Learning to improve the mental health care system
There are many gaps in our mental health system. Trying to defend and manage gaps in quality and delivery can feel overwhelming for psychiatric clinicians and lead to feelings of helplessness.
Psychiatric clinicians learn to care for patients one at a time. However, most are not trained to think about their “system” or to apply scientific thinking to improving systems. They try to keep up with their ever-increasing workloads and compensate for systems shortcomings by working harder, which comes at a personal cost and contributes to an epidemic of burnout. Unfortunately, this does not always lead to better systems. Advances such as electronic medical records and new therapies come with unique challenges. Some solutions, such as extensive documentation or an overreliance on auditing to ensure quality, create additional burdens. It’s unclear what some experts think about 30-50% of all healthcare activity is wasteful.1
Twenty years ago, the Accreditation Council for Higher Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly identified medical resident competencies to include “learning and improvement based on Practice (PBLI)” and “Systems Based Practice (SBP).2 PBLI included a systematic analysis of practices and the implementation of changes to improve them. SBP understood working in interprofessional teams to improve quality and safety and identify system errors.
So how can we best prepare all healthcare workers to “spot and fix” wasteful processes, think and act like problem solvers, and design better systems?
Fortunately, a vast knowledge base on the science of enhancement already exists. Improvement science has been widely used in non-healthcare settings like manufacturing and aviation industries and has also been adopted by pioneers of healthcare quality and safety outside of behavioral health. .3.4
My own entry into this world of improvement science happened while trying to solve quality and safety issues in my organization. I came across a brilliant article titled “Fixing Healthcare from the Inside Out, Today”.5 The author asked, “How can healthcare professionals ensure that the quality of their service matches their knowledge and aspirations? This article got me thinking about the application of improvement science to psychiatry, and it led me to learn about lean methodology, an approach to improvement that matured within the builder Toyota car.
Systems engineering, at its core, is a field that uses the principles of systems thinking to design, manage, and optimize complex healthcare systems. During my journey, I was introduced to a brilliant systems engineer, Antonio DePaolo, who became an inspiring collaborator and the co-author of our book together on the subject.
We co-designed a course called “Lean Problem Solving” in our organization. Participants were encouraged to bring any safety, quality, delivery, cost, or morale issues to the course, and they would learn how to apply the improvement principles to their issue. This course, along with other improvement activities, has gradually changed the culture of our organization.
We began to address chronic and complex clinical issues in our system, such as aggression towards others, unnecessary antipsychotics in patients with dementia, and transitions of care for patients with severe concurrent disorders. We have also been able to improve operational challenges such as access to care, staffing shortages and costs of care while improving communication with others.
Here is an example of continuous improvement from an acute care unit that describes the process of improving care transitions for patients moving from an inpatient level of care to outpatient care. This busy inpatient unit could have between 1 and 8 discharges per day (with as many patients admitted that evening). Intensive release days were not only busy and stressful, but could also be fraught with delays, errors of omission and commission, and dissatisfied family members, staff, and patients.
When we began to observe and study the discharge process, we realized that one of the factors leading to delays was that patients’ belongings were scattered in several places in a disorganized manner. Gathering and organizing everything the patient would bring home from discharge could sometimes take 1-2 hours of a staff member’s time. Social workers would ask a van driver or family member to come at a certain time, but they had no idea how long it would take to retrieve a patient’s belongings (from the unit, security and pharmacy). This process resulted in waiting, frustration and errors, and such errors resulted in callbacks for missing scripts, forgotten belongings or lost valuables.
This observation alone led to multiple improvements: an organized business room, a discharge checklist, and the decision to have everything ready for a discharged patient the day before discharge. Today, we can be sure that if patients leave the unit, they will reliably receive all their belongings and everything they need on time, with no one having to even wait. one minute.
Continuous improvement is a cyclical iterative process. The team then decided to improve the time it takes to complete release summaries, with the goal of having all summaries completed within 24 hours of release. Then the team used the discharge checklist to ensure that every patient who needed nicotine replacement therapy, naloxone or their inhalers would reliably receive them. Once the team learned this way of working, each new issue became an opportunity to apply this improvement toolkit. Continuous improvement has become a means of sustaining improvements and creating empowered and engaged team members who strive for improved quality and results.
Anything that has worked in our complex environment is certainly applicable to any mental health care environment.
Our book sets out the need for such an approach; introduces basic improvement principles and developmental steps for acquiring knowledge and improvement skills; and lists a systematic method of solving complex problems. It also discusses the support needed to create and sustain such a culture of learning and improvement.
In 1998, Don Berwick, MD, a leader in health care improvement, wrote6:
“We believe that the prognosis for the health system is good if physicians actively contribute to improving the system as a whole. If we’re wrong, our agenda at least gives professionals something nicer to do than complain. More importantly, if we are correct in asserting that the seeds of fundamental improvement in health care systems are within the reach of physicians, then physicians can best wield their influence by recognizing the problems that need to be addressed and then doing everything in their power to ensure that the solutions they help develop are technically sound, ethically sound and effective.
Our book is an introduction to applying improvement methods to any mental health system for anyone interested in such an endeavor. It can generate hope and invigorate and empower clinicians to take incremental steps toward a state of continuous improvement and then use their scientific thinking skills to care for diseased individuals and systems that need their help.
Dr Khushalani is co-author of Transforming Mental Health Care: Applying Performance Improvement Methods to Mental Health Care.
1. Health finance staff. The health care debate is fatally flawed. Health financing. 2009. Accessed December 20, 2021. https://www.healthcarefinancenews.com/news/healthcare-debate-fatally-flawed
2. Ziegelstein RC, Fiebach NH. “The Mirror” and “The Village”: A New Method for Teaching Practice-Based Learning and Improvement and Systems-Based Practice. AcadMed. 2004;79(1):83-88.
3. Kenney C. Transforming Healthcare: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. CRC Press; 2021.
4. Toussaint J, Gerard R. On the mend: revolutionizing healthcare to save lives and transform the industry. Lean Enterprise Institute Inc; 2010.
5. Spear S. Fixing health care from within, today. harvard business review. 2005. Accessed December 20, 2021. https://hbr.org/2005/09/fixing-health-care-from-the-inside-today
6. Berwick DM, Nolan TW. Physicians as Leaders in Improving Health Care: A New Series in Annals of Internal Medicine. Ann Medical Intern. 1998;128(4):289-292.