Learning to Improve the Mental Health Care System


How can we best prepare the health workforce to “spot and repair” wasteful processes, to think and act as problem-solvers, and to design better systems?



There are numerous gaps in our mental healthcare system. Trying to defend and deal with quality and delivery gaps can feel overwhelming for psychiatric clinicians and lead to feelings of helplessness.

Psychiatric clinicians learn to take care of patients one at a time. However, most are not trained to think of their “system” or apply scientific thinking to improving systems. They try to deal with their ever-growing workload and compensate for shortcomings in systems by working harder, which comes at a personal cost, contributing to an epidemic of burnout. Unfortunately, this does not always lead to better systems. Advancements, such as electronic medical records and newer therapies, come with unique challenges. Some solutions like thorough documentation, or an over-reliance on auditing to ensure quality, creates additional burdens. It is not well-known what some experts believe that about 30% to 50% of all activities in health care are wasteful.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 everyone 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 a course called “Lean Problem Solving” in 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 others.

Here is an example of continuous improvement from an acute care unit that describes the process of improving transitions of care for patients who were being discharged from an inpatient level of care to outpatient care. This busy inpatient unit could have anywhere between 1 and 8 discharges a day (with as many patients admitted that evening). High-discharge days were not only busy and stressful but could also be occasions for delays, errors of omission and commission, as well as dissatisfied family members, staff, and patients.

As we began observing and studying the discharge process, we realized that one of the factors that led to delays was that patients’ belongings were scattered in multiple locations in a disorganized fashion. Gathering and organizing all that the patient would take back at discharge could sometimes take 1 to 2 hours of a staff member’s time. Social workers would ask a van driver or a family member to come at a particular time, but they had no idea how long it would take to collect a patient’s belongings (from the unit, security, and the pharmacy). This process led to waiting, frustration, and mistakes—and such mistakes would lead to callbacks about missing scripts, forgotten belongings, or lost valuables.

This observation alone led to multiple improvements: an organized belongings room, a discharge checklist, and a decision to prepare everything for a discharging patient the day prior to discharge. Today, we can be sure that if patients leave the unit, they will reliably get all their belongings and everything they need on time, without anyone having to wait even for a minute.

Continuous improvement is a cyclical iterative process. The team decided to improve the time it took to complete discharge summaries next, with the goal of all summaries being completed within 24 hours of discharge. Next, the team utilized the discharge checklist to ensure that every patient who needed nicotine replacement therapy, naloxone, or their inhalers would have these reliably given to them. Once the team learned this way of working, every new problem became an opportunity to apply this improvement toolkit. Continuous improvement became a way to sustain improvements and create empowered and engaged team members who kept striving to improve quality and outcomes.

Whatever worked in our complex setting is certainly applicable to any mental health care setting.

Transforming Mental Healthcare: Applying Performance Improvement Methods to Mental Healthcare by Sunil Khushalani, MD, and Antonio DePaolo, PhD

Transforming Mental Healthcare: Applying Performance Improvement Methods to Mental Healthcare by Sunil Khushalani, MD, and Antonio DePaolo, PhD

Our book lays out the need for such an approach; introduces basic improvement principles and the developmental steps of building improvement knowledge and skills; and enumerates a systematic method of solving complex problems. It also discusses the support needed to create and maintain such a learning and improvement culture.

In 1998, Don Berwick, MD, a health care improvement leader, wrote6:

“We believe that the prognosis for the health care system is good if physicians will contribute actively to improving the system as a whole. If we are wrong, our agenda at least gives professionals something more pleasant to do than complain. More importantly, if we are correct in stating that the seeds of fundamental improvement in health care systems lie within the reach of physicians, then physicians can best exert their influence by recognizing the problems to be solved and then doing everything in their power to assure that the solutions they help develop are technically proper, ethically sound, and effective.”

Our book is a primer on applying improvement methods to any mental health system for anyone interested in such an undertaking. 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 take care of both individuals and ailing systems that need their help.

Dr Khushalani is coauthor of Transforming Mental Healthcare: Applying Performance Improvement Methods to Mental Healthcare.


1. Healthcare Finance Staff. Healthcare debate fatally flawed. Healthcare Finance. 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 practiceAcad Med. 2004;79(1):83-88.

3. Kenney C. Transforming Health Care: 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 the inside, 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 MedicineAnn Intern Med. 1998;128(4):289-292.

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