The ATTC/NIATx Service Improvement Blog

NIATx in New Places

By: Mat Roosa, LCSW-R

NIATx launched in 2003 and has been supporting process improvement change efforts ever since. The NIATx in New Places blog series will share the experiences of NIATx practitioners old and new.

We will learn how NIATx has been rebooted and repurposed in many new settings, and how it continues to have a major impact in the places where the model was originally used. We will hear from some of the original NIATx members who are still finding new ways to use the NIATx tools 20 years later and from others newer to NIATx who are finding paths forward to support new projects and improvements. We will share stories about the impact of NIATx on service systems, provider organizations, and on the paths of individuals who are blazing trails in health and human service practice, policy, and research.

My own career path has been influenced by NIATx more than any other factor, and I look forward to reading about the stories and experiences of others who have used NIATx in new places.

As an agency administrator of one of the founding NIATx agencies, I was looking for tools to improve our services. NIATx opened the door for me to a new vision for process improvement.

I remember clearly the first time I conducted a NIATx Walkthrough exercise for a residential program that I supervised. I was seeking to better understand the customer experience of arriving at the facility, and quickly learned that I couldn’t find a way to enter the building! Then, I sat in the clinic waiting room to understand what it felt like to wait for services. I had walked through that waiting room hundreds of times before but never stopped to sit down. It was apparent there were several important things that could be improved to enhance clients’ experiences when visiting the clinic.

Mat Roosa (seated bottom right) with members of Central New York Services NIATx Change Team, 2003.

These simple and humbling examples of genuine efforts to see the service system through the eyes of the client or customer shifted my vision and led me to make a number of changes that had real and meaningful impact on the people we served.

I maintained my connection to NIATx through my involvement in coaching and mentoring. I coached a number of different projects as I moved from agency administration and clinical practice to governmental planning positions. I now work as a consultant and have a staff position with CHESS at University of Wisconsin–Madison (the home of NIATx). Through the years, I've had the opportunity to partner with and learn from "thought leaders" in this field.

These partnerships helped deepen my understanding and appreciation of how to effectively apply the NIATx principles and tools within hundreds of organizations and systems seeking to implement process improvements. The core NIATx tools (walk through, flow chart, nominal group technique (link these) and the NIATx 5 principles remain a guiding compass for my work supporting organizations to plan, implement new practices, and improve quality. In just the last year, I've had the opportunity to use NIATx in a wide range of new places:

Clinical treatment programs
Substance use prevention
Suicide prevention
Probation
Courts
Workforce enhancement
DEI/ CLAS Standards
HIV/ AIDS service settings
Education and training organizations
Evidence based practice implementation
Medication for Opioid Use Disorders

Through NIATx, I have learned that best practice models are necessary but not sufficient for improvement. The process improvement toolbox of NIATx is the vehicle that carries an array of promising practices into organizations both big and small. NIATx continues to help these systems move forward into new places and sustain those improvements over time. I often think of NIATx as a lever: a simple tool that can, if used with energy and purpose, enable you to move things that seemed too heavy to lift.

Join us for future posts in this year-long series as we share the experiences of others who are making a difference using NIATx in new places. We hope that by sharing these stories and experiences we will inspire others to explore how NIATx can take you and your organization to new places.

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.

ATTC's Pearls of Wisdom: Investing Soundly By Building the Substance Use Disorder Workforce

By Nancy A. Roget, MS and Cindy Juntunen, PhD, Mountain Plains ATTC

According to Benjamin Franklin, “For the best return on your money, pour your purse into your head.” This is sound advice and one that SAMHSA has followed through its funding of the Addiction Technology Transfer Centers (ATTCs). The ATTCs emphasize preparing the SUD workforce to use evidence-based practices when providing SUD services (harm reduction, treatment, and recovery support) to patients and their families through training and technical assistance activities. Preparing the SUD workforce targets both licensed/certified professionals as well as students.

The Mountain Plains ATTC is one of the original 11 ATTCs. In 1993 the grant was located at the University of Nevada with Dr. Gary Fisher as the initial project director. Called the Mountain West ATTC it first served the states of Montana, Nevada, and Wyoming from 1993-1998. Five subsequent successful grant awards (1998 to present) included new partnerships and changes to the states served.

Currently, the Mountain Plains ATTC is housed at the University of North Dakota in partnership with the University of Nevada (Nevada) working with Region 8 which includes six states: Colorado, Montana, North and South Dakota, Utah and Wyoming.

SUD Keys to Education rsources guide, developed by the Mountain Plains and Pacific Southwest ATTCs.

Despite changes over the last 30 years, one area of focus remains a priority for the Mountain Plains ATTC: academic programs and products.

During the initial funding period, the Mountain Plains ATTC built academic programs at Nevada and Great Falls University in Montana, with academic courses also created for the University of Wyoming. The investment of SAMHSA grant dollars built an undergraduate minor and a graduate emphasis in Addiction Treatment Services at Nevada.

These academic programs still exist; 800-plus students are enrolled and taking undergraduate and graduate courses on prevention, harm reduction, treatment, and recovery support services in-person and online in Spring Semester 2023.

From 1998, on, the Mountain Plains continued its focus on academic programs and products which include but are not limited to:

Cross-walk that listed the practice domains of the TAP21 Practice Domains and Competencies for academic courses/curricula- 1999
Work Groups (2000 - present) that include academic faculty from universities and tribal colleges throughout the region, who provide input to ATTC staff on curricular needs as well as the upcoming workforce
Nevada undergraduate courses developed for online delivery 2001

In 2001 the Mountain Plains ATTC created a curriculum infusion effort in response to faculty and institutions reporting difficulties in implementing new programs and courses due to costs and lack of faculty with specific expertise. This infusion process was successfully utilized to find “curricular room” (Dimoff, et al., 2017; Gassman et al., 2001) for SUD and mental health (MH) information as well as a way of highlighting SUD/MH information within a context of a discipline (Redding & Selleck, 1999) This effort was consistent with findings from curriculum infusion research, which demonstrated that the uptake of science-based knowledge into professional practice occurs more frequently if it is ‘functionally relevant’ (Savage, et al., 2018; Taylor & Rafferty, 2003) meaning, taught within a specific discipline or profession.

Finally, the Mountain Plains developed Curriculum Infusion Packages to support faculty who may have limited SUD expertise. The Mountain Plains ATTC partnered with several different ATTCs to create: slide decks with notes, videos, audio recordings, and experiential learning experiences, and test questions on the neurobiology of addiction, stimulants, and self-care. The purpose of the infusion model is to assist faculty in infusing new knowledge, typically evidence-based practices (EBPs), into existing courses by offering brief ”bites of information.”

In keeping with the curriculum infusion methodology, the Mountain Plains ATTC and Pacific Southwest ATTC created a product called SUD Keys to Education (SUD Keys), in January 2023.

This product includes slide decks that are intentionally brief so instruction can be infused in five to 10-minute segments, with some longer options available. Slide decks (not PDFs) are easily downloaded and prepared for immediate use by instructors. Many of the slide decks include video (MP4) recordings and can be used as an alternative instructional delivery method.

For example, the audio slide decks and videos can be played during live training events or downloaded and listened to by students/participants prior to the class or the event (flipped classroom approach). Slide decks currently available include: Stimulants; Alcohol; Stigma; Recovery Support; and Harm Reduction.

Links to the SUD Keys product are available at the Mountain Plains and Pacific Southwest ATTCs’ websites. This product carries on the ATTC’s 30-year tradition of investment in the SUD workforce through curated academic products.

References

Dimoff, J. D., Sayette, M. A., & Norcross, J. C. (2017). Addiction training in clinical psychology: Are we keeping up with the rising epidemic? American Psychologist, 72(7), 689–695. https://doi.org/10.1037/amp0000140

Gassman, R. A., Demone Jr, H. W., & Albilal, R. (2001). Alcohol and other drug content in core courses: Encouraging substance abuse assessment. Journal of Social Work Education, 37(1), 137-145. https://doi.org/10.1080/10437797.2001.10779042

Redding, B. A., & Selleck, C. S. (1999). Perinatal substance abuse education: A review of existing curricula. Substance Abuse, 20(1), 17-31. https://doi.org/10.1023/A:1021344722132

Savage, C. L., Daniels, J., Johnson, J. A., Kesten, K., Finnell, D. S., & Seale, J. P. (2018). The inclusion of substance use-related content in advanced practice registered nurse curricula. Journal of Professional Nursing, 34(3), 217–220. https://doi.org/10.1016/j.profnurs.2017.08.006

Taylor, I., & Rafferty, J. (2003). Integrating research and teaching in social work: Building a strong partnership. Social Work Education, 22(6), 589-602. https://doi.org/10.1080/0261547032000142698

ATTC’s Pearls of Wisdom: Relationship building starts with ‘listening’

By Catelyn Holmes, for the Mid-America ATTC

If there’s one thing Pat Stilen has learned in her decades’ long career, it’s the value of building relationships, and that starts by listening.

“Building relationships and listening, that makes all the difference in the world,” she said.

Stilen, a social worker, retired from her leadership role with the Mid-America Addiction Technology Transfer Center in March 2022. She joined MATTC in 1996, after building a relationship with the members of the staff.

Pat Stilen, former Co-Director, Mid-America ATTC

Her longstanding relationship with the MATTC began three decades ago, when she finally found someone who could listen to the problem she was having: how to introduce the then-new concept of managed care to an entire state of substance use disorder providers.

"I was calling my friend saying, 'How do you go about getting people to accept something new and eventually feel good about it, while they feel reluctant?'" she said.

Stilen sought support from her corporate office on how to make the process successful, but she says all they could say was "We don’t know, good luck".

A friend suggested she contact the directors at MATTC - Sue Giles and Mary Beth Johnson. The pair were able to provide her with the support she sought. That introduction would also change the course of Stilen’s career, leading to her becoming the Co-Director of the MATTC in 1999.

After almost a quarter century in a leadership role with the Mid-America ATTC, Stilen said she could clearly identify ways the care around SUD changed in Region 7 during her career.

The most significant change brought about by the MATTC was changing the tone around what is now known as Medications for Opioid Use Disorder (MOUD) in the region.

The four states that make up Region 7 – Iowa, Kansas, Missouri and Nebraska - were some of the last in the country to adapt to MOUD.

“It felt like (other ATTCs) were lightyears ahead of us,” Stilen said.

Using the technology transfer model, MATTC was purposeful in changing the minds of regional policy makers. The center brought innovators, leaders already doing the work in their region, to the table to brainstorm how to make a real difference with policy makers. After six months of planning, a summit was held which resulted in Stilen writing a grant for buprenorphine.

“It was like the sky opened up and suddenly it was something everyone needed to do,” she said. “We’d spent years trying to do it different ways, but until we got the policy makers to open their minds we didn’t get far. That’s one of the things, [MOUD]…that’s what I’m particularly proud of.”

As proven in the success of changing the field of MOUD in the region, relationship building continues to be a key factor in successfully providing education and support in Region 7. In the ATTCs earlier years, regions were still being identified, which resulted in various occasions where states were being absorbed and transferred by different ATTC partners.

"There was loyalty on both parts,” she said.

As changes occurred, the center needed to adjust how it continued to serve states it already had connection with, while also introducing technology transfer assistance to new collaborators.

One significant means in facilitating relationships within states for Region 7 included the Leadership Institute. After initiating the Leadership Institute in Kansas at the request of the state authority, Stilen recalled providers and directors viewing it as a great opportunity. The model was adapted to other states, which helped providers meaningfully connect with MATTC, and it provided valuable leadership development that was needed at a time when preparing for professionals nearing retirement to leave the workforce.

Mid-America ATTC will be hosting its Leadership Institute in April 2023. Find out more here.

While the Leadership Institute is no longer required by SAMHSA, Mid-America's advisory board has continued to strongly suggest it be a priority. Pat explains, “It is key to develop relationships with people who participate, both as protégé and mentors".

Maintaining those longstanding relationships remains important, a lesson Lisa Carter, her successor at Mid-America ATTC, said she learned from Stilen while preparing to take over as Co-Director.

“Pat always told me that as we were doing succession planning and training,” Carter said. “I know it to be true from my own career experiences… ‘You refer to people, not businesses.’ It’s very true. I spent last summer touring and doing meetings and it is critical.”

For her part, Stilen said she appreciates knowing that the MATTC has been able to sustain the relationships its built over the last quarter century.

"[When] they call you when they need something, you've really made it,” she said.

Embracing Change: A System Framework for Visualizing Change

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.

Embracing Change: How to Infuse Technical Assistance with NIATx Process Improvement Principles

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.