"We began solving chronic and complex clinical challenges in our system, such as aggression toward others, unnecessary antipsychotics in patients with dementia, and transitions of care for patients with severe cooccurring disorders."
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Our mental health care system has numerous gaps. Defending and dealing with gaps in quality and delivery can feel overwhelming for psychiatric clinicians and lead to feelings of helplessness.
Although psychiatric clinicians learn to take care of patients one at a time, most are not trained to think of their “system” or to apply scientific thinking toward improving systems. They try to deal with their increasing workload and compensate for systemic 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. Advancements like newer therapies and electronic medical records come with unique challenges. Some solutions like thorough documentation, or an over-reliance on auditing to ensure quality, create additional burdens. Although it might not be well-known that some experts believe 30% to 50% of all health care activities are wasteful, clinicians likely feel this to be the case.1
Two decades ago, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly identified competencies for resident physicians to include “practice-based learning and improvement (PBLI)” and “systems-based practice (SBP).”2 PBLI included systematically analyzing practice and implementing changes to improve it. SBP included working in inter-professional teams to enhance quality and safety and identifying system errors.
So, how can we best prepare ourselves in the health workforce to “spot and repair” wasteful processes, to think and act as problem-solvers, and to design better systems?
Fortunately, a vast knowledge base of improvement science already exists. Improvement science has been widely utilized in non-health care settings like the manufacturing and aviation industries and has also been embraced by health care quality and safety pioneers outside of behavioral health.3,4
My own entry into this world of improvement science happened while trying to solve quality and safety problems in my organization. I came across a brilliant article titled “Fixing Healthcare From the Inside, Today.”5 The author asked, “How can health care professionals ensure that the quality of their service matches their knowledge and aspirations?” This article made me wonder about the application of improvement science to psychiatry, and it led me to discover lean methodology, an improvement approach that matured at the Toyota car company.
Systems engineering, at its core, is a field that utilizes systems thinking principles to design, manage, and optimize complex systems of care. Along my journey, I got introduced to a brilliant systems engineer, Antonio DePaolo, who became an inspiring collaborator and the coauthor of our book together on the subject.
We codesigned the course “Lean Problem Solving” for our organization. Participants were asked to bring any safety, quality, delivery, cost, or morale problem to the course, and they would learn to apply improvement principles to their problem. This course, along with other improvement activities, gradually changed our organization’s culture.
We began solving chronic and complex clinical challenges in our system, such as aggression toward others, unnecessary antipsychotics in patients with dementia, and transitions of care for patients with severe cooccurring disorders. We were also able to improve operational challenges like access to care, staffing shortages, and care costs while improving communication with
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