Standardizing Addiction Program Transitions through a LEAN Process Pillar 4 – Right service, right...

Standardizing Addiction Program Transitions through a LEAN Process

Pillar 4 – Right service, right time, right place

2015 Annual Addictions & Mental Health ConferenceMonday May 25, 2015Debbie Bang ,Anna Jendzio, Keith Ledger, Jon WhitsonAlso on the Project Team: Megan Maher, Lou-Anne Gribbon, Julia Esposto, Chelsea Rothwell

2PILLAR 4 – RIGHT SERVICE, RIGHT TIME, RIGHT PLACE

Objectives• Define the LEAN© process that was used to

improve the transition of clients from addiction program beds to transition beds.

• Share the standardized tools that were developed to support the process.

• Invite participants to identify how they could incorporate the approach and tools into their service.


Principle Meaning

Identify Customers and Specify Value Specifically understanding from the client’s perspective – what they want

Identify and Map the Value Stream A map of the series of actions that collectively build value for the client

Create Flow by Eliminating Waste Processes that quickly produce value without backtracking or re-work

Respond to Customer Pull Understand the demand from your customer and then create your process to respond

Pursue Perfection Continually strive, constantly learn, improve and sustain

Five LEAN Principles

The success of a LEAN project is dependent upon behavioural change, where all people involved in the process are engaged and truly understand the benefits of LEAN.


Men’s Addiction Service Hamilton (MASH)24 hour Telephone Support – support line for men and their familiesAssessment and Referral – for men wishing to change their substance use and to begin a treatment programWithdrawal Management – 23 beds for men withdrawing from substance use – 9 acute beds and 14 “program beds”Day Treatment – 10 “spots” for men in the community to return to MASH and attend relapse prevention groups with residential withdrawal management clientsSolutions – weekly groups to assist and support men to continue in their recoverySelf Esteem – weekly open group to support men to make the connection between self esteem and substance useTransition beds – 6 beds for men, meeting program criteria and with recovery plans regarding their substance usePositive Psychology Activities – weekly writing group, art therapy, nutrition group, cooking, Hep C class, Hope for Men (peer lead for men having experienced sexual abuse), on-site and off-site self-help, celebrations

5

Factors DataTeam concerns about Transition Program

Consistency of practice, timing, process

Team concerns about Transition Client “passes”

Review of passes – inconsistent, many not recovery / medical related

Client satisfaction results 2% dissatisfied with transition program

Clients Don’t understand how to “get into a transition bed”

PILLAR 4 – RIGHT SERVICE, RIGHT TIME, RIGHT PLACE

Identified Concerns – “The Why”

LEAN

6

Going to Gemba …

actually watching the client activity take place in the real setting!


7

MASH Team Fluid SurveyResults …


8

In your opinion, if we were to start doing the following (choose all that apply) the transitional bed program would be better for clients.

TEAM SURVEY RESULTS

Response Chart Percentage Count

Admit men who are looking for housing only 18.2% 2

Admit men who have vague treatment plans only 18.2% 2

Admit men who have definite / firm treatment plans only

72.7% 8

Admit men only once to our transtional bed program 54.5% 6

Admit men with firm treatment plans only twice to our transitional bed program

36.4% 4

Admit men with firm treatment plans as many times as requested by the man to our transitional bed program

45.5% 5

Other, please specify... 54.5% 6

Total Responses 11

9TEAM SURVEY RESULTS

If a man admitted to our transition bed program leaves or discharges, goes out and uses and returns to a WMS bed a few days later - we would admit him to a transitional bed again? (choose only one response)


Yes, under any circumstances 0.0% 0

No, under any circumstances 27.3% 3

Only if he has a firm treatment plan 0.0% 0

Only if he has only had one stay in transition 9.1% 1

Only if he has only had one stay in transition and has firm treatment plans

9.1% 1

If he still has treatment plans he should be admitted to the transitional bed program

9.1% 1


Total Responses 11


“I believe every admission to our WM centre is to be as a new admission.”

“Only if he appears to be in the stage of change appropriate to refer to treatment and displays behaviors aligned with expectation of Transition.”

“I do believe having clear boundaries is helpful; however, I also believe exceptions do apply. Only giving someone one chance may not be helpful.”

“He should be admitted to observation bed only.”

“He should not be re-admitted. A meeting is needed to discuss client’s actions and goals.”

Continuum of “Other” Responses

If a man admitted to our transition bed program leaves or discharges, goes out and uses and returns to a WMS bed a few days later - we would admit him to a transitional bed again? (choose only one response)


If we were to make the following protocol changes to the transition bed program, the program would be better. (choose all that apply)

12TEAM SURVEY RESULTS (= number of responses)

Transition Program Strengths - Themes• Provides the client with a safe environment

while they wait to go to treatment (5)• Provides clients with an opportunity to focus on

things they have “neglected” (4)• Provides an opportunity for clients to “gain

confidence” with recovery and coping strategies (3)• Provides an opportunity for clients to “stabilize” (2)• Provides an opportunity for clients to be a

“role model” (2)


Transition Program Challenges - Themes• Unclear protocols and procedures to access

transition program (4)• Client “boredom” (4)• Clients become “overconfident” (3)• Unclear protocols and procedures to grant

“passes” (3)• Clients want more “freedom” / outings (2)• Clients need more direction/expectations /

“homework” (2)

14MASH LEAN TEAM PROJECT

Recruiting the Team• Began with discussions in morning huddles –

mostly focused on “concerns”• Invitation to be involved in a LEAN process to

identify the “best approach”• Email “teaser” sent to full team describing the

commitment, timelines, description of LEAN and how the project would unfold

• Team members self-identified to be part of the MASH LEAN Project team

15Mash LEAN Team PROJECT (PDSA)• Monitoring results,

client input, evaluations, tweaking

• Discussion in Huddles, Team and client survey

• Dates set and commitment, Reviewed survey results, Orientation

• Identified macro and micro processes, Value Stream Map Completed

• Initial future state mapped and presented to clients for input

• No consensus, LEAN tools, Voice of Customer, Future state mapped

• Presented plan to colleagues

• New forms, Client information board, Review post surveys

Sustain (ACT) Invitation to LEAN (PLAN)

Mapping Current &

Future State (DO)

Get "Buy-In" (STUDY)

September 2014

October – November 2014

December 2014 – January 2015

February 2015 ->

16MASH LEAN TEAM Project

Value Stream Map of Current State

Simple process ??… NO WONDER the Team and Clients experienced Chaos!!


Mapping the Future State• Used a few LEAN Tools and

developed a Future State• Then we invited the clients to hear

about the new process AND listened to the Voice of the Customer

AND THEN THE WHEELS FELL OFF …

Redefined “pull” from the Voice of Customer perspective.

Me


Re-Mapping the Future State• Scattered coloured sticky

papers on the board• After listening to the Voice of

the Customer, we completed Blue Sky thinking and a Force Field Analysis exercises

The Future State emerged …


The Future State

Macro Steps:• Transition Information

Board• Start Transition Sheet• 1 on 1 • Transition program or

discharge


Emerging Work From the ProjectActivity Who Responsible By When

Review Client Roles and Responsibilities – Add Stage of Change Tool

Megan Nov. 24/14

Create Transition Bed Information Board Chelsea & Anna Nov. 24/14

Criteria Checklist to Transfer to Transition Bed Julia Nov. 24/14

Review Transition Program Expectations – decided to just “self and team monitor”

Lou-Anne Nov. 24/14

Develop Transition Bed Client Survey and Distribute in Aftercare

Lou-Anne Nov. 11/14

Client Whiteboard Legend Keith Nov. 24/14


Transition Information Board


Client Roles & Responsibiliti es Reviewed and update to ensure client and

team responsibilities vs Dos and Don’ts Clearly describes what to expect in all aspects

of the service Includes Stage of Change question and

recovery plan details Place for client and team signature Directs clients to the Transition Board

23MASH LEAN TEAM ProjectMASH - STAGES OF CHANGE/ SELF-MONITORING

CHECKLIST MY NAME: _______________ PROGRAM / DP/ TRANSITION

24Electronic Client Whiteboard

WHITEBOARD LEGEND ETOH - ALCOHOL BNM – BED NEEDS MADE

CR – CRACK / COCAINE D/C - DISCHARGE

CM – CRYSTAL METH SxHx - SEIZURE HISTORY

H – HEROIN DI - TYPE 1 DIABETIC

CA – CANNABIS, WEED, OIL, HASH DM2 – TYPE 2 DIABETIC

Px O – PRESCRIPTION OPIATES 1-1 - SCHEDULED ASSESSMENT

T – IN TRANSITION N - NARCOTICS

T – TRANSITION CANDIDATE B - BENZODIAZAPINES

M - METHADONE CD – CONCURRENT DISORDERS

25Client Survey Pre and Post LEAN ProjectQuestions Findings Nov 2014 Findings Mar/Apr 15

Can you explain the process from program bed to transition bed at Men’s Addiction Services? (post outcome )

100% of the clients could not explain the process of getting from a program bed to a transition bed

100% of the clients surveyed could explain all or major process of getting from program to transition.

Do you think the process from moving from program to transition is consistently applied? (post outcome )

67% of clients did not feel the process was consistently applied - moving men from program beds to transition beds

100% of the clients surveyed did not feel the process was consistently applied. (specifically: clients not following expectations)

How comfortable do you feel approaching staff to ask questions about the process? (post outcome )

83%of client felt comfortable approaching the team to ask questions about the process

80% of clients feel very comfortable asking staff.

On a scale of 1 to 10 how aware are you of the transition bed client expectations? (post outcome )

67% of client were aware/very aware of the transition bed client expectations

100% of clients were aware/very aware of the transition bed client expectations

On a scale of 1 to 10 how satisfied were you with the transition program? (post outcome )

50% of clients were satisfied/very satisfied with the transition program

100% of clients were satisfied /very satisfied with the transition program

How long have you been in the transition program? Clients length of stay in the transition program was 3 to 10 days

Clients length of stay in the transition program was 7 to 49 days


Safe

Supporti

ve

Respect

Involve

ment

Man

age Li

fe

Express

Self

Feel A

bout Self

Voices o

f Exp

Enjoy Life

Satifac

tion0

20

40

60

80

100

Percentage Strongly Agree and/or Agree (Pre)Percentage Strongly Agree and/or Agree (Post)

Aspired to Target %

Men’s Addiction Service HamiltonTransition Program Evaluation Findings

July 1 – November 30, 2014 AND December 1, 2014 – March 31, 2015

1. During my time here I felt safe.2. The supportive care I received met my needs.3. I was treated with dignity and respect by staff.4. I was given the opportunity to be involved as much as I wanted to be in decisions about my treatment, services and supports.5. What I have learned will help me to better manage my life.6. I learned healthy ways to express myself.7. My involvement in the service improved how I feel about myself.8. Spending time with other voices of experience was helpful.9. I believe I have grown in my ability to enjoy life.10. Overall, I was satisfied with the services I received.


Comparative team survey findingsIf a man admitted to our transition bed program leaves or discharges, goes out and uses and returns to a WMS bed a few days later - we would admit him to a transitional bed again? (choose only one response)

Response Pre Project Post ProjectYes, under any circumstances 0% 0%No, under any circumstances 27.3% 46.2%Only if he has a firm treatment plan 0% 23.1%Only if he has only had one stay in transition 9.1% 0%Only if he has only had one stay in transition and has firm treatment plans 9.1% 15.4%If he still has treatment plans he should be admitted to the transitional bed program 9.1% 15.4%

28

What works well as a result of the changes to the transitional bed program? (choose all that apply)

TEAM SURVEY POST PROGRAM RESULTS


**New Transitional Program Information Board 53.3% 8

**New Client Roles and Responsibilities 73.3% 11

**New Stages of Change Client Monitoring Checklist 86.7% 13

**New Stages of Change Team Monitoring Checklist 73.3% 11

**New Electronic Whiteboard Legend 46.7% 7


Total Responses 15


Transition Program Strengths – ThemesPre and Post Program

Pre Project Post Project

Provides the client with a safe environment while they wait to go to treatment (5)

Clarity for team and clients about purpose and expectations of transition program (9)

Provides clients with an opportunity to focus on things they have “neglected” (4)

Provides an opportunity for clients to “gain confidence” with recovery & coping strategies (6)

Provides an opportunity for clients to “gain confidence” with recovery & coping strategies (3)

Able to ascertain stage of change before admitting into transition program (5)

Provides an opportunity for clients to “stabilize” (2)

Clients accountable to self and team (2)

Provides an opportunity for clients to be a “role model”

Provides the client with a safe environment while they wait to go to treatment (2)

NA Provides an opportunity for clients to be a “role model”


Transition Program Challenges – ThemesPre and Post Program

Pre Project Post Project

Unclear protocols and procedures to access transition program (4)

Team consistency about any concerns (10)

Client “boredom” (4) Clients with housing needs vs recovery plans staying in transition program (6)

Clients become “overconfident” (3) Using the program to save OW/ODSP allowances (3)

Unclear protocols and procedures to grant “passes” (3)

Client “boredom” (2)

Clients want more “freedom” / outings (2) Clients become “overconfident” (2)

Clients need more direction/expectations / “homework” (2)

Standardized protocols and procedures to grant “passes” (5)


Next “Work” for the MASH Team - Themes• Consistency with transition program client

expectations (5)• Day Program criteria and expectation (3)• Helping transition program clients plan

Aftercare • Client “boredom”• Clarify procedures to grant “passes”• Streamline documentation


What we learned• Ensure enough time to see the process through• Check in with clients regularly along the way• Check in with other team members regularly and elicit

their input on emerging ideas• Self monitoring checklist clarifies transition program

expectations and the men feel it is empowering and enhances safety for all

• Inspired us to think about what else we need to work on• We, together are very able to find solutions• A LEAN process was helpful – “Blue Sky Thinking”• Eat well during the process

33MASH LEAN TEAM Project – Outcome Measures

Item Indication of Success / Test Frequency

Team colleagues following new process Team understands and are implementing new process. Demonstrated as of November 25, 2014 – ongoing discussions in morning huddles and in huddle minutes.

Transition Information Board Developed, hanging in a prominent place, readability, understood. Demonstrated as of January 2015 – indication in “re-do” of transition client survey Mar/April 2015.

Process clear to clients ** Clients understand new process. Demonstrated in Mar/April 2015 “re-do”

transition client survey – aware of process (** don’t feel all follow process)

Transition Bed Client Survey Survey completed, distributed, improvement noted. Demonstrated – see findings Mar/Apr 2015 client transition bed survey.

Client Satisfaction Improved client satisfaction with transition bed program

Length of Stay Baseline then reasonable length of stay. Currently staying 1 -7 weeks. Still sorting through “reasonable length of stay” – 7 week worked for client.

Successful transition to treatment

Increased number of men going to treatment from transition beds. Antidotally yes – chart audits in July 2015.

Supportive housing use Transition bed tool for clients and team use indicates transition beds are not just used for housing. Antidotally yes – chart audits in July 2015.

Buddy System Articulated in transition bed expectations that these clients will take on a “buddy” role. Question to be added to survey for next 6 month circulation.

Repeat clients Clients involved in transition bed program less likely to relapse and return to withdrawal management bed over time. Antidotally yes – chart audits in July 2015.


ResourcesVery sincere thank you to the clients who shared their thoughts and feelings with us about what was working, what was not and thoughts on the new process.Lean Enterprise Institute, 2015 http://www.lean.org/WhatsLean/OHA Green Belt Course Manual, 2014

http://www.lean.org/WhatsLean/

http://www.lean.org/WhatsLean/


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