Learning Collaborative on High-Risk Drinking
ACHA Presentation
May 30th, 2012
ACHA presentation




Patricia Lanter, NCHIP
Ann Bracken, Dartmouth College
Lisa Currie, Northwestern University
Jason Kilmer, University of Washington
2
Objectives
 Describe the application of improvement methodology
to the college health environment
 Review the measurement strategy for the initiative –
both qualitative and quantitative
 Explain the approach that teams use to engage in and
report on cycles of process improvement
 Present teams’ experiences in participating in the
collaborative and the improvements that they have
made to date
 Faculty expert perspective on NCHIP
3
LEARNING COLLABORATIVE
What Is a Learning
Collaborative?
“The learning collaborative approach is an
adoption and improvement model that is
focused on spreading and adapting best practices
across multiple settings and creating changes
within organizations that promote the delivery of
effective practices.”
Adapted from Institute for Health Care Improvement and National Center for Child Traumatic Stress
4
NCHIP
MISSION
 The Learning Collaborative on High-Risk Drinking
will improve the health of the college student
population using proven, evidence-based
practices.
 The objective of this Learning Collaborative is to
work together to effect measurable change in
reducing the rate of high-risk drinking at
participant institutions, as well as the harms that
result from this behavior.
5
PUBLIC HEALTH APPROACH
Host - Individual
Agent - Alcohol
Environment – Campus &
Community
6
COLLABORATIVE COMPOSITION
7
LEARNING COLLABORATIVE EXPERT FACULTY
FACULTY EXPERTS
•
•
•
•
•
•
•
•
•
JASON KILMER, PhD - University of Washington
DOLORES CIMINI, PhD – University at Albany, SUNY
MICHAEL FLEMING, MD – Northwestern University
LINDA MAJOR, - University of Nebraska, Lincoln
BOB SALTZ, PhD – Pacific Institute for Research and
Evaluation
TRACI TOOMEY, PhD – University of Minnesota
TOM WORKMAN, PhD – Baylor College of Medicine
TOM CASADY, University of Nebraska, Lincoln
LLOYD PROVOST, Associates in Process Improvement
8
Model for Collaborative on High Risk Drinking
Participants (32 Colleges)
Reduce High
Risk Drinking
and Related
Harms
Start Campus Improvement Team
Started with 5 – 7 members each
Prework
Develop
Framework
Faculty
Meeting
February,
2011
P
P
LS 1
June 2011
Individual
D
A
S
AP1
LS2
Jan 2012
Environmt
P
D
A
S
AP2
LS 3
D
A
July 2012
System
S
AP3
Summative
Congress
July 2013
Supports: Faculty Experts NCHIP Staff
LS – Learning Session
AP – Action Period
PDSA – Plan, Do, Study, Act
Email (list-serve) Small Group Calls
Monthly All Collaborative Calls
Monthly Team Reports
9
BTS
Engine for
Improvement
Model for Improvement
What are we trying to
accomplish?
Aim
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
The Model encourages
you to act your way
into learning, rather
than thinking your way
into acting
Act
Act
Plan
Plan
Study
Study
Do
Do
Lloyd Provost, API
Measures
Ideas
From: The Improvement Guide, Associates
in Process Improvement
10
MULTI-TIERED MEASUREMENT STRATEGY
OUTCOME Measures
Capture results related to the project aim – high
risk drinking and related harms [universal]
•
•
High-risk Drinking Rate
Drinking-related Harms Rate PROCESS Measures
“Within the last month have you experienced the following as a consequence of your drinking?”
1.
2.
3.
4.
5.
6.
7.
8.
9.
Capture quantitative and qualitative data about
Did something you later regretted
Forgot where you were or what you
did impact of a particular change or process
the
Got in trouble with the police
affecting drinking outcomes
Had sex with someone without giving your consent
Had sex with someone without them giving consent [institution specific]
Had unprotected sex
Physically injured yourself
Physically injured another person
Seriously considered suicide
 Measures that capture change in key
processes affecting drinking CONTEXT
outcomes Measures
• Prevention
Capture
information about the environment in
• Medical
Care Encounter
Rate
which the improvement work is occurring
• Risk
Identification
• Program
Law
Encounter
Rate
has the collaborative
been successful?
[institution specific]
• AcuteEvaluation:
Toxicity
• Brief Intervention
12
RUN CHARTS – HIGH-RISK DRINKING RATES
COMMON SET OF MEASURES -- COLLECTIVE AND TEAM ADVANTAGES
 Teams report and learn from one another
 Teams monitor progress (frequently and regularly) as
they ‘perturb’ the system with tests of change and
implementation of evidence-based initiatives
 Can compare year to year for events that are not
ongoing (orientation, homecoming etc)
A
B
70.00
70.00
60.00
60.00
C
70.00
60.00
median=47.70
median=56.64
50.00
50.00
50.00
40.00
40.00
40.00
30.00
30.00
30.00
20.00
20.00
20.00
10.00
10.00
10.00
0.00
0.00
median=26.62
8 - 2011
9 - 2011
10 - 2011
11 - 2011
0.00
8 - 2011
9 - 2011
10 - 2011
11 - 2011
9 - 2011
10 - 2011
11 - 2011
12 - 2011
13
SURVEY FREQUENCY
CONTEXT
14
CAMPUS ALCOHOL SYSTEM INITIATIVES
238 Ongoing PDSAs
Intervention
Policy
Enforcement
Individual
Environment
Screening
Treatment
Policy Education
Community/State
15
SYSTEMS APPROACH
PLANTING THE SEEDS…
 Address the entire student population
 Address multiple areas and events
 Evidence-based strategies linked together in
meaningful ways to create maximum
effectiveness
 Implement each strategy fully; measure and
evaluate to continue making improvements
 Work together across campus departments
and with the community
16
LESSONS LEARNED
SUCCESSES
•
•
•
•
•
32 institutions committed to participate
A common focus on student health and well-being is clear
Local / faculty expertise has been remarkable
Past and current work by teams is impressive
Schools are starting to see changes in drinking on their
campuses
CHALLENGES
• Range of improvement knowledge among teams
• Varied contexts within the collaborative
• Range of buy in from teams / leadership
• Learning how to best facilitate collaboration
• Harnessing local team expertise
• Measuring monthly can be challenging to implement
17
DARTMOUTH COLLEGE HEALTH IMPROVEMENT PROGRAM
(DCHIP)
ANN BRACKEN MD PHD
MAY 31, 2012
PRESENTATION AGENDA
 MEET DCHIP CAMPUS IMPROVEMENT TEAM
 DCHIP AIMS AND GOALS
 SELECTED CAMPUS EFFORTS ADDRESSING HIGH RISK DRINKING
19
DARTMOUTH COLLEGE HEALTH IMPROVEMENT PROJECT
(DCHIP) CAMPUS IMPROVEMENT TEAM
Individual
Interventions
Started June
2011
Campus
Environment
Campus Systems
NOW
Starting July 2012
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DCHIP GOALS
FOR 2011-2012 ACADEMIC YEAR
 Screen 95% of incoming class (prior to matriculation) for
alcohol abuse and provide feedback
 Screen 90% of all primary care clinical encounters at Dick’s
House
 100% of students with an alcohol policy violation will
complete the BASICS I program within 2 weeks of incident
 Increase use of Good Sam (medical amnesty) to over 75%
of all alcohol-related interactions with Dept. of Safety &
Security
 Conduct test cycles on 2 innovative strategies for
addressing high-risk pre-gaming in the residence halls each
term
21
ASPIRATIONAL AIM
WITHIN 3 YEARS
 Eliminate Dartmouth-Hitchcock Medical
Center Emergency Department visits for
BAC >0.25, by eradicating this level of
intoxication from our campus community.
22
DCHIP’S INDIVIDUAL INTERVENTIONS ALONG THE SPECTRUM
PreMatriculation
Programs
Referral to DHMC
Intensive
Outpatient Tx
Program
Recovery
Support
Primary Care
Screening
BASICS for
students with an
alcohol incident
23
MEASURE, MEASURE, MEASURE
 4 NCHIP Measures




High risk drinking: 5 or more drinks in a sitting
Alcohol Related Harms
Monthly Medical Encounter Rate
Monthly Law Enforcement Encounter Rate
Blood Alcohol Content (BAC) for medical encounters
Process measures around delivery of interventions
Assessment of high-risk environments at Dartmouth
24
PRIMARY CARE SCREENING PDSA
1. Started with small PDSA in
July 2011 and modified our
sign-in slip
2. And modified our EMR
template for encounter
notes
25
VERY BRIEF INTERVENTION TOOL
Developed a very simple
NIH alcohol use message
for providers to give to
students who say “yes” to
high-risk drinking
One card- back and front
*Designed by our AOD
coordinator, Brian
Bowden
26
HOW ARE WE DOING WITH PRIMARY CARE SCREENING?
• Reaching our screening goal of 90%
• Working on improving delivery of BMI
27
BASICS (Brief Alcohol Screening and Intervention of College Students)
How is BASICS implemented at Dartmouth?
 Targeted toward students who have an alcohol
incident
 First - online assessment
 Next- a motivational interview to “meet students
where they are” with their alcohol use and help them
to make informed decisions about the impact of their
alcohol consumption
 ½ hour BMI session with our AOD coordinator
 GOAL- all students with incident get BMI within 2
weeks of incident
28
HOW ARE WE DOING WITH OUR BASICS GOAL?
•
•
•
•
We have not achieved the stated goal, although we are improving
Online completion ~ 90% within 3 weeks
BMI completion- 56% within 2 weeks, -69% within 3 weeks
96% of the referred students will complete BMI by > 4 weeks
29
BASICS AT DARTMOUTH OVER TIME:
UPS AND DOWNS OF ACADEMIC SCHEDULE
Tracking monthly measures for NCHIP demonstrates the realities
of the Dartmouth academic calendar and the D-Plan
30
BASICS: EFFECTIVENESS AT DARTMOUTH
 We used students’ responses to the on-line BASICS
assessment at baseline and 90 days to investigate
effectiveness of the BASICS program
 BASICS data were downloaded from the BASICS
web-site by OIR
 The final dataset consisted of 94 students with
complete data from Time 1 and Time 2
31
A PROMISING STORY The impact of BASICS at 90 days
We found a significant reduction in the:
 Quantity of alcohol consumed
 Number of days a student drank
 Number of hours a student drank
* Our AOD Coordinator has a fabulous “effect size”
32
USING DATA TO INFORM CHANGE IN THE ENVIRONMENT
The NCHIP Collaborative has helped us to :
 Reduce the silo effect
 Facilitate data collection and sharing
 Look at problems and solutions from all sides
 Use the small tests of change model to move pilots
forward
On the horizon:
 Environmental strategies- moving stated and lived policy
closer, new residence hall intervention
 BASICS with all athletes- Dartmouth Peak Program
 Studying our bystander interventions- Green Team and
Bringing in the Bystander
33
34
Northwestern University
35
NORTHWESTERN’S GLOBAL AIM

Reduce high risk drinking and harms associated with drinking:
a. Decrease the binge drinking rate by 10% every year for the next three years
b. Decrease the rate of self-reported harms, both frequency and severity
c. Decrease the rate of harms to others, both frequency and severity

Increase positive behaviors associated with alcohol:
a. Increase the number and frequency of self-protective behaviors
b. Increase the number and frequency of helping behaviors toward others

Increase participation in timely and appropriate interventions among students
who have been involved in an alcohol-related incident.
Northwestern University
36
BASICS Timeliness PDSA (Individual Level)
SPECIFIC AIM
 Increase timeliness from incident to BASICS intervention.
 Increase consistency of referrals to the appropriate
intervention.
 Increase referring staff’s comfort level in assigning an
appropriate intervention.
Northwestern University
Gathered
input from
referring staff
in order to
revise referral
protocol.
Developed
referral form
for referring
staff to give to
students.
Trained
referring staff
on referral
protocol.
Referral form
revised further
based on staff
input.
Emphasized
consistency
and
accountability.
Implemented
revised referral
form.
Students
given clear
instructions
and messages.
Referring Staff are from: Student Conduct, Residential Life, Athletics.
Northwestern University
38
What did you try?
What did you
measure?
What were your
findings/results?
What changes did
you make to your
process/system?
Implemented training
for referring staff on
referral protocol.
Staff confidence and
consistency in referring
to BASICS.
Number of referrals
have increased;
consistency and
confidence seems to
have increased.
• Clarified referral
protocol.
• Provided training for
referring staff.
Implemented use of
a referral form.
Timeliness:
# of days for
• Incident to Referral
• Referral to Contact
• Incident to
Intervention
Significant decreases in
all three areas.
• Implemented referral
form.
• Emphasized need for
consistency and
accountability with
referring staff.
Referring staff and
intervention staff gave
students consistent
messages.
Student cooperation
with scheduling
process, timeliness.
Appears to have
contributed to
improvements in
timeliness.
• Ensured referring and
intervention staff
were all saying “must”
not “should”.
Northwestern University
39
40
35
30
# of Days
25
20
Feb/Mar/Apr/May
Sept/Oct
15
10
5
0
Incident to
Incident
to Letter
Referral
Referral to
Incident to
LetterContact
to Contact Incident
to Session
Intervention
1
Northwestern University
Average Days from Incident to First BASICS Session
45.0
40.0
35.0
Days
30.0
25.0
20.0
15.0
10.0
5.0
0.0
2011 Pre-Implementation
Fall Quarter
Time Frame
Northwestern University
Winter Quarter
 Simple changes can have a big impact.
 Clear referral protocol
 Referring staff training
 Clear referral form
 Consistent messaging
 Clarify the roles of the referring staff and the intervention staff
 Have enough providers trained before you begin!
 Be consistent in messaging and in holding students accountable for
completion.
Northwestern University
42
NU Nights Implementation (Environment Level)
SPECIFIC AIMS
 Offer late night social events each Friday, starting at 10pm
or later, as a social alternative to off-campus parties.
 Should contribute to the reduction in high risk
alcohol consumption, as stated in our global aims.
 Collect participation, satisfaction and impact data to
support continued funding from NU and additional
funding from Associated Student Government (ASG).
Northwestern University
NU Nights Implementation Timeline
June 2011
Summer 2011
Fall 2011
Winter 2012
Spring 2012
Kirstin
Nordhaus ‘12,
NU Student
Representative
at Learning
Session 1,
proposed
creation of
Late Night
Social Events
Program.
Developed
proposal for
NU Nights for
the incoming
VP of Student
Affairs.
Recruited
students for
organization
which would
run NU Nights.
NU Nights
student
organization
starts planning
events, based
on student
surveys and
freshman
interests
collected via
AlcoholEdu for
College in
summer 2011.
Survey card
developed to
collect data at
events.
Associated
Student
Government
passed a
resolution
expressing
support for
their proposal.
VPSA
approved
proposal;
provided seed
money and a
GA position.
Northwestern University
GA hired by
Center for
Student
Involvement
to support
event
planning.
First NU Nights
events held in
April, in
collaboration
with other
student
organizations
and supported
by social
media efforts.
1. “Chicago”
showing with
dance lessons.
2. Bingo Night.
NU Nights Survey Card
1.
2.
3.
4.
5.
Class Year
On-Campus or Off-Campus Living status
What would you have most likely done tonight if you didn’t attend
this event? Choose 1 answer.
• Stayed home
• Studied
• Gone to a bar
• Attended a party off-campus
• Attended a party on-campus
• Attended a Greek life party
• Attended another social event
• Other (please explain):
Suggestions for future events
Email for NU Nights Listserv
Northwestern University
What would you have done tonight
if you had not attended this event?
n = 179 (from two events)
30%
25%
Percent
20%
15%
10%
5%
0%
Hung out at
home
Studied
Gone to bar or Gone to a party Attended a
club
cultural event
Other
N/A
Activity
Northwestern University
46
What would you have done tonight? - By Housing Type
n = 179 (from two events)
45%
40%
Percent
35%
30%
On-Campus
25%
Off-Campus
20%
N/A
15%
10%
5%
0%
Hung out at
home
Studied
Gone to bar
or club
Gone to a
party
Activity
Attended a
cultural
event
Northwestern University
Other
N/A
47
Summary
The NCHIP Collaborative has helped us to :
 Implement changes we had been considering
but had not acted upon
 Look critically for the small changes that could
add up to big changes
 Enhance partnerships
 Leverage resources for program implementation
 Push for the revitalization of our AOD Coalition
Challenges
 VPSA Transition created an accountability vacuum
Northwestern University
Observations about the NCHIP Experience
Why a Learning Collaborative is Awesome
• Schools acknowledge they
have their own unique
challenges and cultures,
but…
• There’s every opportunity
to learn from other
schools given some really
significant similarities
49
Observations about the NCHIP Experience
Why a Learning Collaborative is Awesome
• Data are being collected on
campus like never before
• How and what we measure
can tell a very different story
• Some of the data over time
reflect changes in thinking by
members of the collaborative
Observations about the NCHIP Experience
Why a Learning Collaborative is Awesome
• Key stakeholders get on
the same page.
• Schools are involving
students, which impacts
buy-in and brings an
important perspective to
the table.
Observations about the NCHIP Experience
Why a Learning Collaborative is Awesome
• Members of the collaborative
learn about best practices for
impacting individuals, the
environment, and systems.
• Through the collaborative,
members can identify strategies
for overcoming barriers and
affecting change on campus
Observations about the NCHIP Experience
Lessons Learned and Future Directions
• No need to reinvent the wheel
• We can make adjustments to wheels that are in place
• The PDSA cycles allow for strategic shifts & changes &
to learn from what worked or didn’t work as well
• With the fall comes new students, who will be greeted
with new programs & policies enacted this year
• Importance of sustaining & extending this effort
• Role of emerging technology
THANK YOU!