Using customer-focused business practices, a research collaborative has succeeded in reducing wait times and no-show rates and increasing admissions and continuation in treatment, according to David Gustafson, Ph.D., director of the Network for Improvement of Addiction Treatment (NIATx).

Programs that received technical assistance from the NIATx process-improvement project -- which uses peer networking and education to promote a customer-focused culture in treatment programs -- achieved some eye-opening results. Among participating programs, the average time to assessment was cut 72 percent, time to treatment was cut in half, and patient retention (through four sessions) increased 123 percent, for example.

"I've never seen a field take to process improvement like the addiction treatment field does," said Gustafson, who also founded the Center for Health Systems Research and Analysis at the University of Wisconsin at Madison. "The results they're getting just blow me away."

Gustafson's personal interaction with the treatment system illustrates that there's a lot of room for improvement when it comes to treating clients like a for-profit business would serve its customers. Acknowledging at the outset of the NIATx project that he knew little about the addiction field, Gustafson -- who does not have a drug problem -- got himself admitted to treatment for heroin addiction.

"I called up and said I needed help," he recalled. "They said, 'You can come in in 4 days for an intake.' They spent two hours asking me about my disease, then concluded that yes, you need treatment, but at the moment we don't have a bed for you, so call us in a week if you still want treatment."

Gustafson called back a week later, and got an answering machine that said to leave a message. "That's all the machine said for six straight weeks in a row," he said. "Seven weeks later, they called and said they had a bed. If I'd been a real heroin addict, I'd never have made it into treatment."

When Gustafson showed up at a meeting to be assigned to a treatment program, the intake coordinator who interviewed him weeks before wasn't there, and the admissions staff was working off of a half-page of written notes about his case. "What happened to the two hours of information I provided at intake?" he asked.

Gustafson didn't blame the staff, which he described as being paid less than workers at Home Depot, often in recovery themselves, and deeply committed to helping those who need treatment. "Between the patient and care lies a canyon of paperwork and burdensome diseases that get in the way," he said.

Gaining the Customer's Perspective

About 30 treatment organizations have taken part in the NIATx training, with another dozen slated to participate. "We make it hard for organizations to get in but easy to get out," said Gustafson. "There are a lot of hoops they have to jump through in order to get in; we admit less than 10 percent of applicants."

Every NIATx participant is required to do a walk-through like the one Gustafson did, to experience first-hand how their own treatment program functions. "One of the things some learned in doing so is that the telephone number in their Yellow Pages ad doesn't work," he said. "Something simple like this, no one knew about until they tried being a consumer ... The first thing you need to do when you are about to change is to assume you don't have the foggiest idea of what it's like to be a customer in your organization."

Those programs that learn to view their operations from a customer's perspective are far more likely to succeed in making organizational changes than those who don't, Gustafson said. But while programs getting help from NAITx were all taught to embrace a customer-centric focus, they sometimes found different pathways to improving their systems.

For example, the Sinnissippi Centers, Inc., of Dixon, Ill., said sharing data with counselors about delays helped cut the lag between initial client contact and assessment, while Florida's Center for Drug Free Living said it eased the problem by committing to do all assessments on a walk-in basis. To improve treatment retention, the Daybreak program gave performance feedback to counselors; for the Prototypes program of Culver City, Calif., the answer lay in doing a better job of identifying at-risk patients.

Gustafson said that program leaders must buy into change if it is going to take root in the organization. "Every single change must be critically important to the CEO or it shouldn't be undertaken," he said. Ideas from outside the organization, as well as some external pressure, also help. "If we try to take all our ideas from inside the organization or the field, we just get variants of the same thing," he said. "If we want ideas that shake the foundation of our organization, we have to go outside."

Gustafson said that programs should not be afraid to make rapid process changes, even if there are some initial bumps or pain at first.

For example, he said, Acadia Hospital in Bangor, Maine, decided to get anyone who called into treatment by 7:30 the next morning. "Initially, this was difficult, but whenever this center makes a change like this, they take a senior manager and put him side-by-side with workers being asked to make the big change," said Gustafson. "The first day, it didn't work well. The staff was a little angry, but the senior manager was right there to troubleshoot and adjust. He worked with them full time for that first week so he could personally experience what the staff went through, and they succeeded."

Building on that initial decision, the organization re-thought what intensive outpatient was all about, said Gustafson, moving from a rigorous sequential process to a more flexible configuration of groups and modalities. "That one change has contributed $1.2 million a year to their margin," he said. "They went from 26 patients a month and a chronic 'not enough slots' condition to admitting 91 patients a month."

Organizations may embrace changes out of a desire to streamline operations or better serve clients, but Gustafson stresses that changes must have a solid business case to prevail over the long run.

"The changes we are trying to put in place will not work unless it improves bottom line," he said. "There are modest changes that can make a big difference for the patients and also for the agency's financial viability."

"Change is not hard; it's easy," added Gustafson. "It's just something we do the next day, and the next day, and the next ... we just do it."

Gustafson spoke at the recent Demand Treatment Lessons Learned Summit, held in Chicago, Ill. The NIATx program is jointly sponsored by The Robert Wood Johnson Foundation's Paths to Recovery Program and the federal Center for Substance Abuse Treatment's Strengthening Treatment Access and Retention (STAR) program.