How to Improve Systemic Problems in Mental Health Care

There are numerous gaps in our psychiatric care system. Defending and dealing with quality and service gaps can feel overwhelming for mental health clinicians and lead to feelings of helplessness.

Although psychiatric clinicians learn to tend to patients one at a time, most are not trained to think of their “system” or to apply scientific thinking to improving systems. They try to manage their increasing workload and compensate for systemic deficiencies by doing more work, which comes at a personal cost and contributes to an epidemic of burnout. Unfortunately, this does not always lead to better systems. Advances such as newer therapies and electronic health records present unique challenges. Some solutions, such as thorough documentation or an over-reliance on quality assurance audits, create additional burdens. While it may not be widely known that some experts believe that 30% to 50% of all healthcare activity is wasteful, clinicians likely agree that this is the case.1

Two decades ago, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly defined competencies for practicing physicians, including “practice-based learning and improvement (PBLI)” and “systems-based practice (SBP).”2 PBLI involved systematically analyzing practice and implementing changes to improve it. SBP involved working in interprofessional teams to improve quality and safety and identify system failures.

So how can we, as health workers, best prepare ourselves to “detect and fix” wasteful processes, think and act as problem solvers, and design better systems?

Fortunately, a vast knowledge base of enhancement science already exists. Improvement science has been widely adopted in non-healthcare areas such as manufacturing and aerospace industries, and has also been embraced by pioneers in health care quality and safety 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 called Fixing Healthcare From the Inside, Today.5 The author asked, “How can healthcare professionals ensure that the quality of their services matches their knowledge and aspirations?” This article got me thinking about the application of corrective science to psychiatry and led me to discover the Lean methodology, an improvement approach that has matured at the Toyota car company.

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Systems engineering, at its core, is a field that uses systems thinking principles to design, manage, and optimize complex systems of care. On my journey I met a brilliant systems engineer, Antonio DePaolo, who became an inspirational collaborator and co-author of our joint book on the subject.

We helped design the Lean Problem Solving course for our organization. Participants were asked to bring any safety, quality, delivery, cost, or morale issue to the course and they learned to apply improvement principles to their problem. This course, along with other improvement activities, has gradually changed the culture of our organization.

We started solving chronic and complex clinical challenges in our system, such as: B. Aggression toward others, unnecessary antipsychotics in patients with dementia, and transitional treatments for patients with severe comorbidities. We have also been able to improve operational challenges such as access to care, staff shortages and costs of care, while improving communication with others.

Here is an example of continuous improvement in an acute care unit that describes the process of improving the transitions of care for patients discharged from inpatient care to outpatient care. This busy inpatient department can have anywhere from 1 to 8 discharges per day (with as many patients admitted that evening). Layoff days were not only busy and stressful, but could also be a source of delays, omissions and commissioning errors, and dissatisfied family members, staff, and patients.

As we began to observe and study the discharge process, we found that one of the factors causing delays was that patients’ belongings were disorganized in multiple locations. Gathering and organizing all of the patient’s belongings upon discharge can sometimes take 1 to 2 hours of a staff member’s time. Social workers asked a van driver or family member to come at a specific time, but they had no idea how long it would take to collect the patient’s belongings from the unit, security, and the pharmacy. This process led to wait times, frustration, and errors—and such errors led to calls for missing scripts, forgotten items, and even lost valuables.

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This observation led to several improvements: an organized luggage room, a discharge checklist, and the decision to prepare everything for a discharged patient the day before discharge. Today we can be sure that when patients leave the ward, they will receive all their belongings and everything they need in a timely and reliable manner, without anyone having to wait a minute.

Continuous improvement is a cyclical iterative process. Next, the team decided to reduce the time it takes to fill out the discharge summaries, with the goal of completing all summaries within 24 hours of discharge. The team then used the discharge checklist to ensure that any patient who required nicotine replacement therapy, naloxone, or their inhalers would reliably receive them. Once the team learned this way of working, each new problem became an opportunity to apply this improvement toolkit. Continuous improvement has become a way to sustain improvement and create empowered and engaged team members who constantly strive to improve quality and results.

Whatever has worked in our complex setting is certainly applicable to any psychiatric setting. Our book sets out the need for such an approach; introduces basic improvement principles and the development steps to build improvement knowledge and skills; and enumerates a systematic method for solving complex problems. It also discusses the support needed to create and sustain such a culture of learning and improvement.

In 1998, Don Berwick, MD, a health care director, wrote6:

“We believe that the prognosis for the healthcare system is good when doctors actively contribute to improving the overall system. When we’re wrong, our agenda at least gives professionals something nicer to do than complain. More importantly, if we are right to say that the seeds of fundamental improvement in health systems are within the reach of physicians, then physicians can best exert their influence by identifying the problems that need to be solved and then doing whatever they can to ensure that the solutions they help create are technically sound, ethically sound and effective.”

Our book is an introduction to applying improvement methods to any mental health system for anyone interested in such an endeavor. It can inspire hope and empower and empower clinicians to take incremental steps toward a state of continuous improvement and then use their scientific thinking skills to care for both individuals and ailing systems that need their help.

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dr Khushalani is Systems Medicine director of behavioral health at Atlantic Health System and co-author of Transforming mental health care: applying performance improvement methods to mental health care.


1. Health debate fatally flawed. Healthcare Finance. 2009. Accessed December 20, 2021.

2. FC Ziegelstein, Fiebach NH. “The mirror” and “the village”: a new method for teaching practice-based learning and improvement and systems-based practice. Academy Med. 2004;79(1):83-88.

3. Kenney C. Transforming Healthcare: 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 healthcare from within today. Harvard Business Review. 2005. Accessed December 20, 2021.

6. Berwick DM, Nolan TW. Physicians at the forefront of improving health care: a new series in Annals of Internal Medicine. Ann Intern Med. 1998;128(4):289-292. ❒

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