Learning from Crisis: PDSA in Times of Challenge

Mat Roosa, LCSW-R
NIATx Coach

Crisis requires that we triage the most urgent matters, and take rapid action to address them.
Crisis demands that we limit our analysis to the critical data points.
Crisis demands that we try new and untested strategies, and rapidly respond to the results of our efforts.

Crisis is dangerous, chaotic, messy, heart-wrenchingly painful,…and also an opportunity for invention.

During the past several weeks you probably have:
  1. Recognized immediate problems.
  2. Prioritized resources.
  3. Taken rapid action to test new strategies.
  4. Made decisions based on key data.
  5. Learned a lot from testing these new strategies and refined your efforts.
Put another way, you have been working your way through a challenging crisis using Plan-Do-Study-Act change cycles.

Rapid-cycle Testing: One of the Five NIATx Principles
“The fifth principle of the NIATx model is what we call rapid-cycle testing. Structured around what’s known as the PDSA (Plan-Do-Study-Act) Cycle, rapid-cycle testing is used to quickly evaluate the impact of potential changes on a given aim. In rapid-cycle testing, the executive sponsor, change leader, or team comes up with ideas for changes to test, and then tests each of those changes in quick succession for a short time on a limited test pool. During each test (a.k.a. PDSA Cycle), the team collects and analyzes data relevant to its chosen aim to determine whether the change has produced a desirable effect on performance levels. Depending on the outcome of that analysis, the team may decide to abandon the change completely and begin testing an entirely new change; adapt the change for further improvement and retest the modified version; or adopt the change, testing it again on a slightly larger scale, or in conjunction with other changes that have already proven successful in testing. In any case, the team uses the knowledge it has gained from one testing cycle to improve subsequent cycles. A new procedure is only implemented on a full scale once it has been proven in testing to yield significant improvement in regard to the project’s aim.”

From The NIATx Model: Process Improvement for Behavioral Health

See related blog post: Make it Quick: NIATx Principle #5

A Perfect Time for Rapid Change

A crisis like the one we are all facing right now is tailor-made for rapid-cycle PDSA change. Many of us have been using the NIATx model—perhaps without even knowing it. Right now is an excellent time to document the PDSA cycles that you have been conducting.

A few questions may help you to refine your understanding of the crisis work that you have been doing, and to document your PDSA efforts.
  • What did you observe through data or experience?
  • What did you do in response?
  • What was the result?
  • What did you learn?
You might also want to use the NIATx Change Project Form to document your recent efforts retrospectively. You can find the form and step-by-step instructions on how to conduct a PDSA Cycle on the NIATx website.

As this crisis persists, we struggle to figure it out as we go. Finding the opportunity in this unprecedented challenge is both difficult and painful. Yet, one way to find purpose and meaning moving forward is to learn everything we can from it.

Consider how rapid-cycle PDSA can teach you more about what you have done and will do, as we work our way through this together.

About our Guest Blogger
Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development, and planning, evidence-based practice implementation. He also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at matroosa@gmail.com

The World in our Hearts: A Message from the ATTC and NIATx Networks

Contributed by the Southeast ATTC
Dawn Tyus, Director
Pamela Woll, Product and Curriculum Development Consultant

Greetings from the makeshift offices we’ve set up in our kitchens and basements and spare bedrooms. The world outside our windows looks like a normal, pretty Spring day, but the world that lives in our hearts is going through some strange, difficult times.

We’re grateful to be able to continue to serve you from our remote outposts, but something important is missing: you. We used to be able to catch up with you at conferences, before and after sessions, and at technical assistance visits. We’re happy whenever we see your little video tile on our Zoom screens, but it doesn’t tell us how you’re doing.

In this field—this culture, really—that has dedicated our lives to the well-being, resilience, and recovery of people with substance use disorders (SUD), you’re probably carrying an extra weight in your heart. We know these times are particularly hard on people whose lives have left them wounded. For people whose SUDs are active, and people whose wounds are still raw in recovery, alcohol and drugs can look like part of the solution, rather than the big flashing hazards they really are.

If you’re a counselor, a coach, a supervisor, an administrator, or any other member of this field, you’ve probably read it in the literature and proved it in your work and your lives: The most healing thing we have going as a field is caring, trustworthy human connection with people. Pandemic disease may be the cruelest kind of disaster, because it robs us of that in-person, face-to-face human connection.

But there’s something we must never forget: This virus may be young and clever and highly contagious, but we have a lot of things it doesn’t have.

  • We have love—for our families and friends, for our colleagues, for our communities, for the people we serve, and for the work we do.
  • We have faith—in recovery, in our values, in our higher powers, in our science, in our skills, and in ourselves.
  • We have a field that has fought its way through loss and pain and stigma and discrimination, to bring real, lasting recovery to people who were once laid low by an illness that has killed far more people than any virus.
  • We have the memory of every time we watched someone make that transition into recovery—and saw a human life transformed before our eyes.
  • And we have the internet—for all the problems it sometimes causes, still a great tool for connection. We can use it to reach out, listen, teach, witness people’s pain, walk alongside them, and BE THERE—for them and with them.
And so, we’re learning to connect, more and more effectively, across the space between us. The many Centers in the ATTC and NIATx Networks have increased our use of face-to-face technologies and our development of resources to help agencies and individuals find the help, guidance, and education they need to stay informed, resilient, and effective in promoting wellness, health, and recovery.

The ATTC Network’s excellent webinar series on Telehealth is only one of many resources on the Network’s trove of Pandemic Response Resources (https://attcnetwork.org/centers/global-attc/pandemic-response-resources-responding-covid-19), and there has never been a better time to dip into the many free e-learning courses available through Health-eKnowledge.

So, we have a lot to say, but something is missing. In this strange, sad, and sometimes heroic world we’re living in, we’d like to hear what you’re going through. We want to know what we can do to help you survive, thrive, and come out of this difficult time stronger, more resilient, and more inspired. Please reach out to us.

We are here for you. We are dedicated to you and the people you serve. We want to connect with you—and help you connect with others—so we can all get each other through this time.

We believe in you. We’ve seen the enormous strengths you bring to your life and your work. We’ve seen the great love that drives you to keep going, even though it’s hard and it sometimes breaks your heart.

Please stay safe and healthy. Please stay connected. And, whatever fears and losses you’re carrying, please know that we hold you in our hearts.

About the Authors:

Dawn Tyus

Dawn Tyus is the Director of the Southeast Addiction Technology Transfer Center (SATTC) at Morehouse School of Medicine, located in Atlanta, Georgia. Dawn has been affiliated with Morehouse School of Medicine and SATTC for eleven years, as a Project Consultant, and was promoted to lead the team as the Project Director in 2011. As Director of ATTC, Dawn is responsible for the management, growth, and business development activities of the project, manage the day-to-day operations including implementation of the policies and programs, responsible for the professional development of staff, as well as new and innovative programs, manage approximately 10 external and internal staff members and consultants, facilitate professional development trainings for clinicians and staff, interface with collaborative partners and stakeholders on a local, federal and state level to organize strategies for statewide initiatives.

Dawn actively work with faith communities to strengthen their awareness, and build their skill set on working with individuals with mental health and substance use disorders.

Dawn is a member of ATTC CLAS Standards and Pre-Service Education Workgroup, Dawn is currently on the board of the Georgia School of Addiction Studies, and the Advisory Board for the Clark Atlanta University’s HBCU C.A. R. E. S.

Dawn has an impressive background in which she brings a wealth of experience from various perspectives. Her background spans many disciplines which include: nonprofit organizations, government, corporate, counseling services, consulting, strategic planning, group and individual coaching She received a Bachelor’s degree in Criminal Justice, and a Masters of Education degree in Community Counseling from Mercer University, and is currently completing her Doctoral degree in Counseling Studies at Capella University. Dawn is also a Licensed Professional Counselor in, the State of Georgia where she provides family, individual, and group mental health therapy.

Pamela Woll
Pamela Woll, MA, CADP is a Chicago-based author, curriculum developer, and consultant dedicated to increasing the resilience and capacity of individuals, families, communities, organizations, and systems of care. Her primary areas of focus include trauma-informed and recovery-oriented systems and services; the physiology/neurobiology of resilience, stress, and trauma; public health approaches to behavioral health and wellness; elimination of health and socioeconomic disparities; and the strengths and needs of service members, veterans, and their families. Her recent publications include Compassion Doesn’t Make You Tired: Unmasking and Addressing “Compassion Fatigue”; Addressing Stress and Trauma in Recovery-oriented Systems and Communities, and You Fit Together: Body, Mind, Resilience and Recovery, all published in 2017 by the ATTC Network Coordination Office. Many of the materials she has written are available for free download from her web site, https://sites.google.com/site/humanprioritiesorg/.

Traditional Ways of Sharing Modern Knowledge: Peer-to-Peer Learning Communities

Jeff Ledolter Program Manager of the Tribal Opioid Response TA ProgramNational American Indian and Alaska Native ATTC

Image posted with permission of all participants. 

In February 2020, the National American Indian and Alaska Native ATTC hosted a regional technical assistance meeting in Oklahoma City for recipients of the Tribal Opioid Response grant. It was similar to meetings we had held in other regions. Doctors, nurses, grant managers, counselors, and other health professionals from 15 tribal health clinics in the surrounding states came together in a hotel conference room to talk about a common sickness in their comm­­unities: opioid use disorder.

We began each of the three days normally, that is, in a good way. Each morning, a tribal elder native to the region welcomed participants with a brief invocation, or song, or smudge. We explained the services we offered, along with our partners at the Association of American Indian Physicians, whose headquarters was just down the street. Speakers were scheduled over the two and a half days to cover topics ranging from presentations on stigma to telehealth demonstrations, but most of the time was reserved for the attendees to speak and share their experiences.

Hosting this meeting as a non-native, it was crucial to consider the culture of the communities and the indigenous strategies that they have developed over generations to address communal issues. Acting with cultural humility establishes trust and buy-in from the community and lets them factor in their existing strategies. It’s also important to engage for a long period. Providing TA means making a commitment and thinking about strategies that will work for the long term. Community-based, tribally-based participatory programming is essential to actually affecting change that will last. Our role is not to direct tribes how to act of what to do, but to meet them where they are at, provide them with the best, most up-to-date knowledge that we can and work with them to find solutions relevant to their people and that reflect their wealth of indigenous knowledge.

After brief introductions, representatives began sharing their stories. As we started, the magnitude of the problem facing us was palpable. Each person understood the threat that opioid use disorder posed to their community, and this showed in their presentations. This had touched their families and neighbors, and threatened to cut the bonds that united them as a tribe. They explained the goals they had for their communities, as well as the barriers: lack of community buy-in, stigma towards medication-assisted treatment (MAT), staff turnover and burnout. But as these representatives shared their experiences, their tone became more confident and enthusiastic. As these professionals explained how they thought they had been facing these problems alone, they saw how many others were experiencing the same thing.

One attendee m­entioned their difficulty filling beds in their treatment facilities. Another immediately asked if they could send patients from their neighboring state, and they traded information. One attendee from an Oklahoma tribe explained how they developed a prevention program for native youth by forming traditional stickball leagues. Another explained how patients were denied services because they didn’t have official identification, so they partnered with local recovery centers to hold “ID Expos,” where donated funds would be used to pay for issuing acceptable documentation. They explained that in 18 months they created over 1000 IDs, prompting a flurry of questions from the audience.

As one representative put it: “This training lacked the underlying fear of failure, desire to ‘one-up’ everyone, pride, tendency to exaggerate credentials and success of programs, and relationship hesitancy. It was so refreshing to hear humility, openness about struggle and challenges, see the desire to learn new info and personal engagement between participants.”

Often when presented with overwhelming challenges, it is easy to become discouraged and give up. But even in modern times, tribes can gain strength from a resource they have relied on for generations: each other. The opposite of addiction is not sobriety, but connection.

To see a collection of TOR resources that our ATTC has prepared, please visit our website at: https://attcnetwork.org/centers/national-american-indian-and-alaska-native-attc/tor-resource-page

For more information on our center’s programs and events, visit https://attcnetwork.org/centers/national-american-indian-and-alaska-native-attc/home or email Jeff Ledolter at jeff-ledolter@uiowa.edu.

DEBUNKED Podcast launched to Debunk Myths about Harm Reduction

By Dr. Sandra H. Sulzer

The Tribal and Rural Opioid Initiative of Utah State University has launched a podcast to debunk myths around harm reduction. The first two episodes are already released with a pending special episode on COVID-19 myths in production.

While harm reduction strategies such as syringe distribution and naloxone education are the gold standard best practices recommended by the CDC, NIH and NIDA, there is still substantial resistance toward these methods, sometimes even amongst providers. There is evidence that abstinence-only treatment strategies are sometimes perceived to be morally superior, regardless of the evidence base. Harmful beliefs about Medication Assisted Treatment (MAT) prevent some health providers from offering the best healthcare possible, and it may deter family members and others in support networks from offering needed support to persons who are in recovery and utilizing these services. For example, some people who have used or still use drugs have criminal convictions and may have lost their driver’s license. In those cases, it can be the difference between relapse and recovery to have a family member or friend willing to help provide transportation to a methadone clinic or needed appointments. When there is general stigma toward MAT, and people hold beliefs such as “you are substituting one drug for another,” fewer people get access to needed care. DEBUNKED works to openly talk about myths like this one in order to change beliefs around harm reduction best practices.

Our podcast is based on a systematic review of 99 articles related to effective stigma reduction around addiction treatment services. We also draw from two curricula we have designed that provide continuing education credits to substance use disorder counselors as well as naloxone training to community members that have both show statistically significant reductions in stigmatizing beliefs. Every DEBUNKED episode is planned and curated by an editorial board that includes persons in recovery or who use drugs, affected family members, public health experts and research scientists in partnership with Utah Public Radio. This program is funded by the Substance Abuse and Mental Health Services Rural Opioid Technical Assistance grant with additional support provided by Regence Blue Cross Blue Shield. The Tribal and Rural Opioid Initiative also receives support from The U.S. Department of Agriculture, National Institute on Food and Agriculture Rural Health and Safety Education funding.

You can learn more about our Tribal and Rural Opioid Initiative efforts at http://khs.usu.edu/outreach/troi and you can access our DEBUNKED podcast and promotional video from http://khs.usu.edu/outreach/debunked, or check out @DebunkedPod on Twitter, Instagram and Facebook.

Sandra Sulzer Bio:
Dr. Sandra Sulzer oversees the DEBUNKED podcast as the Director of the Office of Health Equity and Community Engagement and the Tribal & Rural Opioid Initiative. She has a PhD in Sociology and, Community and Environmental Sociology from the University of Wisconsin-Madison with a specialization in medical sociology and social psychology. She completed a health services research postdoc at the University of North Carolina- Chapel Hill, Cecil G. Sheps Center for Health Services Research and an integrative medicine postdoc at the University of Wisconsin-Madison, Department of Family Medicine and Community Health. She is faculty in the Masters of Public Health program at Utah State University where she teaches Public Health Communication and Holistic Health.