By David H. Gustafson, University of Wisconsin-Madison
Summary: Since the passage of healthcare reform, there have been many discussions about how the mental health and substance use disorder (MH/SUD) system will need to change. Of the many components involved in a system redesign, the identification of essential ingredients is crucial to its success. In an effort to determine what essential ingredients the new MH/SUD system requires to optimally meet the needs of its customers, we convened a group of 16 multi-industrial experts who analyzed data collected from a string of 7 focus groups and 15 interviews with people dealing with or working in the SUD field. This paper summarizes the 11 essential ingredients our group identified.
Introduction: System redesign has been the subject of decades of extensive research (Delbecq, 2010; Delbecq, 1975; Van de Ven, 1999; Van de Ven et al. I and II, 1980). Many characterize the processes of redesign as aim creation, problem and asset exploration, solution development, solution testing and adaptation, and implementation. One key process (often interspersed between problem exploration and solution development) is the identification of essential ingredients: Regardless of what solution is developed, it will need to contain certain ingredients to be successful. Many systems design theorists suggest that a key to identifying essential ingredients is to reach outside the boundaries of the field to identify how the best systems in other fields accomplish basically the same thing, and identify what they do that distinguishes them from others in that field. For instance, suppose an organization wanted to improve an internal communications system. One might ask what other field specializes in communications, and what organization stands out in that field. The information technology field comes to mind. Apple would certainly appear among the top of most people’s lists. The next question: “What makes Apple so Good? And what can we learn from them?”
We don’t need to visit or interview people at Apple to learn the answer. When an organization is outstanding in a particular arena, analyses of their proficiencies abound. A quick Google search of, “What makes Apple so Good?” produced 9,020 references. Valuable ideas can be identified by looking for commonalities in a sample of references. One example of such a reference is a note by Nathan Schulhof (2007), credited by some as the father of the MP3 industry, on why the iPod was so successful. He points out that Apple was “the first to afford the recording industry, producers, and musicians with a marketing and distribution system that provided wide-scale distribution, dignity and rights to the artists, and well-deserved revenue to those parties . . . offering the full solution in a one-stop shop with successful branding targeted at the youth . . . that worked, period."
So what does this reveal? If the communications system we develop is to be successful, it needs to: 1) focus on a very specific customer (they focused on youth), 2) work exactly as promised (no bugs), 3) reward the producers of the content of the communications that are used, and 4) provide content, marketing, and distribution all in one stop. Most, if not all, of these characteristics may seem obvious (e.g. know your customer) but few organizations really commit themselves to doing that. It is also interesting to note what is absent from the list. Apple, for instance, does not try to be the cheapest or even the first to market; e.g. the iPad.
In rethinking the addiction treatment system, it is in our best interests to identify the essential ingredients the new system requires to optimally meet the needs of its customers. This is what we attempted to do in an ongoing project intended to redesign addiction treatment.
Methods: Over 4 months, staff from the Network for Improvement of Addiction Treatment (a University of Wisconsin-Madison initiative using quality improvement and information technology to improve access to, retention in, and relapse prevention after addiction treatment) conducted and analyzed data from 8 groups and 15 interviews with people dealing with SUD (patients, families, criminal justice personnel, and community organizers as well as primary care, SUD treatment and human service providers). Four included mixtures of patients, families, addiction treatment providers, criminal justice and child welfare personnel, and primary care clinicians while four were subdivided so that patients and unrelated families were separated from professionals. The groups, run by Gustafson and Mosgaller from our research center, were held in Augusta ME, Princeton NJ, Peoria IL, Manitowoc WI, and four in Madison WI.
Each group employed the Nominal Group Technique (Delbecq et al., 1975) where participants were separated into groups of 7-9 in size. We began by asking each person to silently generate a list of the most important personal and organizational barriers they face in trying to do their "job" (e.g. parent a person who is dealing with substance abuse, or patient trying to stay clean and sober, etc). These ideas were listed on a flip chart, one idea from each person and continuing until all ideas were posted. The ideas were discussed for clarification and a quick prioritization was made to get a rough idea of relative importance. We then repeated the process to identify key assets each group brings to the table. After all group meetings were held, the ideas generated were combined to eliminate duplications but done so that subtle differences in otherwise duplicate items could be included. The specific results are the subject of a forthcoming paper.
The products of those interviews were fundamentally important to redesigning the system, because they gave us goals to shoot for. They also provided a sense of the resources we have available. For instance, a family committed to doing almost anything to help a loved one's recovery may also have skills in communication and information search. Knowing this allows us to develop their commitment and skills into a resource that may positively affect recovery. There are many ways to do this. We set out to identify the essential ingredients that must be present in any successful effort to develop them as a resource. During this process, we also attempted to describe the existing addiction treatment system as a reference point for future design work.
We then convened 12 insightful people from in and outside addiction treatment and healthcare for a one-day meeting at a local monastery. They included: Timothy Baker PhD, clinical psychologist and addiction researcher; Dhavan Shah PhD, communication scientist; Colleen Heinkel PhD, clinical psychologist for returning veterans; Kimberly Johnson, former SSA director and addiction treatment director; Fiona McTavish, program management; Todd Molfenter PhD, health systems engineer; and Tom Mosgaller, community organizer (all from the University of Wisconsin); Ronald Diamond MD, psychiatrist community mental health; Patricia Gabow, former public health director; and Brian Joiner, quality improvement consultant (Madison WI); and Jay Hansen, Prairie Ridge Treatment (Mason City IA) and Michael Boyle, Fayette Companies (Peoria IL), both addiction treatment leaders; as well as one parent of an alcohol dependent child, and one drug abuser.
The author employed an evidence-based-index, development-group process (Gustafson et al 1983) to conduct the exercise. Attendees were interviewed prior to the meeting to seek their advice regarding the essential ingredients that must be present in any system that would meet needs identified in the Nominal Group process. After extensive discussions supplemented by literature reviews, we had a list of potential essential ingredients. These were presented at the meeting, which initiated further discussion and revision. Following the meeting, a revised list was sent to all attendees. They were asked to assign priorities to each of the essential ingredients on the list.
Specific solutions were not developed at the meeting, because systems theorists suggest that there are advantages in large-scale system redesign to holding off on specific solutions until essential ingredients are well understood (Delbecq, 1994). Hence, the reader will not find allusions to integration with primary healthcare, co-location, disease management, etc., although the function of treating the whole patient (not just their addiction) is prominent. We also focused on the environment, as it is an important consideration in refining essential ingredients. For example, a teenager living in a household with smokers or large concentrations of dust mites will have a harder time managing their asthma. Similarly, addressing addiction issues without also considering the environment in which an addict lives reduces the likelihood of success.