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System-Level Toolkit

System-Level Change Projects

In NIATx system-level Change Projects, Change Teams work to eliminate system-level barriers to effective service delivery. Making system-level changes serves many purposes, and one of the most important is to lead by example. In making changes at the system-level, you address the issues of your customers—the provider agencies—in the same way that providers address the needs of their customers.

Provider as Customer

By considering provider agencies as the customers of regulatory or reimbursement services from the state (or another regulator or payer), you can use the same tools that a provider uses to identify the barriers faced by clients seeking treatment. Ask providers what system-level processes or policies create barriers to providing quality service.

Some Common Barriers

  • Funding. Providers list lack of funding as the primary impediment to effective service delivery.
  • Paperwork. Ask for specifics. What paperwork? Is it licensing requirements for documentation? Data collection forms for state data systems? Reimbursement forms? Reducing paperwork is always a good choice for a system-level Change Project.
  • Regulatory requirements. Providers cite duplication, lack of clarity, or contradiction of requirements, along with burdensome documentation as barriers to improving access and retention.
  • Internal processes. Long response times for inquiries, licensing and contracting lag times, multiple review requirements, lack of accountability, difficulty finding the right person to answer a question or solve a problem.

Conduct a Walk-through

Systems leaders need to walk through their own processes to understand what providers experience. Some walk-through ideas to consider:

  • Do an intake with a provider. How much of the information requested is really necessary? What does the state really require?
  • Sit down with the person who fills out the state data collection forms and walk through the process of entering data for a real person.
  • Call your office with a contract question and see how it gets routed or answered.
  • Sit down with a treatment agency staff person who is trying to fill out next year’s contract forms. Experience the process from his or her perspective.
  • Participate in a license review; sit on the provider side of the table and follow up with an interview of the provider about the requirements.

Start a Change Project and Make a Change

Identify a Change Project based on the results of your walk-through and discussions with providers, form a Change Team, and use the PDSA model of rapid-cycle change to make improvements.

Regulatory changes take a long time in most places. Do you have waiver authority? Waiving regulations for some agencies for a short period of time can be one way to test out a regulatory change (the DO in the PDSA Cycle). Involve the providers when rewriting the regulation. They will be able to help you identify pitfalls of changed language and the unintended consequences of removing barriers in a certain way.

Requirement or Fable?

System-level Change Projects often expose long-held beliefs about regulations or paperwork that are false or obsolete. Some procedures become institutionalized based on the preferences of a single licensing or contract reviewer. Staff members may continue to adhere to a rule that no longer exists. Treatment agencies may unwittingly use multiple forms to satisfy one requirement.

As a former SSA used to ask providers, “Show me where it is in the regulation. Is it a licensing requirement? A contract requirement? In Medicaid regulation? If it isn’t there, then you don’t have to do it, no matter who told you you do.”

Study the change: If you have piloted a change using waiver authority with a small group of agencies, measure how it worked. Did it decrease the amount of time they spent doing some aspect of their process? Has it improved their ability to see clients more quickly or to see more clients or to spend more time in engaging clients rather than filling out paperwork? What is the feedback from the providers? Are you ready to change the regulation?

If you have gone through the regulatory change process, how much negative feedback did you get with the rule change? This is one measure of how helpful it is and how involved the providers have felt in the process.

Act: There are three things you can do after a pilot, just as there are for providers: adapt, adopt, abandon.

Additional Information

Further Reading

STAR-SI State Leadership Calls

Advancing Recovery Framework