1st Edition
Transforming Mental Healthcare Applying Performance Improvement Methods to Mental Healthcare
One in five U.S. adults experiences a mental illness within a given year. With more than 550,000 people working to support this underserved community, the mental healthcare system has grappled with inadequacies and shortcomings in safety, quality, and care delivery. There is a wide range of problems, from access-to-care issues and errors, to complications stemming from poor care. Our country is also on an unsustainable path as our healthcare expenditure keeps growing. To add to all of this, we are facing a rampant epidemic of burnout among healthcare workers. Modern advancements introduced with many promises—such as electronic medical records, newer medications, or advanced treatments—have created unique challenges when ushered into a highly regulated healthcare system.
What does it take to provide patients with everything they need—the right quality of care, at the right time, and at the right cost—to keep them healthy? Which process steps add value? Which steps are wasteful? A widely accepted fact is that a conservative 30-50% of every step in the mental healthcare process does not help patients feel better or stay better. When considering delays in care, workarounds, excessive documentation, and an overuse of auditing, the care system has moved highly skilled clinicians away from providing value, as administrative tasks continue to encroach on their time. There is a clear need to rethink and redesign the system of care.
This book is a primer for understanding the current state of the mental health system and the performance improvement skills and leadership acumen needed to address existing challenges. Sheppard Pratt, the award-winning, leading institution for mental healthcare in America, provided the focus on mental healthcare and became the laboratory for this body of work over the course of eight years. It hired a seasoned systems thinker with improvement expertise to work with mental health professionals and solve some of their most complex and chronic problems.
The book is a result of the collaboration between a practicing psychiatrist in a leadership role and the systems engineer. Working together, they demonstrate how to think about redesigning care and redefining the nature of work to enhance value for both the people served and the healthcare workforce. They crafted a multi-pronged approach towards culture change at Sheppard Pratt, including implementing a course on "Learning to Improve," which introduced staff to a performance improvement methodology. There are several vignettes interwoven throughout the book that describe the complexities and constraints of the system. Solving some of these challenges creates a new paradigm of work while minimizing waste and enhancing value.
TABLE OF CONTENTS
Preface
Acknowledgments from Sunil Khushalani, MD
Acknowledgments from Antonio DePaolo, PhD
Foreword by Steven S. Sharfstein, MD
Foreword by Steven J. Spear, DBA, MS MS, MIT Senior Lecturer and author of The High Velocity Edge
Introduction
About the Authors
SECTION ONE
THE NEED FOR PERFORMANCE IMPROVEMENT METHODS IN MENTAL HEALTH CARE
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
REFERENCES
SECTION TWO
VALUE AND WASTE IN PSYCHIATRY
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
REFERENCES
SECTION THREE
DEVELOPING THE HEALTHCARE WORKFORCE FOR PERFORMANCE IMPROVEMENT
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
REFERENCES
SECTION FOUR
IMPROVEMENT METHODS FOR MENTAL HEALTH ORGANIZATIONS
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:
REFERENCES
SECTION FIVE
LEADING A NEW KIND OF WORKFORCE
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
REFERENCES
Afterword by Harsh K. Trivedi, MD, MBA
Biography
Sunil Khushalani, MD, is a psychiatrist who specializes in Addiction Psychiatry. He is passionate about learning improvement science and integrating it into the field of mental health and addictions. This book is his first on the subject of improvement science as applied to mental health. For the last decade, he worked on teaching and integrating these ideas and methods at Sheppard Pratt.
He obtained his MBBS degree from Seth Gordhandas Sunderdas Medical College/ King Edward Memorial Hospital in Mumbai, India. He then completed his residency at the Department of Psychiatry at New York University Medical Center/Bellevue Hospital in 1997 and came to Sheppard Pratt in 2000. He is board-certified in Psychiatry by the American Board of Psychiatry and Neurology. He is also certified by examination by the American Board of Addiction Medicine. He was recently serving as the Medical Director of Adult Services at Sheppard Pratt and the Service Chief of the Inpatient Co-occurring Disorders Unit at the Towson Campus of Sheppard Pratt. He also served as a physician advisor for the Stanley Research Group and the Operational Excellence team at Sheppard Pratt. Now, he works as the Chief Medical Officer for Kolmac Outpatient Recovery Centers.
He is also an Assistant Professor at the University of Maryland School of Medicine, and he has always maintained an interest in training psychiatry residents. He helped develop a course on 'Lean Problem Solving' at Sheppard Pratt and taught performance improvement to staff and psychiatry residents in the Sheppard Pratt System. He is a Distinguished Fellow of the American Psychiatric Association and a Fellow of the American Society of Addiction Medicine. He has been voted as a Top Doctor in Addiction Psychiatry by Castle Connolly and Baltimore Magazine.
He has conducted workshops and delivered many presentations on performance improvement in mental health at many regional, national and international meetings.
Antonio DePaolo, PhD, is a transformation executive and a Baldrige Fellow with over 22 years of experience in improvement science. This is his first book on improvement science applied to mental health and highlights his implementation work over more than seven years at Sheppard Pratt. Before that, Antonio spent 16 years in several industries, from automotive and transportation to life science and semiconductor packaging. He most recently ventured into healthcare by joining the University of Maryland Medical System as the Vice President of Transformation and Continuous Improvement for Upper Chesapeake Health. Antonio earned his B.S. in Industrial Engineering and Masters of Industrial Engineering from the University at Buffalo. He later completed his formal education with a Doctorate of Philosophy in Management with a focus on leadership and organizational change from Walden University. Throughout his career, Antonio had several mentors, including being mentored by Japanese Sensei while leading improvement efforts at a division of The Stanley Works located in Rhode Island. His major accomplishment was the full transformation of Wabash National, a struggling trailer manufacturer in Lafayette, Indiana, where he developed the manufacturing systems and laid the groundwork for improvement. As a result of his work, the company returned to revenue growth and profitability by removing a cumulative cost burden in excess of $250M and led to the organization winning The U.S. Senate productivity excellence award presented by Senator Richard Lugar. Antonio has volunteered his time to speak at local, national, and international settings and the American Psychiatric Association.
"If you are a leader in a mental health organization who is passionate about improving the efficiency — and, more importantly, the effectiveness — of everything your organization does, then Transforming Mental Health Care will certainly point you in the right direction.
The authors share an important combination of experiences, from clinical care and systems engineering, to provide a translation of the "Lean" methodology that will help you provide continually safer, higher quality care at a lower cost and with less delay.
This book goes beyond tools and methods and extends into the critically-important topics of culture, leadership, and change management. Transforming Mental Healthcare effectively models the Lean method by first identifying problems and opportunities (gaps) before getting into causes and, finally, solutions that drive better performance.
Beyond the benefits to patients, clinicians (and all staff who play various roles in the support of care) will find a more engaging, less frustrating workplace in which they can contribute to continuous improvement, if not excellence. Everybody wins!"
Mark Graban, author of Lean Hospitals, Healthcare Kaizen, and Measures of Success
"Applying the modern sciences of quality improvement to the field of behavioral health care may sound like a stretch; but think again. In "Transforming Mental Healthcare," Sunil Khushalani and Antonio DePaolo, a psychiatrist and an engineer, show just how promising and powerful that combination can be. Every knowledgeable student of health care systems knows today that mental health must be brought to the center of the agenda, and this timely, unique book makes improving mental health care practical and accessible to all."
Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
"This book offers a detailed and sobering look at the current state of psychiatry in the U.S. Using patient vignettes the authors explain how lean thinking could relieve suffering and help communities build sustainable mental health systems."
John Toussaint, MD, Executive Chairman, Catalysis, Inc.
"Transforming Mental Healthcare is a wonderful undertaking. Ideally, we all have capability and confidence, the accumulation of life's experience, overlaid with resilience and agility, being able to perceive and process situations and then make dynamic adjustments—some fleeting others longer term—thereby improving comfort and competence. Bravo to Khushalani and DePaulo for showing how the very organizations missioned with restoring those qualities to our loved ones have the same characteristics, self-reflective in their adaptation and adjustment, constantly improving the care they deliver."
Steven J. Spear, DBA MS MS, MIT Senior Lecturer and author The High Velocity Edge
