Lessons Learned in Systems Change

Idaho Behavioral Health Transformation Workgroup Forum

March 24, 2010

Dave Wanser, Ph.D.Visiting Fellow

LBJ School of Public Affairsdavid.wanser@austin.utexas.edu

Executive DirectorNational Data Infrastructure Improvement Consortium

dwanser@ndiic.com

The topics:

• What lessons have I learned in systems change?

• How to develop cross government coordination

• What mistakes can you avoid based on our previous experience?

• Working with legislative bodies

• Measuring success

Who am I? Why am I here? Admiral James Stockdale

• NorthSTAR

• HB 2292 – merged health, MH and SA

• MH Transformation

• Governor’s Drug Demand Reduction Advisory Committee

• New Mexico Purchasing Collaborative

Coordinating versus cooperating

• Other agencies are always willing to tell you how to do a better job – that’s coordinating.

• Cross agency collaborations for a managed system require each agency to share in staffing a dedicated team with necessary skills – and autonomy to get the job done

• The only way to ensure cooperation is for:– all entities to have skin in the game– The Legislature and/or Governor to order it to be so– A shared clinical logic and structure – Data collection mechanisms that show how the entire

system is performing

Lesson #1Real system change is extremely hard to do

It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system.

For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new one.

Nicola Machiavelli

System (re)design

• The plan for the new system always looks great on paper• Systems are generally not designed in the first place • System design plans rarely operate as planned • Transforming a system and having to navigate around

sacred cows is a recipe for no change at all. Typical sacred cows include:– Children’s services and other “special populations”– Traditional funding and payment arrangements– Certain providers– State-supported versus private providers– Traditional providers of each respective agency

• Making the system more logical for consumers pushes complexity upstream

Lesson #2 There are no simple answers

Starting off on the wrong foot

• Uniqueness trumps having an organized system• No clear authority structure• Ignoring economies of scale • Lacking a clinical framework: including standardized

functional assessments and service level packages• Not having a viable financial model (capitation for it’s

own sake is not a viable financial model)• Hoping that community services will somehow emerge

from a system design effort• Confusing system transformation with cost cutting

Lesson #3Implementing without a sound foundation

ensures failure

Working with the legislature• There has to be legislative champions for the system change-

preferably in the majority party• Advocacy organizations need to be fully engaged, on your side,

informed throughout the entire process - and you have to share good and bad news

• You must have data about system performance that is timely and accurate

• This data needs to be provided to them by agency leadership periodically and preferably before someone complains

• Anecdotes have a longer shelf life than Twinkies• Providers in a legislator’s district are always an exception to the rule• Legislators always say they want government agencies to work like

a business. This logic is flawed in 2 ways:– More than 50% of businesses fail

Lesson #4Government innovation is usually an

oxymoron

Measuring success

• There are different stages of maturity of managed systems and the performance metrics need to evolve as the system does. For example, first stage performance measures:– See clients– Pay providers– Give us data

• System performance data needs to be available to all stakeholders

• The funding entity(s) must own and control the data• Strong contract, aggressively but fairly managed• Incentives and tensions are required to change the

status quo

Lesson #5Focus on the vital few indicators- but

manage them proactively

Final Lesson:The caravan can’t stop for every barking

dog.