Much of the focus on quality improvement in behavioral health is dedicated to “the what,” as it focuses on enhancing the quality of services through the implementation and sustainment of high-fidelity evidence-based practices. But without also focusing on the process, “the how”, the capacity for lasting improvement is limited.
The NIATx model for improvement, developed in 2003 at the Center for Health Enhancement Systems Studies (CHESS) at the University of Wisconsin–Madison, builds on a foundation created by process improvement pioneers from the 1950s. W. Edwards Deming and others enhanced manufacturing processes across a range of industries by understanding that everything that we do is a sequence of steps: a process. Deming helped us to see that process is the primary driver of the customer’s experience of quality. While the quality of the product (the “what”) is important, the process (the “how”) has the biggest impact on the customer’s experience. As we applied these concepts to health care, we came to understand that the patient’s experience of care was more influenced by factors such as on-time service delivery and a provider who engages with and listens to them, than the actual quality of the clinical services delivered.
Over two decades, NIATx has advanced this earlier thinking into a model designed for substance use services. NIATx has subsequently expanded its footprint across a wide array of human service settings, assisting thousands of provider systems in improving their processes using a simple set of accessible tools.
The four core NIATx tools for improvement:
- Walk-Through: A role play of the customer experience conducted by the change team.
- Flowchart: A process map of the process experienced during the walk-through that builds consensus among team members regarding the current process and potential areas for improvement.
- Nominal Group Technique: A structured brainstorming method designed to select a strategy to address the needs revealed by the walk-through and flow chart.
- PDSA Plan-Do-Study-Act: rapid cycle testing of the strategy selected in the Nominal Group Technique.
The NIATx model was developed through research about the traits of organizations that succeed when implementing change. An analysis of data from 640 organizations in 13 industries covering 80 potential contributing factors revealed five that consistently drive successful change. These five factors became the five NIATx principles.
The NIATx Principles:
- Know and understand the customer
- Fix key problems of leadership
- Pick a powerful change leader
- Get ideas from outside the field
- Use PDSA rapid cycle change
The first of these factors, knowing and understanding the customer, was found to be the most critical factor. This emphasis on the customer has been central to the influence of NIATx over the decades as we have focused on the unique experiences and needs of each person served.
It has been a logical pivot for us to shift from service recipients to the workforce as we apply these principles. Understanding the applicant, interviewee, or new hire as the customer has helped us to apply the NIATx tools and principles to determine how best to enhance their customer experience during the hiring and onboarding process.
The workforce challenges of the behavioral health industry have led leading NIATx thinkers to consider how best to apply these NIATx tools to support critical workforce goals. Our current model considers workforce issues through four key processes:
Recruit > Hire > Retain > Promote
With this new process orientation, we can start asking the right process questions.
What do we need to do to enhance the recruitment, hiring, retention, and promotion processes to increase the number of people who apply, interview, accept positions, and are successfully onboarded and retained in those positions?
Each of these four processes link together to reflect the full worker experience. Each process requires separate considerations and distinct indicator metrics to determine whether PDSA tests of change have achieved the desired results.
Too often, behavioral health provider systems talk about “the workforce challenge” without focusing on the specific subprocess that requires attention. This would be similar to walking into an unfamiliar grocery store and asking the staff for help in finding the “dinner food.” The “ingredients” needed to improve recruitment are different from those required to address hiring or retention.
NIATx got its start with a focus on patient access to care and retention in care. These original improvement aims addressing wait times, admissions, no-shows, and continuation have been retooled to focus on the needs of the behavioral health workforce. NIATx has worked with multiple provider systems through training and technical assistance to engage in PDSA rapid-cycle testing of specific workforce improvement strategies.
- If we change the job posting by doing A, will that result in more eligible applications?
- If we engage applicants using strategy B, will more of them attend interviews?
- If we create a kinder, more empowering interview process using strategy C, will more applicants accept the positions offered to them?
- If we provide meaningful growth opportunities using strategy D, will staff members be retained in certain positions for longer periods?
Each of these examples can be explored through the core NIATx tools sequence.
Providers use small change teams to walk through the customer experience by role-playing the process of completing an application or an interview. They then complete a flowchart that reveals the details of the workflow associated with the process. Once an area of focus has been identified, the team uses Nominal Group Technique to brainstorm and select a strategy to test using a Plan-Do-Study-Act (PDSA) change cycle. Each effort is designed to be completed with existing resources and to focus on a clear business case for the organization.
One common NIATx approach to improvement is the use of a learning collaborative. We have found that providers who come together and share ideas can benefit greatly from collaborative learning opportunities. The application of this collaborative model to workforce issues has had some key challenges. It can be difficult for providers to share their workforce struggles with peer organizations that operate in the same marketplace. Many providers are hesitant to share the specifics of workforce concerns. They fear that such disclosures may damage their reputation. This is reminiscent of similar challenges addressed in the earliest days of NIATx. We have worked hard to shift the culture of behavioral health systems toward open disclosure. Organizations that understand their own challenges are typically the most successful. Sharing challenges related to the four workforce processes is the quickest path to improvement.
More providers have come to understand how the NIATx tools that they have applied to service customers can achieve similar results with workforce customers. We cannot improve what we cannot understand. And the only way to understand the four workforce processes of recruitment, hiring, retention, and promotion is to explore the details of each process, and to use tested tools to improve them. NIATx has proven itself to provide an excellent toolbox that many teams are now using to understand the process and enhance the workforce experience. Providers interested in learning more about the NIATx tools and their application to workforce needs can explore the following resources:
- NIATx tools for Continuous Quality Improvement in mental health services
- NIATx website
- Live NIATx training and NIATx e-course
- NIATx tools in substance use settings or workforce applications
Mathew R. Roosa, LCSW-R, is a NIATx Trainer, Technical Assistance Provider, and Subject Matter Expert at the Center for Health Enhancement Systems Studies (CHESS) at the University of Wisconsin–Madison. Please direct any questions or inquiries to the author, Mathew Roosa, at matroosa@gmail.com or Roosa@wisc.edu.
Citations for publications that describe the origins and foundational concepts and tools of NIATx:
Capoccia, V. A., Cotter, F., Gustafson, D. H., Cassidy, E. F., Ford II, J. H., Madden, L., … & Molfenter, T. (2007). Making “stone soup”: Improvements in clinic access and retention in addiction treatment. The Joint Commission Journal on Quality and Patient Safety, 33(2), 95-103.
Evans, A. C., Rieckmann, T., Fitzgerald, M. M., & Gustafson, D. H. (2008). Teaching the NIATx model of process improvement as an evidence-based process. Journal of Teaching in the Addictions, 6(2), 21–37. https://doi.org/10.1300/J188v06n02_02
Gustafson, D. H., Johnson, K. A., Capoccia, V., Cotter, F., Ford, J. H., Holloway, D., … & Owens, B. (2011). The NIATx model: Process improvement in behavioral health. Madison, WI: University of Wisconsin-Madison.
McCarty, D., Gustafson, D. H., Wisdom, J. P., Ford, J., Choi, D., Molfenter, T., … & Cotter, F. (2007). The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and retention. Drug and Alcohol Dependence, 88(2–3), 138–145. https://doi.org/10.1016/j.drugalcdep.2006.10.009
