Transforming Mental Healthcare

Applying Performance Improvement Methods to Mental Healthcare

Sunil Khushalani, Antonio DePaolo

• Publisher: Productivity Press
• Year: 2021
• eBook ISBN: 9781351582452
• Topic: Business
• Subtopic: Operazioni
• Index: Business

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.

Section IThe Need for Performance Improvement Methods in Mental Healthcare

DOI: 10.4324/9781315099224-1

I. A Focus on the Mental Health ‘System’ of Care

Nearly one in five individuals in the United States is affected by mental illness (Ezez, 2019).¹ In 2017, according to the National Institute of Mental Health (NIMH), an estimated 18.9% of all adults aged 18 or older had any mental illness (AMI). An estimated 4.5% of all adults aged 18 or older had a serious mental illness (SMI). We all know someone who struggles with a mental illness, and more often than not, their mental illness is a chronic condition. Finding good quality, safe, and effective treatment is essential to managing these conditions. The availability of a reliable healthcare provider or system goes a long way in reducing a struggling patient's functional impairment and the stress or burden of a caretaker. As part of receiving care, a patient may have to navigate different professionals, clinics, laboratories, pharmacies, or even hospitals. Entities that offer these services can be havens of comfort, or they can be laden with obstacles in the way of receiving accessible and reliable care.

VIGNETTE 1.1

Dr. Samuel was a busy psychiatrist. He received a call from Jenny, an old acquaintance. Her boss Pete was suffering from disabling panic attacks and wanted to see a psychiatrist right away. She wondered if Dr. Samuel would see Pete soon to help him with his condition. Dr. Samuel asked her to have Pete call his office to make an appointment. When Pete called the office, he was told by the office assistant that there were no openings for an initial appointment for six weeks and offered to put his name on a waiting list. He let Jenny know who called Dr. Samuel to ask him what could be done about the long wait. Dr. Samuel then called his assistant and instructed her to ‘double book’ Pete for the next day so that he could be seen sometime in the morning. Dr. Samuel knew there was typically a no-show or last-minute cancellation. Pete arrived in the morning and had to wait until the lunch hour to be seen by Dr. Samuel because every other patient showed up for their scheduled appointment.

As a mental health practitioner, imagine that a loved one decided to seek services at your hospital or clinic. Think about the overall care that this person would receive at your current workplace and their complete journey from the time they enter your system to the time they leave. Ask yourself questions such as ‘How quickly are they able to access services?,’ ‘Are questions and concerns readily addressed?,’ ‘How is the quality and nature of the diagnosis, treatment, and support services provided?’ and ‘What is the overall satisfaction and outcome for patients?’ These are all great things to consider, but the real question is, ‘will the current system of care be acceptable to you, or is there room for improvement?’

VIGNETTE 1.2

Colleen, a new nurse practitioner in an acute psychiatric inpatient unit, had a longer average length of stay than her peers in the same unit. Her supervising Medical Director asked her what was contributing to patients staying longer, to which she replied: ‘Since their insurance covers our patients’ costs, what is the advantage of reducing the length of stay?’ This question surprised the Medical Director, who did not expect such a response. He began to question if new psychiatric practitioners were being trained to manage the day-to-day rather than the big picture of a patient's care. He wondered if he could shift their focus toward the total impact of patient services offered while also focusing on managing the patient cases in front of them.

Discussing cost is a thorny issue. On the one hand, medical practitioners want to provide the best care possible regardless of cost. On the other hand, such care's financial implications on both the individual and the healthcare system can cause the costs to rise for everyone. Whether the family member is financially supporting the care of a patient suffering from a chronic mental illness or a business leader is worried about choosing the best healthcare plan for all their employees, there is constant concern about the value a patient receives for the amount of money that is being spent. As costs keep rising, everyone in the healthcare system is under constant pressure to make difficult financial decisions.

VIGNETTE 1.3

Josh was admitted to a psychiatric inpatient unit for suicidal ideation. His allergy to tomatoes was listed in the medical record. For lunch, he was served a garden salad with cherry tomatoes. He let the charge nurse know who called the kitchen and informed them of the mistake. They sent a replacement tray with a pizza on it. He asked to speak to the doctor on call. He spoke out assertively about the apparent error and pointed out that the pizza was made with tomato sauce. He sarcastically said to the doctor, ‘I came here for suicidal thinking, but it seems to me that someone in the hospital wants to kill me.’

Administrators routinely hear complaints about processes that don’t work as desired. They often aim for a good patient experience and have to apologize to patients or family members for their bad experiences. Patient experiences are variable as they receive care. The risks associated with faulty or broken processes within a system of care are too significant. Asking employees of a health system to be careful, to try harder, or even retraining them does not easily eliminate potential errors before they affect a patient.

VIGNETTE 1.4

Sameer, a software engineer, was suffering from back pain for four years. His primary care provider treated him with oxycodone 20 mg four times a day for the last three years. After losing his job over two months ago, Sameer became depressed and started taking oxycodone six times a day. When his primary care provider found out about this, he discharged Sameer from his practice abruptly and told him to seek care elsewhere. Sameer went to the ER with worsened pain and informed the psychiatric social worker that he had been drinking 6–8 glasses of whiskey a day since he was laid off. During the assessment, he said that he was trying his best to cope. He had been feeling depressed and also felt that his pain had gotten worse. He was even tempted to use heroin when he was feeling desperate. He was out of his pain medications, and the withdrawal symptoms were excruciating. The social worker became very concerned about him, considering that the number of opioid overdose deaths had been rising astronomically.

Legislators are always concerned about how the present-day healthcare system functions so much so that it is part of every campaign today for political office. Errors, complaints, and shortcomings of the current system often make headlines in the news. Many psychiatric patients do not get the appropriate care and are falling through the cracks. Healthcare has become fragmented into specialty silos, and the providers within and between these silos often don’t talk to each other leading to recurrent problems and rising expenditures.

There are several existing inefficiencies within the overall healthcare structure and processes leading to undesirable outcomes. These challenges are ubiquitous, seen all over the world, and they beg for improvements. Healthcare systems have been growing organically for decades. Looking at how our healthcare system is organized, there is a clear and imminent need for an overhaul and redesign. Practitioners need to learn to ‘diagnose and treat’ poorly functioning systems of care. They also need to ensure that each patient receives evidence-based care reliably.

VIGNETTE 1.5

Lashanda and Joseph were in their twenties and newly married. Joseph had been getting more and more paranoid lately and was convinced that someone was following him on his most recent drive back home. To avoid this, he drove through narrow back roads and came home late. He seemed terrified and disheveled. Lashanda was very worried about him. She called their family doctor, who advised her to take him to see a psychiatrist. After having made multiple phone calls to at least 20 different psychiatric practitioners and practices, she couldn’t find a single available outpatient provider within their insurance network. One evening Joseph did not return home and called her frantically, saying he was afraid to come home. He felt that the people were following him and would find out where they lived. He did not want to put her life in danger as well.

The current health system (which also includes the mental health system) is unsatisfactory in many ways. Improving it is not only necessary, but there is an urgent need to make it accessible and sustainable. Some analysts say that rising healthcare costs make the United States less competitive in the world (Johnson, 2012) and are cannibalizing the country's other vital priorities.² Psychiatric providers genuinely need a new paradigm of their roles at work. They need to think about the processes that exist in their workplace. They also need to direct more focus and energy on transforming the care system to ensure that each patient receives the best care possible. The quality gaps between what is truly possible and what is currently available are large, and there is a tremendous amount of improvement work needed to close that gap. Practitioners need to learn how to engage in such imminently needed performance improvement efforts.

II. A New Paradigm for the Mental Health System

Administrators, regulators, or accrediting agencies may suggest top-down changes to the system, but they can never match the expertise, knowledge, and capacity for innovation of the healthcare workers themselves. Much like the patient experience, healthcare workers experience variation in their processes as they provide care to a patient. They are the closest to the patient (front line) and have a vantage point where meaningful understanding and change can occur in a system. Partnering with front-line staff and clinicians provides a valuable resource of ideas and inspiration for change and redesign. They know what steps are beneficial for patient care, and they also know what additional steps are superfluous.

Engaging all workers in thinking about the improvement of their workplace is not new. Several industries outside of healthcare have engaged their workforce in performance improvement for decades, which has led to the creation of very safe and highly reliable systems. When considering the progress made in the airline or automotive industry through engaging their front-line staff, the healthcare industry has not kept pace.

However, some healthcare systems are testing the waters with various improvement methodologies. These centers are learning from other industries and radically transforming the experience of care and output of their systems. They are not just improving the quality, safety, and delivery of their services but are doing it with fewer expenditures, greater engagement, and satisfaction of their employees.

Mental health practitioners are being introduced to performance improvement methods, but many in the field are still unaware and oblivious to the usefulness of these newer methods and paradigms.

In 2003, the American Psychiatric Association (APA) presented a vision for the mental health system calling for a...

Table of contents

• Cover Page
• Endorsements Page
• Half-Title Page
• Title Page
• Copyright Page
• Contents
• Forewords
• Preface
• Acknowledgments
• About the Authors
• Introduction
• Contributors
• 1 The Need for Performance Improvement Methods in Mental Healthcare
• 2 Value and Waste in Psychiatry
• 3 Developing the Healthcare Workforce for Performance Improvement
• 4 Improvement Methods for Mental Health Organizations
• 5 Leading a New Kind of Workforce
• Afterword
• Index