The ATTC/NIATx Service Improvement Blog: December 2022

By Maureen Nichols, South Southwest ATTC director

Much of the work by the Addiction Technology Transfer Center network and their partners in behavioral health care systems focuses on making changes that improve the lives and health of communities, families, and individuals.

Examples include providing intensive training, feedback and coaching to counselors working in substance use treatment programs in a specific evidence-based practice, such as Motivational Interviewing (MI), or supporting a primary care clinic in a change process to implement Screening, Brief Intervention and Referral (SBIRT) for substance use for all of their patients. Many times, change projects run up against unplanned system barriers that blunt positive outcomes: high turnover in staff results in loss of counselors with MI training and experience, policies and procedures at the primary clinic impede implementation of SBIRT.

As a tool for planning for system changes projects, the South Southwest ATTC has incorporated a systems research framework developed by John J. Kineman, PhD, that we have found to be a useful tool for understanding complex systems: the PAR Holon Framework[1] .

PAR Holon Framework

The framework applies broadly to systems, and is derived from two sources, relational biology and Participatory Action Research (PAR). The framework was first introduced as a tool for discussing approaches to system change during a Region 5, 6, and 7 SAMHSA and Regional ATTC project focused on aligned workforce development and career ladders for Peer Recovery Support Specialists and Community Health Workers in 2018.

We have since gone on to use the framework as a way of intentionally organizing our thoughts around system change strategies in a variety of contexts.

The framework visualizes four components of a complex system, represented by four quadrants. The first two, on the bottom left and bottom right, represent actions taken in a system and resulting outcomes. They are similar to the structure of a traditional logic model utilized in implementation of a new project, in which we envision a series of actions leading to a series of outputs and outcomes. They also correspond to the Act and Observe phases of participatory action research.

The top right quadrant of the framework represents goals, purpose, and meaning that individuals within the system bring to the functioning of the system itself. The upper left quadrant reflects the permissions and restrictions every system works within – what can and cannot be done. These quadrants correspond to the Plan and Reflect phases of participatory action research. Each quadrant interacts and impacts the other simultaneously within a complex system.

Additionally, complex systems have many subsets, or layers, that reflect these same four quadrants.

For example, in a health care system there is an individual layer, between a patient and a doctor, or an individual seeking support in recovery and a peer recovery specialist. At this level, there are actions that take place, (consultations, tests, planning, referrals, for example) and outcomes of those actions for the individual that can be measured (physical, mental and quality of life).

Each of the pair of individuals brings their own values and beliefs to their interaction in the system and works within a set of permissions and restrictions (affordability, insurance rules, ethical guidelines, etc.) that underlie the system. Another layer in a health care system is training and education, where providers take action to obtain training and education, which results in workforce level outcomes, professions have a set of established values and ethics, and boards existing to set and monitor licensures and certifications.

At a service provider organizational level, there are program designs and steps to implementation, outputs, and outcomes that can be measured at an organizational level, organizational mission and visions statements, and rules and regulations that organizations must adhere to in order to remain in good standing and stay financially viable.

Additional layers can be considered, around funding and regulation, community, family etc.

Using this multilayered framework to diagram components of a system allows change makers to discuss the best intentional approach to their work. Should we begin in the lower right quadrant, designing out change strategy based on the existing data? Do we seek to influence people beliefs and values around the system change, which might then impact their actions and permissions and restrictions? Do we provide additional funding for our change activities, which provides people permission to take actions to support the change goals. At what levels of the system will our change initiative have the most impact? Where are our change efforts pushing up against existing components of the system and experiencing resistance? What if the outcomes we seek are for people who are minimally engaged with the system, if at all?

Visualizing the complex interactions using this framework helps us prepare and respond to change efforts in systems.

[1] Kineman, J. [Chapter 2]. (2016) P. B. Systems research framework. In M. C. Edson, P. Buckle Henning, & S Sankaran (Eds.), A guide to systems research philosophy, processes and practice. (pp. 21-58). Singapore: Springer Publications.

About the author

Maureen Nichols is Director of the South Southwest Addiction Technology Transfer Center (SSWATTC), at the Addiction Research Institute in the Steve Hicks School of Social Work at the University of Texas Austin. She has thirty years of experience in substance use program development and evaluation at the state and community level. Her professional areas of focus include systems change and quality improvement, technology transfer, and mental health and substance use recovery.

By: Kristina Spannbauer, Communications Specialist for the Great Lakes ATTC, MHTTC, & PTTC

One of the greatest aspects of NIATx process improvement is the adaptability of this model. Over the past several years, the Great Lakes ATTC, MHTTC, and PTTC have developed hybrid training series integrating NIATx principles with other in-demand technical assistance (TA) and intensive technical assistance (ITA) offered by our centers. Some of the special focus topics featured in these series are the National Culturally and Linguistically Appropriate Services (CLAS) Standards, suicide prevention, school-based mental health, recruitment and retention, telehealth services, and supporting the COVID-19 workforce. Behavioral healthcare and prevention professionals from our region who have participated in these hybrid courses consistently report greater success in implementing and applying the skills learned during training thanks to the inclusion of NIATx principles.

In the spirit of embracing change, I sat down with Alfredo Cerrato, Scott Gatzke, and Mat Roosa–three of the Great Lakes ATTC, MHTTC, and PTTC's subject matter experts and most experienced trainers–to better understand their considerations, planning processes, and experiences when it comes to "infusing" our TA and ITA content with NIATx principles and the Change Leader Academy (CLA) curriculum.

What considerations and adaptations were required when integrating the NIATx model for process improvement with other technical assistance and training courses?

Mat: Since NIATx has a process focus, it naturally pairs with a wide array of content to help people improve how they do what they do. As we've worked to include NIATx with our other trainings, we've found that it's easier to market content than it is to market process. For instance, people tend to be more interested in learning evidence-based practices than they are in learning process improvement strategies, but we've also discovered that the combination of content and process draws people in. Folks are eager to learn process tools that help them implement evidence-based practices at both an individual and organizational level.

Scott: I agree. As we've continued to develop and host hybrid courses, it's become apparent that participants are quicker to engage with the content when they are learning process improvement strategies in relation to applicable, real-life practices they will use in their work.

Alfredo: I approached the process from a cultural perspective. As we've worked to integrate NIATx with our other technical assistance offerings, it's extremely important that we always prioritize culture and culturally appropriate service delivery. When developing the CLAS Standards Change Leader Academy, we were dedicated to maintaining the integrity of the original CLAS Matters! training, as well as to making abstract concepts more concrete through the application of scientific methods and academic vocabulary.

What benefits and/or challenges did you experience when integrating NIATx with other trainings?

Mat: We found that conducting hybrid courses with two trainers–one who focuses on the "content" and one who focuses on the "process"–has been really beneficial. For example, Alfredo knows NIATx and he's also our expert trainer for CLAS Standards. He and I function as co-trainers in the CLAS Standards Change Leader Academy with Alfredo taking the lead on CLAS content while I primarily teach the process improvement aspects of the series.

Alfredo: We've learned a lot while developing and facilitating the CLAS CLA. One of my main takeaways is that for this specific co-training approach to be effective, subject matter experts (SMEs) in any field must also understand the NIATx principles and be able to apply process improvement tools in their particular field(s). Likewise, the NIATx trainer must be able to speak the language of the SMEs when explaining concepts or providing examples.

As a trainer, what has been your most memorable experience(s) when facilitating these trainings?

Scott: Hearing the stories of how the NIATx tools (i.e., walk-through, flowcharting, nominal group technique, and PDSA cycles) empower the change leaders attending the training to better understand their customers, connect with leadership and staff in their organization, and make an actual improvement to their processes is very rewarding.

Alfredo: In the CLAS Standards Change Leader Academy, I am particularly impacted by how people connect the historical dots and open up to the possibility of change. I also notice that they become more aware of how current culture is changing their worldview and how past worldviews have shaped their culture.

Mat: I always love it when people are willing to be open and acknowledge that they are struggling to implement... they understand that knowing the material is not enough to get the job done. I also love seeing people who typically may not have much power in their system or organization become empowered with the NIATx process. It's inspiring to watch them gain confidence and respect from their peers and create a significant impact on the quality of services being offered. Those are typically my favorite moments.

What advice would you give to those interested in learning more about NIATx or how to apply NIATx to their work?

Alfredo: Culture is intrinsic and vital to every person. In that sense, cultural considerations trump those of process improvement, but it's important to remember that every process can be bettered or refined by first considering culture. If not considered, the process improvement effort will likely fail. However, we must also acknowledge that process is needed to understand and affect cultural change. Without an understanding of process and process improvement, negative culture will be organically perpetuated. Both concepts need one another to facilitate better outcomes.

Scott: When you really need to improve something, help your change team stay laser focused on the narrow, specific aim you have identified for your change project. Everyone’s world is full of competing needs and urgent issues, which often leads to “scope creep” for many change projects (e.g., adding multiple deliverables or goals for the project). As soon as the aim of the project becomes unclear for the team, the change project will, at best, flounder or it will become completely disbanded. As a change leader, keep the aim of your project front-and-center for your executive sponsor and change team. Only work on the activities which move toward achieving the change project aim.

Mat: My advice is quite simple: 1) attend a NIATx Change Leader Academy; 2) use the NIATx tools; 3) practice them over and over; 4) work as a team; and 5) find ways to understand that EVERYTHING is a process, and every process can be improved.

I would like to sincerely thank Alfredo, Scott, and Mat for sharing their expertise and wisdom in this blog post. On behalf of the Great Lakes ATTC, MHTTC, and PTTC, we also thank our many contributing subject matter experts, content creators, regional and national partners, and of course, the dedicated workforces of the Great Lakes region who keep our team focused on innovation, positive change, and serving our communities.

About Our Subject Matter Experts:

Alfredo Cerrato is the Senior Cultural and Workforce Development Officer for the Great Lakes ATTC, MHTTC, and PTTC. He is also a nationally certified trainer on Culture: An Integral Part of Mental Health Services for Hispanic and Latino Populations by the National Hispanic and Latino Mental Health Technology Transfer Center in Puerto Rico and a national trainer on cultural topics for the National Association for Alcoholism and Drug Abuse Counselors (NAADAC). Mr. Cerrato has 25 years of international relations experience and specializes in cross-cultural communications, conflict resolution, and process improvement.

Scott Gatzke is Director of Dissemination for the Great Lakes ATTC, MHTTC, and PTTC. He is a NIATx trainer and coach with over 25 years of experience in process design and quality improvement in manufacturing, healthcare, and non-profit organizations.

Mat Roosa is a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant and trainer in the areas of quality improvement, organizational development, and planning, evidence-based practice implementation. Mat’s experience also includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human services agency administration.

Embracing Change: A System Framework for Visualizing Change