Transforming Mental Health Care : Applying Performance Improvement Methods to Mental Health Care book cover
1st Edition

Transforming Mental Health Care
Applying Performance Improvement Methods to Mental Health Care

  • Available for pre-order. Item will ship after August 27, 2021
ISBN 9781032070384
August 27, 2021 Forthcoming by Productivity Press
184 Pages 44 B/W Illustrations

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Book Description

Each of us working in the mental health system has grappled with the inadequacies and shortcomings of our current system. We have been reminded time and time again that our system is fraught with quality and safety problems that leave patients and their families at the receiving end of sub-standard care and dissatisfied. There are a wide range of problems from access-to-care issues to errors to complications stemming from poor care. Even modern advancements such as EMRs or newer medications such as atypical antipsychotics have created their own unique challenges as they are integrated into our system. The system as a whole requires a closer examination with regards to whether or not it flows seamlessly, and whether or not it provides the right quality at the right time and at the right cost, because our patients and their families deserve nothing less. Our country is on an unsustainable path as our health care expenditure keeps growing, and it is projected to reach 20% of our GDP by 2020. Mental health professionals have gotten used to doing whatever it takes to provide each of our patients with everything they need in order to keep them healthy. In doing so, we have not been able to view the big picture of how our system operates. We do not have a clear idea about which of the steps in our processes add value and which are just wasteful, in that they do not add any value to the patient or their experience of care. Workarounds, excessive documentation, and over-reliance on auditing in order to ensure quality have become an accepted reality in our highly-regulated industry. Nevertheless, it is a widely accepted fact that a conservative 30-50% of everything we do does not add value to the life of our patients.

If we are like spokes in a fast-spinning wheel, how can we observe the path along which we are travelling, to either make sense of it or to do something to change its path? Many of us are so busy seeing patients, documenting about the care we provide them, doing research, attending meetings or performing our administrative duties that we have very little time available to think of how we can improve our system. Even if we wanted to improve it (as required by AGGME’s and ABMS’s core competencies), most of us have not been taught the necessary performance improvement skill set which is so prevalent and widely used in other industries. It also might be hard to imagine for many how a methodology that emerged and evolved in the world of manufacturing can be an effective methodology when applied to mental health care. In conjunction with our collaborative work at Sheppard Pratt Health System, our mental health professionals have been working with a systems engineer to apply this extremely rich knowledge base of performance improvement methods in order to solve some of our most troubling and chronic problems as a mental health system. In doing so, we are seeing some very promising results in the first few years of our work.

This book is a primer to the performance improvement skill set as it is applied to unique problems in our field of mental health care, which takes into account the real challenges that are relevant to our field, is a highly needed gap in the literature. The Institute of Medicine laid out six aims for improvement in response to the scathing 2001 report entitled, Crossing the Quality Chasm. It proposed a vision - an imperative call to make our system more effective, safe, patient-centered, timely, efficient and equitable. In 2008, the Institute for Healthcare Improvement articulated its bold "Triple Aim" initiative. It urged all of us to try to redesign each of our microsystems with their three aims - to improve the patient’s experience of care to include both quality and satisfaction, to improve the health of populations, and finally to reduce the per capita cost of health care. This book provides the steps toward achieving these aims.

Table of Contents



Acknowledgments from Sunil Khushalani, MD

Acknowledgments from Antonio DePaolo, PhD

Foreword by Steven S. Sharfstein, MD


About the Authors



I. A focus on the mental health 'system' of care

II. A new paradigm for the mental health system

III. The Burden of Mental Illness

IV. The connection between Behavioral Health and Overall Health

V. Current State: Access to care (and its impact on society)

A. Boarding in the Emergency Room

B. Homelessness

C. Mental Illness in Jails

VI. Current State: Safety

VII. Current State: Quality

A. Underuse

B. Overuse

C. Misuse

VIII. Current State: Delivery of care (Fragmentation of care)

IX. Current State: Cost/Waste

X. Current State: Morale/ Workforce challenges

XI. A call for a better system

A. Crossing the quality chasm

B. The Quadruple Aim

XII. Forces of Change

A. Moving away from the model of a 'Cottage Industry'

B. Technology

C. The voice of the patient

XIII. Learning from our context (Groundbreaking Improvement Efforts in Medicine)

XIV. The Need to Reinvigorate and Redesign Mental Health Care




I. Value

A. Value and the Patient

B. Value and the Family

C. Value and the Organization

D. Value and the Provider

E. Value and the Payer

F. Value and the Government

G. Value and the Continuum of Care

H. Value Added, Value Enabled, and Waste

II. Waste

A. Eight forms of waste

1. Overproduction

2. Defects

3. Waiting

4. Transportation

5. Motion

6. Extra Processing

7. Inventory

8. Non-Utilized Talent

B. Waste Walks

C. Constraint Management

D. Waste in Psychiatry

E. Within Treatment Waste

F. Between treatment waste

G. The Cost of Waste




I. A newer approach to work

II. The development of an improver

A. Developing Awareness

B. Fostering an improvement mindset

C. Acquiring performance improvement knowledge

1. Appreciation for a system:

2. Knowledge about variation:

3. Theory of knowledge:

4. Psychology:

D. Applying and practicing improvement skills

E. Developing performance improvement skills into routine habits

III. Preparing the medical professional to learn performance improvement skills




I. Plan-do-check-act cycle

II. Standard Work

III. PDCA vs Research

IV. A3 Thinking

A. Plan

1. Project Title

2. Business Case

3. Project Y

4. Scope

5. Project Management

6. Measure

7. Observation

8. Process Map

9. Sub-Process Map

10. Time & Motion Study

11. Spaghetti Diagrams

12. Measurement for improvement

13. Measurement Tips

14. Visual representation of data

15. Goal Setting

16. Root Cause Analysis

17. Cause effect Diagram

18. 5-Why's

B. Do

1. Brainstorming

2. Try-storming

3. Pilot Study

4. Change Management

5. Action Plans

C. Check

D. Act

1. Standard Work

2. Monitor and Response Plan

3. Cascade Plan

IV. PDCA and Kata

Improvement Kata questions include:




I. Leadership and Culture

A. Building Trust

B. Developing Strong Interpersonal Relationships

C. Fostering Teamwork

D. Giving Appropriate and Timely Feedback

II. High-performing leadership

A. Toxic cultures

1. An Aggressive or Hostile Culture:

2. An Analysis-Paralysis Culture:

3. The Fire-fighting Culture:

B. High-performing leadership: the case of ‘high-reliability organizations

1. Preoccupation with failure

2. Reluctance to simplify

3. Sensitivity to operations

4. Commitment to resilience

5. Deference to expertise

III. Leadership and motivation

IV. Getting started

V. A long term-investment

VI. An uphill task


Afterword by Harsh K. Trivedi, MD, MBA

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Sunil Khushalani

Medical Director, Adult Service Line at Sheppard Pratt Health System

He is a Clinical Assistant Professor in the Department of Psychiatry at the University Of Maryland School Of Medicine. He got his medical degree from Mumbai University in India. He finished a psychiatric residency from the Department of Psychiatry at New York University Medical Center/Bellevue Hospital program. He is Board Certified in Psychiatry by the American Board of Psychiatry and Neurology. He is also a Diplomate of the American Board of Addiction Medicine. He also directs an inpatient unit and a partial hospitalization program at the Sheppard Pratt Health System. He has been a lean facilitator at Sheppard Pratt since 2009. He is the co-creator of a course at Sheppard Pratt on ‘Lean Problem Solving’ which has been offered to participants on the topic of Lean Performance Improvement Methodology, as they apply this learning to solve problems encountered within the Sheppard Pratt Health System since 2013. He has presented several workshops and lectures on applying Lean Methodology to problems encountered in mental health care settings. Since 2014, he has been a member of the patient safety workgroup of the APA council on quality care. In 2016, he was voted as a ‘Top Doctor’ by Castle Connolly and the Baltimore Magazine.

Antonio DePaolo, PhD

Director of Lean Transformation

Sheppard Pratt Health System

Antonio DePaolo, PhD is an accomplished Executive with 20 years of experience in operations, performance improvement, strategy deployment and corporate development. His leadership philosophy is a blend of situational and servant leadership to fully engage staff in executing the value proposition of an organization. He provides a solid foundation of customer focus to advance organizational alignment, communication, and collaboration thus achieving significant organizational improvement. He has a proven track record of leading cross functional resources and delivering on corporate objectives.

Mr. DePaolo is currently the Director of Lean Transformation at Sheppard Pratt Health System which consistently recognized as one of the nation's top mental health systems, offering psychiatric care for mental and behavioral issues. He holds a PhD in Applied Management and Decision Sciences from Walden University and a Masters of Engineering, Industrial Engineering from the University of Buffalo. He’s an experienced trainer in the principles of Lean manufacturing, Ergonomics and Change Management to name a few.