wait times between client first contact and assessment from 10.44 days to 3.74 days, a 62.4% improvement. Year 1 STAR-SI agencies have improved their units of service provided to clients in the first 30 days post-admission by 12.5%, from 4.3 to almost 5 units.

We have faced many challenges during STAR-SI’s life in Iowa. Challenges have ranged from our data coordinator being sent to Kuwait with his National Guard unit, to debilitating flooding during the summer of 2008. The data coordinator’s absence presented us with unique challenges in staffing. The state change leader ultimately picked up the data coordinator’s duties, and this reallocation of responsibility provided us with the opportunity to experience what agencies have been telling us: adequate staffing is mandatory when managing data-driven change projects.

 

Iowa’s flooding was devastating to STAR-SI agencies and their clients; one agency where STAR-SI was implemented was shut down for over six months. Worse, the agency lost many of its clients. While we can measure the impact in terms of data elements, it is the human cost that remains difficult to fathom.

We have learned numerous lessons from STAR-SI. Among them is an important one that might have less to do with improving access and retention rates than it does with state and provider agency staff learning how to think in new ways about what might be best for clients. At IDPH we frequently hear from providers and their customers about “customer service.” The flavor of some of these stories has changed, though, since STAR-SI came to Iowa. Where we might have once heard from an agency about creating an “open door policy” allowing clients to come in any time to discuss issues and how this improved client satisfaction, we began hearing about a different brand of systemic changes—for example, Alcohol and Drug Dependency Services’ (ADDS) story of how it took NIATx principles and applied them in creative ways to improve customer and staff satisfaction. ADDS is a substance abuse treatment agency in Burlington, Iowa that serves clients in outpatient and residential settings; it participated in Iowa’s first year of STAR-SI.

 
ADDS director Rick Swanson said, “Following completion of our second change project and about six months into the process, other outpatient offices in Mt. Pleasant, Keokuk and Wapello began to ask if they could get in on this type of process. We did a presentation to our monthly all-staff meeting about the NIATx process so that everyone in the organization would have some basic information about the activity they had seen. I believe the ideas that especially caught their attention were the concept of doing a walk- through from the perspective of a client and the concept of having a team closely involved with the change project that would investigate and implement the proposed change.

The enthusiasm was overwhelming. What we thought would be a “slow and easy” approach to diffusion quickly became a noisy demand for inclusion in the change process.

 

A great example of residential substance abuse services embracing the process improvement project occurred when our staff did a walk-through of the residential treatment facility at mealtime. The essence of the activity was this:  The staff placed themselves in a mindset of clients at the residential treatment facility. While dining there, they thought the meal service was sterile, to say the least, and not especially inviting. The change team leader, our Food Service Supervisor, polled current clients to determine their perceptions, asked for a satisfaction rating on our food service, and fielded their change suggestions.

Suggestions included: a) posting the menu on a restaurant-style white board prior to each meal, b) having tables set with dinnerware rather than using a cafeteria process, and c) occasionally using table cloths. Clients were polled following the implementation of these changes to again measure satisfaction and to see if the previous perceptions of clients had changed. They had.

 
What can we take away from this story? NIATx principles can be used to improve service in ways that might not be measured with access and retention tables. Process improvement projects can diffuse to any part of the organization and result in improvement in all areas of the organization. Change teams and change leaders, regardless of background, can shine when given the opportunity.

Director Swanson’s concludes “that anyone, in any position, can function as an effective change team leader, given the tools necessary to get the job done. I think diffusion of those tools was demanded by other parts of our organization for several reasons, including the excitement that was generated by the change teams, which served as examples to others in the organization—the infectious nature of excitement that always surrounds success.”

 

ADDS has recently begun to track staff participation in change projects as part of the formula that determines the year-end employee bonus structure.

 

We in Iowa understand that it is important to reduce wait times, increase admissions and improve client retention. But we have found that improvements in a statewide treatment system cannot always be measured with access and retention data. Indeed, at one time, some of us might have viewed a performance management data system that was access- and retention-driven as being in conflict with state-level and agency-level goals to improve staff and client satisfaction.

But it is clear that the rewards from our STAR-SI involvement are broader. From agencies expanding how they think about and implement process improvement, to measures that go beyond client outcomes, to IDPH’s experience of building collaborative relationships with providers, to creating learning experiences for staff to build process improvement capabilities, Iowa has moved on to a new way of thinking about service delivery. As Kathy Stone, Iowa’s SSA director observed, “We might not always have all the resources we would like or the fastest data system or the most funding. But we do have the power to support the providers and the state-level service systems to continue improving the collaborative learning foundation we have built.”