Abstract
Healthcare systems are slow to evolve, and much needed innovation often falls short of the transformation needed to streamline services and improve efficiency across the board. Lean Behavioural Health aims to lead by example. It applies lean principles to a large complex metropolitan psychiatric service, showing that sustained cultural and institutional change can be achieved and more importantly, maintained, with proper stewardship. It is a departure from asking what needs to be changed to embedding a culture of change within the whole organisation.
Edited by the top levels of management of King’s County Hospital, including the chief executive, chief of staff and chief innovation officer, the book is a frank account of how a chaotic service turned things around. The ‘burning platform’ that began this process was the tragic death of Esmin Green in the psychiatric emergency room in 2008. The subsequent investigations exposed concerns about overcrowding, illegal use of physical and chemical restraints and allegations of neglect. Instead of responding in a knee jerk fashion, the management took a step back and used lean principles of defining value and responding to pull factors to ultimately focus on what was most important for the patients and making the system flow smoothly to meet those needs.
The book is written for both clinicians and administrators and acts as a fascinating overview of how Kings County Hospital operates within the health service infrastructure of the state of New York. It does not presume any prior knowledge and explains each stage of its journey in depth. It starts with an explanation of ‘lean’ – a term coined by MIT researchers to capture the principles and tools of the Toyota Production System – and explores how lean can be applied to behavioural health. It is honest about the challenges of balancing long-term and short-term goals and realistic about financial incentives and restraints. The book then details the work of individual emergency, inpatient and outpatient departments with a style that is a mix of instruction manual and reflective narrative. Throughout, there are boxes for case studies and personal insights. The book offers many examples of good practice, such as using interactive whiteboards for handovers and embedding data capture into information technology (IT) systems. It highlights the difference to patient satisfaction of seemingly small changes, such as ensuring that patients’ properties are kept safe.
The editors are self-conscious of the resistance faced in using lean. They openly acknowledge that people aren’t cars, but argue that clinicians need to be better managers. As a clinician at the beginning of my career, the book helped me to identify improvements in the workplace in my own personal practice and bring these to the attention of my supervisors. The changes that are made at Kings County Hospital, however, are inherently top down and rely on using external support and training. It is difficult to say how achievable it would be for grassroots change within organisations where the top management were not so enlightened. The ethos of quality improvement is admirable. It should be everyday practice – the lean process, the editors would argue, makes it easier to do so. However, for a clinician without any business or management background, translating the words of the sensei is making common sense rather more complicated.