Arlington - Med Pass Process (reduce diversion)
Aim Statement:Decrease med pass from four hours (plus) to three hours (max) by 4/1/24
Location:Arlington Detention Facility
Start Date:01/16/2024
End Date:04/01/2024
Name of coalition or program:Arlington Detention Facility
What customer population are you trying to help?Individuals in need of MOUD
Executive Sponsor:Captain Souder
Change Leader:Aubrey Graham
Change Team:
Jessica Gasque
Bilal Nazam
Patricia Soukup
Lieutenant Flowers
How will you collect data to measure the impact of change? Who will collect it?
Jessica and Aubrey currently collect data on medication.
Create a distribution list to inform team how long med pass took each day and issues that occurred. Aubrey will compile this information for the change duration of 2/5- 2/16 to report out.
What is the expected impact of this change project? How will the Executive Sponsor know?
Reduction in med pass hours will assist with staffing as well as safety (diversion). Could free up staff to provide other programming.
PDSA
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PDSA Cycle #
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1
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Cycle Begin Date
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02/05/2024
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Cycle End Date
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02/16/2024
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What is the change to be tested?
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Start time and location of Suboxone pass.
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PLAN
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-Begin suboxone pass @ 8:00am
-Begin suboxone pass in 7B to ensure everyone is dosed prior to beginning programming.
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PDSA Cycle #
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2
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Cycle Begin Date
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03/04/2024
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Cycle End Date
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03/25/2024
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What is the change to be tested?
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Reduction in misuse/diversion/better documentation of misuse/diversion
*There is no data currently being collected regarding number of or frequency of misuse/diversion. Therefore there will be no past data to compare to the new data collected.*
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PLAN
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-Captains will complete suboxone pass to observe process
-Captains will read the same script regarding med administration protocol
-Captains will send any observations of misuse or potential diversion to the distribution list for dhs and medical to provide counseling
-A category will be added to the drop down in CJRMS to track any incidents of misuse/diversion
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Project Outcomes
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1. What was the project end date? (e.g., when you stopped making changes)
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2/16/2024
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2. What did you learn? (e.g., what were some lessons learned? Any unexpected outcomes from your change efforts?)
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We learned it was helpful to start earlier to complete mat pass with the clients before they attend programs, court, and work.
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3. What was the financial impact of this change project? (e.g., Increased volunteer hours; Reduced staff time; etc.)
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Reduced staffing time to complete med pass which freed up staff to help in other areas of the facility. Assists in decreased need for overtime staff, etc..
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Sustainability Plan
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A. Who is the sustain leader?
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Captain Souder
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B. What changes do you want to sustain?
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We will continue to begin MAT pass between 8 & 830 AM.
We will continue to begin MAT pass in a specific housing unit that contains the most programs and workforce inmates.
We will continue to track data and share information on spreadsheet.
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C. What sustain steps are being taken to ensure that the changes stay in place and that it is not possible to revert back to the old way of doing things?
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We will continue to track date on the mat pass spreadsheet.
We will continue to send daily emails with the information to compile data.
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D. What is the target sustain measure? (i.e., if data drops below this point, the Change Team will intervene to get things back on track.)
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If we go back to mat pass taking 4-5 hours, we would need to re-evaluate if we are following the changes, we made that were making a difference.
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E. What system is in place to effectively monitor the sustain measure?
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daily emails
spreadsheet
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