Project # / Interim Process Evaluation Report

Transcription

1 Appendix B: Interim Prcess Evaluatin Reprt Prject # / Interim Prcess Evaluatin Reprt BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Reprt prepared by Kristy Hyak and Jane Cllins, BC Mental Health and Addictin Services 31 Mar 2011

2 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Initiative Backgrund British Clumbia s DTFP Strengthening Treatment Systems initiative targets cmplex system-change acrss the prvince. This initiative aims t align prvincial planning and practice with the principles f the Natinal Treatment Strategy t strengthen substance use services and supprts in BC. This initiative invlves a brad Knwledge Exchange framewrk using a Change Management Mdel and tlkit t supprt evidence-infrmed system change 1. The mdel fcuses n practice change implementatin using prcesses designed t plan, launch, and supprt change. The 2008 situatinal analysis demnstrated that there is unprecedented buy-in frm prvincial and reginal leads in mental health and substance use t implement the BC Strengthening Treatment Systems initiative. Initiative Management BC Mental Health & Addictin Services (BCMHAS), an agency f the Prvincial Health Services Authrity, is prviding verall management fr this initiative. Executive lead fr this initiative is Shannn Griffin, Directr, Planning & Strategy Develpment, BCMHAS. Prgram lead is Jane Cllins, Prgram Manager, Research & Netwrks, BCMHAS. A c-management team frm acrss the six Health Authrities 2 has been assembled t plan cllabratively t link and leverage pprtunities acrss Health Authrities. The c-management team are mental health and substance use senir peratinal / strategic leaders frm each f the Health Authrities. The c-management team (Addictin Knwledge Exchange C-Leads) are members f the Prvincial BC Substance Use Netwrk (BC SUN) and the majrity are als members f the Prvincial Mental Health and Substance Use Planning Cuncil. C-management supprt is prvided in kind by the Health Authrities. The Health Authrity c-leads are invlved in all aspects f the prject, cllabrative planning, prfessinal capacity building, implementatin, and nging supprt. There are six Addictin Knwledge Exchange Leaders (ne per Health Authrity) that cme frm diverse prfessinal backgrunds (e.g., mental health and addictin scial wrk, clinical nurse educatrs, cmmunity develpment). There is a matrix reprting structure fr the Addictin Knwledge Exchange Leaders wh reprt t the designated Health Authrity c-lead and the prvincial Addictin Knwledge Exchange Team Manager. The Ministry f Health (MH) lead fr this initiative is Amanda Seymur, Manager, Mental Health and Substance Use, Ministry f Health. The DTFP team has develped a cllabrative, pen, transparent team culture and structures t supprt the wrk incrprating reflective prcesses t review and adapt structures and prcess t supprt functins. 1 Evidence-infrmed System Change frm a Change Management Perspective: A Tlkit fr Leaders. (2007). BC Mental Health and Addictin Services, An agency f the Prvincial Health Services Authrity, Vancuver, British Clumbia, Canada. 2 British Clumbia is divided int five reginal Health Authrities (Nrthern, Interir, Vancuver Castal, Fraser, and Vancuver Island), and ne prvincial health authrity (Prvincial Health Services Authrity)

3 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Table 1: Addictin Knwledge Exchange Leaders and Health Authrity C-Leads Health Authrity Addictin Knwledge Exchange Leaders Health Authrity Addictin Knwledge C- Leads Nrthern Health Interir Health Fraser Health Vancuver Castal Health Vancuver Island Health BCMHAS/Prvincial Health Services Authrity Franca Petrucci Cathy Tetarenk Marika Sandrelli Marelyn Rugg Paula Beltgens Tm Hetheringtn Jim Campbell, NH Executive Lead MH&AS Cliff Crss, Prgram Directr, Mental Health & Substance Use Cmmunity Integratin Services Rae Samsn Cmmunity Integrated Service Manager, Mental Health and Addictin Services Sherry Mumfrd, FH Directr, Clinical Prgrams, MHAS Addictin Services and Langley and Maple Ridge Mental Health Heather Hay, Prgram Directr, Reginal Prgram fr Cmplex Mental Health and Addictin Ppulatins Michelle Dartnall, Manager, Yuth and Family Substance Abuse Services Janet James, Area Manager Adult MHAS Shannn Griffin, Directr, Planning & Strategy Develpment The verall gal f BC s DTFP initiative is t build an addictin KE infrastructure that facilitates the implementatin and supprt f evidence-infrmed practice and KE activities, and fsters linkages acrss the system f substance use services and supprts in BC

4 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel BC s DTFP Addictin Knwledge Exchange team has facilitated pen, cnsultative, cllabrative planning prcesses t identify BC s DTFP addictin knwledge exchange pririty areas t strengthening the system f substance use services and supprts in BC. Table 2 presents the pririty areas which have been cnceptually gruped int KE t strengthen clinical practice and KE tls/mechanisms at a system level. Table 2: BC's DTFP Addictin Knwledge Exchange Pririty Areas Wrkfrce Capacity Develpment KE t supprt the implementatin f evidenceinfrmed practice cre addictin practice (CAP), mtivatinal interviewing/ change talk, client directed utcme infrmed appraches, cgnitive behaviural therapy, dialectical behaviural therapy, mindfulness therapies trauma-infrmed practices KE t supprt the implementatin f residential treatment standards KE t supprt the develpment f Cmmunities f Practice (CPs) KE t supprt Natinal Treatment Strategy alignment KE t supprt increased linkages t primary care methadne maintenance treatment cmmunicatin strategies t enhance linkages t primary care KE t reduce stigma and discriminatin KE t enhance system capacity t engage and supprt yuth, families and care-givers f yuth with substance use and mental health cncerns Systems-Level Framewrk/ Standard/ Plicy/ Prtcl Develpment Framewrk fr addictin KE and wrkfrce develpment linked t quality/ safety, diversity, and accreditatin rientatin scan and review f supervisry practices scan f current framewrks Residential treatment standards Enhanced KE infrastructure fr the system f mental health and substance use KE netwrks, and assciated prvincial netwrks Natinal Treatment Strategy Alignment planning tls Methadne maintenance treatment pharmacy guidelines Anti-stigma evidence review/ recmmendatins t infrm prvincial antistigma framewrk develpment Implementatin guidelines t supprt cllabrative practices acrss services and supprts t engage and supprt yuth and families and care-givers f yuth with substance use and mental health cncerns - 3 -

5 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Prcess Evaluatin Methds This prcess evaluatin was supprted by an intensive tw-day reflective practice prcess facilitated by Michael Quinn Pattn, a wrld expert in utilizatin-fcussed and develpmental evaluatin. The reflectin invlved the Addictin Knwledge Exchange Leaders, Health Authrity C-leads, DTFP evaluatin steering cmmittee, key clinical champins frm acrss the system and the prject management team. These tw days invlved intense reflectin including the review f prject summaries, change management prcess jurnal reprts and sharing data acrss the team. The DTFP Addictin KE team Data Analyst and Prgram Manager cllated and summarized the infrmatin fr this reprt. BC s DTFP initiative represents system change within a system displaying cmplexity characteristics, bringing with it implicatins fr evaluatin. Cmplex systems exhibit distinct characteristics, such as nnlinearity (small actins stimulate large I am quite genuine in saying I am impressed by yur level f engagement and penness. reactins), emergent utcmes, Michael Quinn Pattn adaptive and respnsive elements, dynamical interactins, and cevlutinary change amngst thse invlved. Within a cmplex system, cause and effect is cntingent n cntextual and dynamic cnditins practice is emergent and cntingent 3. The evaluatin f this initiative is infrmed by a develpmental evaluatin apprach t track the cmplex system change. This apprach recgnizes the dynamic nature f change and supprts dcumenting the change prcess, allwing fr nn-linearity, and tracking what emerges during a particular timeframe t infrm baselines fr what may emerge in the next timeframe. The path frm baseline will be nn-linear, retrspectively revised and emergent. Data surces reviewed: KE briefings Netwrks, Addictin KE Team Prject Summaries Change Management Prcess Jurnals Key Infrmant Reflective Interviews Onging evaluatin data Stakehlder feedback, surveys, interviews 3 Pattn, M. Q. (2010). Develpmental evaluatin: Applying cmplexity cncepts t enhance innvatin and use. New Yrk: Guilfrd Press, pp

6 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel BC Implementatin Prcess and Prgress Tward Outcmes Was the prject implemented as intended? The BCMHAS Change Management Mdel and KE framewrk is used t guide the wrk. The Addictin KE team has develped and adapted tls and mechanisms t supprt targeted system changes at multiple levels, and acrss a variety f settings. As was the case with the develpment f the prpsal, the implementatin f the DTFP initiative has been a cllective prcess with supprt f senir leadership f the Prvincial Mental Health and Substance Use Planning Cuncil and in cnsultatin with the Ministry f Health and the Prvincial BC Substance Use Netwrk. The implementatin f this initiative using the change management mdel invlves nnlinear iterative prcesses, rapid appraisal and respnse, and cmmunicatin and engagement feedback lps supprted by nging evaluatin. This type f implementatin is new territry in health care services. The flexibility required and critical success factrs t supprt system change varied acrss regins. In sme regins implementatin has been strngly supprted acrss all levels and in ther regins implementatin has been limited in scpe as expected given different stages f readiness t change acrss regins. The Addictin KE team has develped tls and mechanisms t dcument and supprt the change prcess. The team pilts and refines tls and mechanisms t dcument and supprt system change. This adaptive prcess has the tangible benefit f building ur knwledge base n hw t facilitate cmplex system change. The team als develps and mdels knwledge exchange and change management prcesses in ur team perating and administrative structures. This initiative has made significant prgress, especially ver the past year, t strengthen and supprt evidence-infrmed practice and linkages and exchanges acrss BC. The team has used pen cllabrative prcesses t develp KE tls and mechanisms t supprt evidence-infrmed practice at bth the practice and system levels within and acrss Health Authrities. This is all the mre impressive cnsidering the dynamic shifts in system structures that have ccurred during the first 18-mnths f this initiative. There were significant system re-rganizatins in all but ne health authrity during this time. Rather than individual rganizatins, regins r Health Authrities develping KE tls / mechanisms in islatin this initiative has set a new nrm in resurce sharing, building n strengthens, cllabrative planning, learning, evaluating, linking and sharing within and acrss Health Authrities, the Ministry f Health and Ministry f Children and Family Develpment. There is a new nrmative iterative prcess in which capacity is built frm within, develping and adapting KE tls / mechanisms t be respnsive t cntext and wrking cultures, relevant t audiences t supprt and strengthen the implementatin f evidence-infrmed practice. This apprach is being used acrss the DTFP addictin KE pririty areas utlined in Table 2. Cntained in the summary belw is the example f this new nrm in actin in the initiative f Mtivatinal Interviewing (MI) / Change Talk that was implemented ver the past year, in additin t ther pertinent examples f the DTFP prgress twards utcmes. Funded in part by the DTFP, MI / Change Talk curriculum, wrkshp and pre / pst wrkshp tls were develped t supprt the implementatin f MI / Change Talk - 5 -

7 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel acrss mental health and substance use services in Fraser Health Authrity (FHA). The KE methdlgy, curriculum, wrkshp, pre / pst testing tls, and the clinical trainers frm FHA were shared with Nrthern Health Authrity (NHA) t supprt implementatin f MI / Change talk acrss NHA. Clinical trainers frm Vancuver Island Health Authrity (VIHA) bserved the implementatin t infrm plans t supprt implementatin in VIHA. The early benefits f crss-reginal sharing have been dcumented. Enhanced KE infrastructure and tls t facilitate / supprt evidence-infrmed practice The Change Management Tlkit has expanded thrugh pilting, and testing f tls within and between Health Authrities. In assessing cnsent t change, engagement with leadership thrugh interviews and cnsultatins identified and highlighted sustainability f utcmes (by building existing staff capacity within HAs). The team has demnstrated the imprtance f nging invlvement with leadership t integrate KE planning with peratinal plans. T understand the current cntext, a pre-wrkshp cllabrative inquiry tl was refined t capture rural and remte cntexts. This enhanced understanding f hw t supprt peple s learning with limited infrastructure fr infrmatin sharing (see Appendix A). The MI / Change Talk wrkshp curriculum was mdified and cntextualized. Themes fr wrkshps generated by care examples frm participants and acrss settings resulted in a strengthened curriculum with thery linked t practice, and the develpment f skills labs run by champins. Clinical specialists / trainers frm FHA facilitated and VIHA trainers bserved the wrkshps. As a result f the participatin the curriculum was further strengthened with the sharing f expertise amng the trainers. Enhanced KE mechanisms t facilitate / supprt evidence-infrmed practice t enhance stakehlder cmmitment and engagement Supprt fr the develpment f cmmunities f practice (CPs) as a mechanism t supprt and sustain evidence-infrmed practice has been perceived as a significant value-add (see CP Wrdle). Participants reprt that CPs prvide the infrastructure t share experiences f their practice acrss settings, and supprt building relatinships t fster safety, trust and cmfrt t share practice experiences. Enhanced cllabratin and understanding n hw t implement and sustain evidenceinfrmed practice using KE prcesses and structures: Cllabratin thrugh crss-reginal pst MI wrkshp supprt was develped amngst MI Practice Champins t fster the implementatin f evidence-infrmed practice (MI). MI Champins are participants wh demnstrate a far reach acrss their clinical cmmunities and teams, and wh have scial capital, with a shared passin t be deeply invlved in the initiative. They identify knwledge gaps fr further learning - 6 -

8 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel exchanges (e.g., talk therapy, cgnitive difficulties pst acute withdrawal, learning t use visual cues, mind maps). MI Champins meet via telecnference t supprt uptake and blending f MI appraches int practice. MI practice champins have benefited frm management supprt in rder t prvide a 3-year cmmitment t be MI practice champins within and acrss clinical teams. Enhanced cllabratin between HAs was demnstrated in attendance at the Annual MI / Change Talk Summit fr practice champins, which was expanded beynd its rts as a FHA practice champins event t include identified champins frm NHA and VIHA. The MI Summit was a pwerful knwledge exchange experience. Participants reprted making significant impacts t renew and strengthen their practice. An emergent utput frm this summit was the c-creatin f KE tls / mechanisms t supprt practice pstsummit: Change Talk calendar (with tuch stnes and visual cues f the experience, incrprating MI materials and images that capture the spirit f MI fr participants, metaphrs, slgans, clinical practice examples, scheduling fr CP dates). Speed-dating prcess (creatin f reflective questins based n MI Summit experience and cmmitment t interview date in 4-6 weeks pst summit and reprt back respnses. Enhanced availability, understanding, and uptake f evidence-infrmed practice infrmatin The investment in clinical champins with cnsent and supprt frm management and peratins is a cncrete example f the increased cmmitment and value add f the DTFP initiative. The impact f clinical champins t supprt practice change within and acrss clinical teams is an illustratin f the cmplexity cncept f nn-linearity: hw small changes in cmplex systems can have large effects. Fr example, a change intrduced in a clinical team meeting by a MI clinical champin was t start ff the weekly staff meetings with the fllwing reflectin: What did yu learn frm yur client this week, and hw did that change yu as a prfessinal? The intrductin f this client-centred reflectin has nw been systemized int practice acrss a regin s mental health and substance use wrksites. MI / Change Talk dialg is nw being adpted acrss health care sectrs including hme health and metablic mnitring. Change Talk Tlkit this KE tl incrprates practice-infrmed evidence t supprt the uptake f MI/Change Talk evidence-infrmed practice. This tlkit has been develped and strengthened this year with input frm clinicians and clinical specialists / MI trainers frm acrss HAs. Fllwing the change management mdel, nging evaluatin, and revisin f curriculum and tls are nw incrprated int the iterative new nrm fr the develpment f KE tls and mechanisms t supprt evidence-infrmed practice Systemizing individual knwledge int cllective knwledge supprts evidence-infrmed decisin making. In the face f dynamic system re-rganizatin, knwledge abut substance use evidence-infrmed practices is nt a given at leadership tables and acrss sectrs. Addictin practice and system knwledge is t ften lcalized t key individuals acrss the system. KE tls (e.g., Addictin Leadership Primer fr Mental Health and Substance Use Leadership decisin making, Addictin Guidebk primer fr leadership in ther sectrs - FHA) are being develped t supprt evidence-infrmed - 7 -

9 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel decisin making. There is als cllective recgnitin f the legacy such primers prvide t supprt successin planning and mitigate knwledge lsses when key individuals leave the system. There is leadership cmmitment fr these primers t be living dcuments with nging review and revisin. Perceptin f Added Value: Acrss the system there are very psitive perceptins f the added value frm the DTFP Addictin KE initiative. Belw are a summary f key themes that have emerged frm interviews and feedback frm service prviders, managers, evaluatrs, leaders acrss mental health and substance use services and supprts in BC. Perceptin f enhanced KE infrastructure t supprt evidence-infrmed practice Feedback frm leadership and participants in a newly re-rganized health authrity has been psitive and there are early indicatins f enhanced supprt fr evidence-infrmed practice. CAP and MI are wrking well fr me. Our teams have been fcusing n the integratin f MH and AS and this training has been very desirable! Especially fr ur flks wh have nt had much expsure i.e. t cncurrent disrders. CAP and MI tk us leaps and bunds ahead. Operatins Manager Feedback frm participants in KE events / wrkshps / system reviews highlights an appreciatin f cmbining evidence reviews (grey and white literature) with KE / pen space methdlgies (e.g., reflective practice circles, cllabrative inquiry, wrld café) that are tailred t the cntext, supprt inclusin and address mral distress. An example is the respnse t the apprach taken in the review f clinical supervisin practices - cmbining literature review with appreciative inquiry. Participants reprted feeling appreciated, engaged, renewed, and experiencing a shared cmmitment, shared respnsibility t c-rdinating and mbilizing existing assets and resurces t strengthen and supprt clinical supervisry practices. Tw significant benefits stand ut t me when cnsidering the Addictin Knwledge Exchange prject: they are the cnfidence I gain in knwing ur system values the wrk enugh t ensure we as cunselrs are being prvided with the mst up-tdate infrmatin and theries in wrking with ur clientele; and the access t the peple within the psitin and their materials t prvide bth an immediate and lngterm impact n hw I wrk with clients, their families, and the larger cmmunity. Cunselr, Yuth and Family Addictin Services Perceptin f enhanced KE mechanisms t supprt evidence-infrmed practice The apprach t develping practice standards has been recgnized by the senir stewards in the system as a new benchmark fr develping prvincial standards. The change management mdel and KE framewrk were used t guide the develpment f new prvincial residential standards fr yuth and adult substance use services and supprts. Using the prcesses develped during the prvincial review f residential addictin services and supprts in BC, wrking grups frm the BC Substance Use Netwrk wrked cllabratively with the Ministry f Health t develp draft standards in cnsultatin with service prviders acrss settings inclusive f the diversity f residential settings and prgrams. The pprtunity t explre peratinal and system-level cnsideratins in an pen dialg helped t strengthen the standards. KE plans t - 8 -

10 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel supprt the implementatin f the standards will cntinue t engage service prviders t develp cntextualized KE tls. KE mechanisms, such as cllabrative inquiry, reflective practice circles, and pen space methdlgies t engage stakehlders t understand the current cntext, generate agendas, and shape curricula have elicited psitive respnses. Participants reprt feeling supprted, empwered, and having a shared respnsibility fr learning. The DTFP initiative has been psitive. Smetimes staff g t a wrkshp and it is frgtten, hwever with this training, the cntact that participants have had prir t the wrkshps, has been really gd. They then have had the wrkshps [and then] there is cntact after the training and their skill set is actually being imprved. Operatins Manager I feel like the system cares abut me. It s the first time I ve felt like this in a lng time. MI wrkshp participant Perceptin f enhanced cllabratin and understanding n hw t implement and sustain evidence-infrmed practice The intentinal fcus n relatinships and scial capital has strengthened capacity within the system. The team uses KE strategies t identify, empwer and link champins acrss all levels f rganizatins and the system (leadership - frmal and infrmal, evaluatrs, and practitiners). System change is facilitated thrugh relatinships and scial interactins, champins facilitate this - scial currency, scial capital as valuable resurces. Last week at a cmmittee meeting I attended (abut cmmunity partnership and cllabratin), I shared my experience frm the MI Summit, highlighting the spirit f Mtivatinal Interviewing. And the spirit f the grup cnnectin, and even at a deeper level fr many, the cnnectin with ur self. And it brught back the lveliest f memries f thse tw days and hw prfund the whle experience was fr me. An experience that I think is s rare. An experience f deep respect and equality and celebratin and listening t truly understand and the cmpassin and the risks peple tk frm deep within and the acceptance and care that each and everyne f us had fr each ther. It was like truth frm an inner place and reality f what really matters and even Brenda, ur server, stepping int the circle with us feeling welcmed and accepted as part f ur grup. And as I described my experience and the strength f the cnnectin between us, I culd see that the cmmittee members were understanding and maybe even captivated n sme level, and I wndered if I was a 'champin' in a way, with the wrds I expressed and shared with them. And later, as I reflected, a wrd seemed t cme up ver and ver in my mind and it seemed t sum up my experience at the Summit. And that is 'celebratin'. Celebrating what is real and truly imprtant and celebrating each and every ne f us in ur precius and unique ways and celebrating ur wisdm and strength and celebrating a cnnectin that is s rare and had such deep meaning fr me. MI Summit participant Acrss the majrity f BC s Health Authrities cntracted agencies prvide the bulk f direct substance use services. Befre the implementatin f the DTFP, KE mechanisms such as reginal addictin service netwrks had been established in different Health - 9 -

11 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Authrities t supprt evidence-infrmed practice and linkages and exchanges acrss services. The visual belw highlights the impact f investment in clinical champins t strengthen the addictin KE infrastructure in Fraser Health. Befre DTFP Implemented (June 2008-Nv 2009) After DTFP Implemented (Nv 2009 March 2011) Mark Gheen, Clinical Lead Mark Gheen, Clinical Lead text text Legend text Mtivatinal Dialgue Champin Existing Addictin Service Netwrk Addictin Services Leadership Cntracted wrk site / team Executive Leadership Direct Service wrksite/team This example illustrates mvement frm a mre centralized leadership t a shared leadership structure that harnesses infrmal and frmal netwrks. DTFP investment supprts netwrk creatin amng champins while expanding the number f champins t supprt a large service system that includes bth cntracted and direct service staff. The champins are invited t supprt ther evidence-infrmed practice initiatives, such as Cre Addictin Practice and Client Directed Outcme Infrmed practice. These champins have becme strng cmmunicatin crdinatrs. Prir t the DTFP, a clinical specialist prvided practice supprt fr hundreds f clinicians. Nw, clinical practice supprt is distributed with clinical leads wrking with abut 40 peple, and each champin prvides supprt fr his r her wn netwrk f wrk sites. Prgress twards enhanced system cllabratin within and acrss regins has been supprted by intentinal fcus n prmting and prviding space fr crss-service and crss-sectr cllabratin. An example f prgress twards enhanced system cllabratin attributable t the DTFP is bridging the gap between separate adult and yuth systems n Vancuver Island. The DTFP c-management team invlves leadership frm acrss these separate systems. Thrugh the DTFP initiative planning and implementatin is bridging bth systems. KE events t supprt evidence-infrmed practice are nw being c-facilitated with participatin f bth yuth and adult service prviders with a fcus n strengthening cllabrative practice and smther transitins acrss adult and yuth systems

12 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Overall I have been very impressed with the DTFP s activities regarding knwledge exchange. I think that the plans have been carefully develped in cnsultatin with ur prgrams and ur department. The wrkshps rganized re. CDOI, Develpmental Evaluatin, and CAP have assisted many Health Authrities stay current and netwrk twards better practice and care f ur respective clients. Lking back n my career in Addictins ver the last 2 decades, I wuld say that in many ways this exchange f infrmatin and cmmunicatin lead by DTFP and the Knwledge Exchange leadership represents a return t wrking as a mre cllabrative and chesive prvincial bdy f prfessinals. I feel hpeful and supprted in my wrk, in large part because f this initiative, and the pprtunities generated by what seems like a lt f carefully cnsidered and well executed series f events/initiatives. Crdinatr, Clinical Practice & Special Prjects Thrugh invlvement with this initiative there is a perceptin f increased trust and cllabratin acrss ministries and within and acrss health authrities. Part f this has been attributed t a shift frm cmpeting fr resurces t shared respnsibility, cllabrative planning and cllective attentin t legacy / sustainability t strengthen the system. Acrss BC SUN members the DTFP is perceived as shifting frm cmpetitin t cllabrative planning as the new nrm. In additin t the perceptins f shifts at the system level there is als an appreciatin fr the pprtunities t build relatinships amng individual clinicians and services acrss sectrs. Cmmitments t affect system change at decisin-making level t use KE and change management prcesses The change management mdel and KE framewrk were used t guide the develpment f new prvincial residential standards fr yuth and adult substance use services and supprts. The standards were develped using KE appraches, engaging leadership in pen, transparent prcesses that cmbined what we knw frm the published evidence with cntextualized practice knwledge in BC. This apprach t develping practice standards has been recgnized by the senir stewards in the system as setting a new benchmark fr develping prvincial standards. BCMHAS change mdel has been adpted by the Clinical Imprvement Steering Cmmittee in FHA, prmting enhanced cllabratin. This demnstrates the perceptin f added value fr the apprach when used at the service prvider and decisin maker level. The change management prcess helps develp cmmn language that facilitates translatin acrss diverse cntexts t supprt system change

13 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Were the expected activities undertaken and utputs delivered? BC s DTFP system initiative has delivered utputs as indicated in the prject lgic mdel and wrk plans. Using flexible adaptive prcesses inherent in the BCMHAS change management mdel many f the planned activities have been designed t be develped iteratively and cllabratively with stakehlders within and acrss regins. Respnding t emergence has resulted in activities and utputs that have exceeded initial plans. Expanded develpment f Cmmunities f Practice: The initial plan was t develp prvincial cmmunities f practice linked t the established prvincial leadership specialized health and substance use knwledge exchange netwrks. Guided by the change management mdel, the plan was quickly adapted based n learnings frm attendees at the initial DTFP-supprted wrkshps, and the CP initiative was expanded. Supprt frm the DTFP has facilitated the develpment f a number f reginal / lcal / prvincial CPs that are linked t leadership netwrks and supprt shared learning in a variety f cntexts acrss sectrs and specialities (e.g., Nrthern YCD, Adult Addictins, Yuth Addictins, and Eating Disrders). Expanded infrastructure plans t supprt web-based learning: the DTFP team is develping nline tls t supprt prvincial learning exchanges between CPs. The riginal plans fr the develpment f a static web-based infrastructure t supprt ne CP have been adapted t supprt emergent CPs linked t the leadership system-level prvincial specialized Mental Health and Substance Use Knwledge Exchange Netwrks. MI / Change Talk fr Leadership Wrkshp: representatives and leaders frm diverse sectrs (substance use services and supprts, mental health services, schls, and the RCMP) within a regin spearhead a cllabrative shift frm reactive prtcls t develping practive prtcls fr yuth experiencing substance use and mental health cncerns. Facilitated by invited Addictin KE team leads, benefits f practive cllabrative prtcls were highlighted in the wrkshp. Expanded anti-stigma messaging fr a variety f audiences: the early stages f this wrk (cnsent t change / understanding the current cntext) revealed gaps in knwledge and pprtunities t expand anti-stigma wrk. The plan has expanded t include a systematic review f literature n strategies designed t address stigma (self, scial, and structural) assciated with substance use. This evidence review will prvide the fundatin t present well- infrmed DTFP antistigma wrk plans fr 2011/12. These will be shared with decisin-makers, health care planners and the BC Gvernment s 10-year plan implementatin team, t supprt evidence-infrmed plans t effectively reduce substance use-related stigma. What curse changes were made, why and what is the impact n the prject s ability t reach its expected utcmes? Cmplex system change invlves adjusting, adapting and dcumenting the change prcess. Thse invlved in the initiative cntribute t the built-in reflective practice t adapt and strengthen the initiative with nging curse changes. Summarized belw are a number f key curse changes related t initiative management that have had a psitive impact n prgress tward expected utcmes

14 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Change t Initiative Management Based n ur experience the skill set required t successfully lead and manage this initiative, bth at the individual and rganizatin level, include: cnceptual understanding f knwledge exchange and knwledge exchange methdlgies cnceptual understanding f the nn-linear prcesses inherent in the BCMHAS change management mdel cmfrt, flexibility and adaptability t wrk with nn-linear prcesses cmfrt and rganizatinal supprt fr the risk-taking inherent in managing this cmplex initiative cmfrt and skill with pen prcesses (fr example, emergent agendas, pen space, cmfrt with the unknwn and knwing that knwledge exchange will uncver pssibilities well beynd what an individual/small grup culd generate in islatin) cmfrt, skill and supprt fr facilitating pen, inclusive multi-stakehlder, cllabrative, transparent planning prcesses cnceptual understanding f the multiple systems f substance use services and supprts in BC strng prject management skills including strng financial management skills ability t wrk effectively and cllabratively with partners frm acrss rganizatins and levels within rganizatins (e.g., HR, finance acrss 6 health authrities, the Ministry f Health and multiple ministries) strng cmputer literacy skills strng strategic and rganizatinal awareness and leadership skills, including the ability t recgnize and fster strategic partnerships strng scial capital respected trusted leadership cmbined with a track recrd f high perfrmance cmfrt, skill and accuntability t wrk within psitin scpe The skills and aptitude t engage in pen, inclusive multi-stakehlder planning prcesses that are adaptive and flexible is nt the nrm in health care. Withut these skills and the leadership risk-taking t implement this initiative as intended it can quickly mrph int traditinal linear tp-dwn clsed system planning supprted by linear prject management structures. The change in Executive Leadership ccurred in February 2010 and changes t Addictin KE team management and administrative supprt ccurred in June The change in the initiative management has had a psitive impact n the initiative. There has been a dramatic shift frm clsed prcesses t pen cllabratin with a fcus n trust, shared understanding, relatinships, cllabratin and reflective practice. Fr example, initiative planning includes hnuring safe spaces with mutual transparency shared transparency, shared resurces, shared respnsibility and pen accuntability. Develpment and dcumentatin f adaptive prcesses and structures With the change in initiative management there has been a shift frm using linear wrk plans t dcumenting prgress twards utcmes using change management prcess

15 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel jurnals. This shift supprts dcumentatin f the nn-linear change prcesses, capturing meaning and impacts. This shift has fstered a learning culture in which we articulate prcesses, learn, plan, d, learn and dcument what we d and why changes are made. Financial Cntrls t spend within 1% variance The team adapted prcesses and structures fr financial cntrls t ensure the initiative financial management is aligned with Health Canada 1% variance requirements. As with all team prcesses and structures the team engages in reflective practice t evaluate hw the prcesses are wrking with the gal t imprve and streamline prcesses. The adapted prcesses and structures have been established in cllabratin acrss Health Authrities and the Ministry f Health, invlving multiple financial systems with different financial calendars. The team incrprated financial reprting int weekly team checkins, and mnthly team meetings. In additin, Health Authrities invice mnthly fr DTFP-labur and nn-labur csts. Planning Cycle and pririty setting As utlined in the prpsal the initial planning cycle was t cnduct ne annual review and planning sessin in March with new pririties set annually. This riginal plan reflects the traditinal annual planning cycles in place in health authrities that are tied t fiscalyear end and fcused n utputs nt lnger term utcmes. This traditinal planning cycle des nt fit the reality f this DTFP systems initiative. The DTFP Addictin KE team, in cnsultatin with Prvincial BC SUN and the Prvincial Mental Health and Substance Use Planning Cuncil, agreed t pririty areas f fcus ver multiple years and have develped an nging adaptive planning cycle with planning prcesses incrprated int mnthly meetings and Prvincial BC SUN meetings n an nging basis. Apprach t KE web-based infrastructure develpment The change in the apprach t KE-infrastructure web develpment is linked t the change in initiative management. The strng strategic skills and sftware develpment experience f the new executive lead and team manager cmbined with pen cllabrative team prcesses facilitated significant shifts in the KE web-based infrastructure develpment plans. The Addictin KE team identified the imprtance f web-based mediated learning t cnsider in system develpment. These included: technlgy facilitated learning is an agent f learning nt just a repsitry web-based infrastructure can be a catalyst fr learning imprtance f crss-sectr linkages that can be facilitated strategic recgnitin f the imprtance f linking cmmunity f practice web-based infrastructure t the specialized system f mental health and substance use knwledge exchange netwrk cllabrative practice imprtance f engaging stakehlders in planning, develpment and evaluatin frm the start dynamic respnsive system develpment was an iterative prcess

16 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel cllective cmmitment t use pen surce technlgies t supprt KE imprtance f assessing sustainability issues during the early develpment phase cllabrative develpment prcess and recgnitin that the expertise t develp the system invlves resurces beynd the team This curse change has resulted in expanded web-based infrastructure develpment, engagement and cnsultatin acrss the prvince. The usability and early develpment wrk will be cmpleted at the end f this fiscal year, with plans fr iterative develpment ver the next tw fiscal years. The result will be a dynamic and adaptive addictin KE web-based infrastructure Timing f Natinal Treatment Strategy Alignment wrk As utlined in BC s DTFP prpsal, ne f the first activities envisined fr the team was t map the substance use services and supprts system against the Natinal Treatment Strategy tiered mdel. This wrk has been intentinally delayed in recgnitin f the whle-scale system re-rganizatins that ccurred in five f the six Health Authrities and the Ministry f Health ver the first 18-mnths f this initiative (fr mre n this, refer t Challenges and Areas fr Imprvement). This delay has benefited the initiative by prviding time fr develping methdlgy using enhanced cnsultative prcesses t assess the alignment f substance use services and supprts with the guiding principles and cre cncepts f the Natinal Treatment Strategy. The KE t use the NTS-alignment self-assessment tls has the ptential t strengthen the diverse rganizatinal and system structures by prviding service planners, and leaders with infrmatin t strengthen their system f services and supprts. Challenges and Areas fr Imprvement What challenges were encuntered and hw were they addressed? Summarized belw are the majr challenges encuntered and strategies used t address them. Cmplexity and Initiative Management This initiative invlves cllabratin acrss different levels f gvernment and acrss and within health authrities and sectrs in BC using prcesses and methdlgies that were nt part f business as usual in health care. Cmmunicating cmplexity and use f nn-linear prcesses in structures where the nrm is input / activities / utput linear prcesses is an nging challenge. Facilitating change in its cntextual cmplexity is the crux f this initiative. The value-add f fstering KE appraches is self-evident after methdlgies are intrduced and participants experience the impacts. The Addictin KE team has adpted a number f strategies t address this unknwn including: Mdeling the methdlgies and prcesses in the wrk we d rather than fcus n explaining the methdlgies and prcesses in the abstract. Strategically engaging leadership in KE events t supprt: (1) evidence-infrmed practice (fr example, Client Directed Outcme Infrmed practice, Develpmental Evaluatin, Cre Addictin Practice, MI / Change Talk fr Leadership); (2) experience the learning and impacts f using KE and pen space methdlgies and

17 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel (3) prvide infrmatin t supprt strategic system changes. Supprting and recgnizing leadership fr the shared risk and cllective leaps f faith required fr the successful implementatin f this initiative. Develping and supprting nging reflective practices t adapt structures t supprt the initiative. Recgnizing the strng in-kind c-management leadership required frm senir leaders acrss the Health Authrities and the Ministry f Health. The success f this initiative is largely dependent n the amazing in-kind cntributin f the cmanagement team. Develping pen, trusting cllabrative relatinships with leaders acrss in-kind supprt services is crucial t the success f this initiative including finance, and human resurces. Cllabratively develping financial cntrl systems, tls and prcesses t manage the cmplexity f the financial reprting acrss health authrities and the Ministry f Health: the team has develped strng relatinships with their respective finance departments. The use f KE methdlgies t facilitate the implementatin and supprt f evidence infrmed practice and t fster linkages acrss the system f substance use services and supprts in BC has been fr many in the system a new experience. The team fcuses n fstering knwledge exchange appraches, and has pilted feedback mechanisms t capture the emergence f perceptin f value becming self-evident t the participants and the system. This apprach is taken ver defining r explaining knwledge exchange in the abstract. Belw are examples t illustrate the psitive respnses frm participants frm a variety f DTFP Addictin KE events frm the past year: Yu never understand the value f knwledge exchange until yu experience it. I learned mre frm the MI experience than frm 6 mnths n ther cmmittees. Senir Executive, Mental Health and Substance Use Yu are teaching knwledge exchange by ding knwledge exchange. Health Authrity Evaluatr Implementing a system level initiative during times f dynamic system change The timing f the initiative cincided with system re-rganizatins affecting substance use services and supprts in five f the six Health Authrities and the Ministry f Health. Thankfully the BCMHAS change management mdel is adaptive and prvides a framewrk fr wrking amidst shifting Health Authrity and Ministry structures. The Addictin DTFP Team assessed cnsent t change acrss the health authrities and cllectively decided t fcus the first year n develping skills, tls and mechanisms t supprt the wrk and fcus n relatinship building within and acrss Health Authrities. Assessment f the current cntext f health authrities revealed change fatigue and mral distress in the face f system re-rganizatin. Therefre, rather than intrduce the initiative with a splash and lead ff with Natinal Treatment Strategy Alignment wrk, the team shifted plans t identify existing strengths and wrk cllectively acrss Health Authrities t share resurces and supprt evidence-infrmed practice implementatin acrss regins (see previus example n the stry f MI / Change Talk in FHA, VIHA,

18 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel NHA). As a result, the DTFP investment in knwledge exchange has been frmally recgnized by leadership as a mechanism t reduce mral distress. System change and re-rganizatin impact n HA evaluatrs and evaluatin plans One f the impacts f system wide re-rganizatins was the depletin f evaluatin resurces that were riginally intended t be available t prvide in-kind evaluatin supprt fr this initiative. This has necessitated develping strategies t supprt reflective, iterative internal evaluative capacity building: Identifying and engaging evaluatrs with an interest, aptitude and availability t prvide evaluatin supprt Develping and supprting a develpmental evaluatin CP learning grup Attracting Michael Quinn Pattn, a wrld leader in develpmental evaluatin, t prvide cnsultatin and mderate a Develpmental Evaluatin wrkshp t supprt evaluatin capacity building Strategically inviting leadership frm acrss Health Authrities t the Develpmental Evaluatin wrkshp 4 Incrprating KE methdlgies and rapid feedback lps int pre/during/pst wrkshp activities t demnstrate develpmental evaluatin in actin (see Appendix B fr example f the end f wrk shp interview and feedback summary fr participants) Enhancing capacity within the Evaluatin Steering Cmmittee: nging evaluatin prcesses are supprted with reflective practices and wrking grups. Success Bandwagn and Scpe Creep The DTFP initiative in BC is successful in that activities, utputs and impacts are gaining recgnitin and the beginnings f transfrmative changes are emerging. With success cmes the challenge f scpe creep, in which the DTFP initiative and KE are perceived as the slutin t all rganizatinal issues. In a prblem / slutin-fcused, and crisisriented system, the success bandwagn pses significant challenges t managing expectatins and wrklads. KE is nt the slutin t peratinal shrtages. The team is mindful f the danger in translating supprt fr evidence-infrmed practice uptake n the backs f individual clinicians withut attentin and supprt fr the system-level cmpnents required (clinical supervisin, plicy and prcedures, adequate staffing levels). The Addictin KE team has develped strategies t mitigate scpe creep: Establishing team prcesses t cllectively review pprtunities and empwer partners Develping transparent cllabrative prcesses fr decisin making with shared respnsibility, shared cmmitment and pen accuntability with partners Building reflective prcesses int team structures Onging areas fr imprvement: f e3-1a74d1e0ad

19 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Attending t feedback lps with decisin makers t track and reprt n emergent issues and utcmes, while maintaining an adaptive agenda t stakehlders needs. Managing expectatins f emergent utcmes, requiring rapid feedback lps t explre strategic pprtunities as they emerge What wrked particularly well? Strengthening, renewal and regeneratin fcus This initiative is using a knwledge exchange framewrk that is NOT a skill deficit mdel. The apprach the team has been using invlves cmbining evidence review, with strength based analysis using KE strategies and pen space methdlgies t engage and strengthen system. Successful KE methdlgies nw in regular use acrss the system include: Open space methdlgies t prvided space t supprt meaningful dialg Reflective Circles Wrld Café s Appreciative Inquiry lking fr what wrks as a way f addressing barriers and challenges Emergent Agendas Inclusive and emergent planning develping crss-sectr advisry grups, linking, examining and strengthening existing infrastructures. T supprt evidence-infrmed practice the team has incrprated evidence review and strength based appreciative inquiry prir t KE wrkshps t assess the current cntext and cntextualize the evidence-infrmed practice wrkshps. The engagement f learners in the develpment f KE events has the immediate impact f prmting practice reflectin and renewal. Participants reprt that the intentinal fcus n valuing clinical expertise and prviding pen spaces fr knwledge exchange has deepened their capacity t d the wrk. Amng the aspects that have wrked particularly well t supprt this strengthening, renewal, and regeneratin fcus are: Infusing relatinal practice int a mechanized system. KE events / initiatives have created space fr reciprcal prcess Remving cmpetitin fr resurces and building n strengths within and acrss health authrities C-creating and adhering t a cllective agenda Fcusing n adapting ver replicating: cntextualizing evidence-infrmed practice mirrrs what wrks in substance use treatment (i.e, guided change prcess) Incrprating multiple targets within a KE event: cmbining evidence / practice review, fcusing n relatinships and renewal, identifying and investing in clinical champins and existing infrastructure t uncver the pssible C-creating a team culture f penness and inclusiveness in decisin making and acting as if Supprting legacy planning by develping KE tls and mechanisms t systemize existing clinical substance use knwledge t supprt evidence-infrmed decisin

20 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel making (e.g., creatin f Addictin leadership primer fr mental health and substance use leadership) Empwering system service prviders as leaders There has been a cllective investment in identifying and supprting clinical champins, which is supprted by the change management prcess. Champins are natural infrmal leaders within the system with scial currency and credibility. Investing in champins prvides a resurce that can survive turbulence and system challenges. The decentralized leadership prvided by natural infrmal leaders and facilitated cnnectins t fficial leadership structures strengthens existing infrastructure by harnessing the natural infrmatin crridrs t strengthen and supprt bth evidenceinfrmed practice and leadership decisin making (fr mre n this, see The Stry f MI / Change Talk). Being pen and respnsive t emergent pssibilities One f the imprtant lessns learned during the first year is the imprtance f engagement and understanding the cntext prir t KE events. Using cllabrative inquiry methdlgies befre KE events has helped rganizers and participants understand current cntext and bring practice cntext int the cnsciusness f participants befre a KE event. The team fsters penness t encuraging and supprting emergent ripple effects frm KE events. This has resulted in partnerships and cllabrative prtcl develpment acrss sectrs in which partners take the respnsibility fr leading change t system and practice. This effect is demnstrated in the grwing recgnitin and appreciatin fr adaptive planning, and cmplexity and grwing interest in develpmental evaluatin methdlgies. Observed at a wrkshp n fstering CPs in health care was the subsequent emergence f CPs spreading acrss regins: the fcus f the wrk shifts frm being KE event driven t becming strategic catalysts fr change acrss services and sectrs. Evlving adaptive structures t supprt initiative Addictin KE leaders are designated psitins embedded within each Health Authrity, wrking clsely with a designated C-manager. These were new psitins with a unique placement that allwed the fcus t be acrss regins within a Health Authrity, and wrking cllabratively as part f a prvincial team t lk brader t link and leverage, leading t capacity building within and acrss Health Authrities. Addictin KE leaders are perating in the cnceptual messy middle, in which a labyrinth f adaptatin exists in a cnfluence f tp-dwn/bttm-up rganizatin and decisin-making. What culd have been imprved? The scpe and cmplexity f the DTFP KE system level initiative results in awareness f the inherent cmplexity f bumping up against multiple levels f nn-dynamic administrative bureaucratic structures. Given the reality f the shifts in funding, multiple gvernment electins, prrgues and a cllective under-appreciatin fr the peratinal cmplexity f system change initiatives we have limited cmments in this sectin t administrative areas that culd have been imprved based n ur experience ver the past 18-mnths

21 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Flw f funding Timeliness f funding frm Health Canada has required cnsiderable leaps f faith and deficit financing withut signed cntributin agreements. Reprting Requirements DTFP / Health Canada Lgic mdel and evaluatin framewrks d nt fit the cmplexity f ur initiative. The team experiences cnsiderable difficulty trying t fit ur cmplex system change initiative int the impsed linear lgic mdel and reprting requirements. It wuld be widely appreciated and welcmed if Health Canada shuld decide t explre cnsultatins t mdify the evaluatin framewrk t reflect cmplexity t supprt future initiatives. Mnthly breakdwn and reprting f spending nt reflective f Health Authrity practices given different fiscal years acrss Health Authrities (calendar vs. April- Mar), different perid cut-ffs, and different accunting systems. Tight financial management required is nt a given. With the multiple bureaucratic prcesses invlved acrss Health Authrities, Ministry f Health and Health Canada: quarterly, nt mnthly, breakdwn fr at least the first tw quarters wuld be helpful, as the amunt f administrative requirements reduces ur ability t d the wrk. Health Canada DTFP Administratin and Cmmunicatin The under-resurced administrative infrastructure at Health Canada impacts the ability fr Health Canada t prcess cntributin agreements in a timely manner. Acknwledging and understanding the cntext at Health Canada has helped BC s team t wrk cllabratively with staff at Health Canada t identify and streamline prcesses. As a result f delays, deficit financing was required n the part f BC s Health Authrities and Ministry f Health. The initial lack f cmmunicatin abut variance requirements until after the first year f the initiative negatively impacted cllective financial prjectins fr BC s DTFP. Ministry f Health DTFP Administratin and Cmmunicatin Changes in prject leadership at the Ministry f Health highlight the imprtance f : Dcumenting and articulating dynamic changes t gvernment structures and prcesses Linking strategically DTFP planning t planning acrss ministry prgram areas and gvernment branches t identify and ptimize pprtunities t link and leverage plans Cmmunicatins within and acrss Health Authrities Cmmunicatins, engagement and evaluatin infrastructure were impacted by structural changes within and acrss Health Authrities (including, but nt limited t: Lwer Mainland cnslidatin, IHA and NHA re-rganizatins). The advantage psed by the restructuring was mre face-t-face time with leadership, which helped build credibility fr the initiative. This placed a heavy lad n the KE team t create wrk-arunds that were time cnsuming and limited ur ptential impact because f reach issues. In ging frward with re-rganizatins nw in place, the team plans t link and leverage using existing and new cmmunicatins channels and structures

22 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Lessns Learned What are the key lessns frm this prject? Imprtance f Leadership during prpsal develpment The develpment f the prpsal ccurred ver a 9-mnth perid and invlved extensive cnsultatin and supprt frm leadership within and acrss health authrities and ministries. The prcess benefited frm mental health and substance use knwledge and experience frm a variety f perspectives clinicians, administratrs, researchers, and plicy makers. During the first year f the BC Substance Use Netwrk, the experience f wrking cllabratively with the ministry, facilitated by BCMHAS t review BC s addictin residential treatment system, helped strengthen relatinships and trust t cllectively develp the DTFP prpsal. The pen, transparent, cllabrative planning prcesses used in the develpment f the prpsal laid the fundatin fr cntinued cllabratin fr the implementatin f the initiative. Amng leadership were members f the Natinal Treatment Strategy wrking grup and primary authrs f the NTS knwledge exchange mdel. Having members f the wrking grup with in-depth knwledge f the NTS enhanced cnceptual clarity. Imprtance f Leadership during planning and implementatin One f the key lessns learned is the amunt f cmmitment and in-kind supprt required frm very busy senir clinical leaders t cllectively steward this initiative. BC is very frtunate t have senir visinary leaders with cllective appreciatin fr the significance f this pprtunity. DTFP Addictin Knwledge Exchange Leaders are a remarkable grup f prfessinals frm diverse backgrunds, reflecting the interdisciplinary nature f the substance use field. The legitimacy, scial capital, and cmplementary strengths cmbined with willingness t cllectively learn, share and supprt pssibilities within and acrss health authrities has been critical t the success f this initiative. This initiative has been strengthened by identifying and supprting clinical champins frm within the system and the recgnitin f the imprtance f scial capital and existing infrmal infrmatin crridrs. Finally, invlving leaders in planning, and evaluatin n an nging basis has been critical t develping and strengthening leadership supprt. Respect and recgnitin fr strengths, reginal variability, and shared pprtunities The respect and recgnitin fr strengths, reginal variability and shared pprtunities are central t BC s DTFP systems prpsal. The system level pririty areas have been endrsed at bth the prvincial and reginal levels with and thrugh the DTFP are being wrked n within reginal and lcal cntexts. One f the strengths f this apprach is t link and leverage pprtunities acrss health authrities sharing materials, methds, staff resurces, and lessns learned t plan and shape the wrk acrss the prvince. This cllabrative planning and practice is a significant accmplishment as it remves barriers between institutins, rganizatins, and sectrs and has fundamentally shifted the nrm in cllabrative planning frm dividing mandates t c-creatin. Imprtance f relatinship building The intentinal fcus n relatinship building during the early stages f change (cnsent t change / understanding the current cntext) and thrughut the change prcess has

23 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel been critical t the success f this initiative. Fstering linkages and exchanges acrss diverse systems f substance services and supprts has a basis in scial interactins. The attentin t the imprtance f relatinships, trust and reflectin during change in the initiative management has als been critical fr team prcesses and structures. Imprtance f nging review f adaptive structures A cautin learned in the first year f this initiative is that traditinal linear prject structures/framewrks/prcesses can be detrimental. The premature adptin f frmalized structures will result in frustratin, and cnstrained innvatin. The ability t develp, refine and use adaptive structures t supprt this initiative has been based n a slid fundatin f mutual trust, respect, shared decisin making, shared accuntability and shared respnsibility. The cmmitment t reflect, review and adapt structures t supprt functin is a significant cmmitment based n trust and a cllective leap f faith. Imprtance f nging assessment f strategic alignment Traditinally, the fcus n strategic alignment ccurs at the beginning f an initiative. Illustrating strategic alignment with ther pririties / plans already endrsed, such as the Healthy Minds, Healthy Peple-A 10-year Plan t Address Mental Health and Substance Use in BC and ther plicy directives is critically imprtant t establishing and maintaining cnsent t change. In recgnitin f the dynamic nature f system change nging re-assessment f strategic alignment is critical, bth t guard against untended negative impacts (e.g., initiatives wrking at crss purpses), and t ptimize links t strategic plicy directives. Imprtance f nging management f expectatins In recgnitin fr the dynamic nature f systems, this initiative was designed t be adaptive t change and includes a lng list f system fcus areas that align with existing prvincial and reginal pririty areas. It has been critical t recgnize the ptential fr verlad, prtect against scpe creep and cllectively manage expectatins. T supprt being mindful f scpe creep is an intentinal facilitated discussin at team meetings, mnitred and cllectively addressed by ur team. Imprtance f alignment within and acrss pririty areas Within and acrss Health Authrities there are a number f evidence-infrmed practices being strengthened (e.g., MI / Change Talk, Cre Additin Practice, Mindfulness, Client- Directed Outcme Infrmed practice, trauma infrmed practice) acrss a variety f settings and sectrs. The vlume f practice change targets and settings can be verwhelming and have negative impacts n an peratinal level. There is an intentinal fcus t reflect with leadership n hw different initiatives are aligned, t review and link curriculum t strengthen existing initiatives in an nging manner

24 Prject # / Interim Prcess Evaluatin Reprt 31 Mar 2011 BC s Drug Treatment Funding Prgram (DTFP) Systems Initiative: Strengthening Substance Abuse Treatment Systems Evidence-based System Change Using a Cmprehensive Change Management Mdel Recmmendatins What changes are recmmended t help ensure the prject reaches its expected utcmes? The recmmendatins frm this interim prcess evaluatin are summarized belw and highlight the areas fr cntinued fcus t supprt the nging success f this initiative t reach expected utcmes. Invlving f leaders in planning, and evaluatin n an nging basis is critical t develping and strengthening leadership supprt. Onging cllabratin with Health Canada DTFP administratrs t streamline and refine funding and reprting prcesses. Onging develpmental imprvements t manage expectatins, while balancing space t allw fr recgnitin f emergent utcmes requires n-the-fly decisinmaking and cntinual refinement f feedback lps and cmmunicatin channels. Onging reflective practice t review, dcument and adjust structures t supprt cllective planning will cntinue t strengthen alignment with strategic pririties and peratinal plans. Cntinuing t refine strategic alignment prcesses t cllabrate with Ministry f Health and link with BC s 10-year implementatin planning prcess. This can supprt identifying areas t link, leverage, and strengthen system tgether. Onging attentin and review f Addictin KE team and Health Authrity prject management methdlgies can minimize the divergence t linear prject management methdlgies, mrphing frm nn-linear prcesses what we d is shaped by hw we recrd and measure. Establishing pen decisin-making prcesses t evaluate and respnd t emergent needs cllectively t mitigate risks and increase pssibilities and within and acrss Health Authrities. Acknwledging that meaningful engagement and cmmunicatins requires time and cmmitment. Embedding messages within existing cmmunicatin channels and structures, and increasing use f infrmal infrmatin crridrs can streamline the prcess. Cntinuing t build capacity fr shared respnsibility in evaluatin acrss Health Authrities: clearly define rles and expectatins; refine, integrate and strengthen duble feedback lps and strategic alignments, and dcument real versus intended impacts and utcmes and why changes made. Cntinuing t enhance and refine knwledge management systems (including webbased) t supprt the grwth f the initiative. The evlutin f change management prcess jurnals as a repsitry fr narrative represents a cultural shift frm busy wrk t dcumenting the emergent stry f the initiative. Cntinuing t respect and hld scial spaces t prmte practice. Knwledge exchange takes place in scial interactins. Recgnizing scial spaces where clinicians thrive fsters meaning and sense making in practice. Traditinal knwledge disseminatin in health care cunters this apprach with hierarchical, dminant prcedural knwledge. Relying slely n a best practice mentality undermines the rle that sharing f tacit knwledge can play in strengthening care

25 APPENDIX A. MI Pre-wrkshp Appreciative Inquiry Questinnaire Nrthern Health August 23, 2010 Intrductin MOTIVIATIONAL INTERVIEWING WORKSHOPS 2010 NORTHERN HEALTH AUTHORITY Mental Health and Addictin Services As part f the Nrthern Health Authrity Strategic Gals and the Drug Treatment Funding Prgram (DTFP) prvincial pririties, we have an pprtunity t ffer Mtivatinal Interviewing Wrkshps facilitating knwledge exchange by using a cllabrative enquiry-based apprach. Fur wrkshps are being ffered t a ttal f 80 participants. The Nrthern Interir and the Nrth East will each hst ne wrkshp, and the Nrth West will hst tw wrkshps. The DTFP supprts crss-sectral initiatives; therefre seats are designated fr bth Cmmunity Agency clinicians and Nrthern Health clinicians. While the gal f the Mtivatinal Interviewing Wrkshp rllut is t prvide relevant and valid prfessinal develpment, the specific cllabrative enquiry-based apprach has been chsen t facilitate the achievement f the fllwing additinal bjectives: 1. Offer an pprtunity fr practitiners t acquire knwledge and skills supprting an evidence-based cunselling technique (Mtivatinal Interviewing) 2. Offer this wrkshp as an pprtunity t netwrk and t enhance linkages. 3. Strategically apply principles f Knwledge Exchange: using a cllabrative enquiry-based apprach as an aspect f building the Nrthern Health learning and innvatin culture 4. Evaluate the impact f these appraches fr: a) Strengthening ur cllective capacity t manage change, an essential cmpnent f cntinuusly imprving the quality f client service prvided, b) Supprting staff prfessinal develpment, and c) Enhancing staff engagement Backgrund What is Mtivatinal Interviewing? Nrthern Health s Mental Health and Addictin Services (MH&AS) acknwledges that Mtivatinal Interviewing is ne f the mst bradly recgnized and evidence-supprted cunselling appraches in the field. Althugh riginally develped in the addictins field, Mtivatinal Interviewing has gained prminence and applicability t a range f ther health issues, including mental health. In particular, MI is a client-centered, fcused apprach that avids labels, cnfrntatin, and specific interviewer-generated gals fr client behaviur change. What is Cllabrative Enquiry-Based Apprach? A cllabrative enquiry-based apprach is ne that strives t integrate the existing knwledge and skills, as well as the unique experiences, f each practitiner with the evidence based knwledge, in ways that help ensure that the learning is relevant and meaningful t each participant in their specific cntext. The cllabrative enquiry-based apprach will cntinue fllwing the MI wrkshp, t be determined by participants based n emerging needs. Fr example, a Cmmunity f Practice grup may be initiated t facilitate peer supprt, as wrkshp participants cntend with applying the new learning back in his/her agency and their cmmunity cntext