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What is ‘lean psychiatry’?

By Joseph P. Merlino, MD, MPA


In 2008, Esmin Green, a patient on the psychiatry ER floor of Kings County Hospital Center, died. International news coverage, lawsuits, and a US Department of Justice investigation ensued. The Behavioral Health department was to ensure the full and timely compliance with the resultant court decrees for drastic improvements in the care of the mentally ill at the hospital.

Our “initial state” was described as a mental health system operating in crisis mode, focused on putting out “fire” after “fire.” We were operating our numerous services in seven old buildings spread over a 44-acre campus. We were short-staffed; a good number of staff had been transferred to our service from other parts of the hospital and unfamiliar with work with psychiatric patients. Morale was low given the seemingly unending onslaught of negative publicity.
The prevailing culture was largely complacent and dispirited. Staff could be described as exhibiting signs of learned helplessness or hopelessness. They were largely not patient-centered or looking to empower patients, and not functioning as a coordinated interdisciplinary team. We lacked a leadership infrastructure and operated with an antiquated care delivery model. Inpatient units operated without “unit chiefs” and records were kept on paper without a system of chart review for quality and compliance. There were no interdisciplinary training programs in place that brought clinicians together with a unified vision of care delivery. There was no model or hunger for change as a result of this learned helplessness that overtook many.

Kings County Behavioral Health needed to dramatically transform all services at Kings County Hospital Center’s behavioral health programs. We envisioned a totally transformed psychiatric ER as well as an inpatient and outpatient infrastructure adequately staffed by caring, competent professionals. We wanted our new building to both symbolize as well as actualize a true transformation from the “snake pit” featured in the New York tabloids to the city’s “flagship” public hospital. Quality and safety processes had to change, and outcomes had to be radically improved with leadership and line staff trained in the profession’s best practices for assessment, diagnosis, treatment, and aftercare. The use of technology and data was seen as a tool to help us lead, manage, and deliver the needed improvement in quality care.

Looking east along Winthrop at Kings County Hospital Center on a sunny late afternoon. Downstate Medical Center is south (right) of this building. Photo by Jim Henderson. Public domain via Wikimedia Commons.
Looking east along Winthrop at Kings County Hospital Center on a sunny late afternoon. Downstate Medical Center is south (right) of this building. Photo by Jim Henderson. Public domain via Wikimedia Commons.

How were we to accomplish this? Where should be begin? How were we to proceed? To guide us along this seemingly impossible journey, it was decided to adopt the principles and practices embodied by lean.

No, “lean” isn’t a euphemism for managed care. Lean refers to a philosophy of management involving the process of identifying value vs. waste in what is delivered to the customer – our patient. Lean empowers the staff that directly does the work to identify waste and inefficiencies and to create solutions to the problems identified. The results are put into effect very quickly, usually within days not months or years later.

We assembled a leadership team, who in turn needed to recruit adequate numbers of competent staff to join our ranks. Then we had to ensure their training so they both understood what was required by the court and had the competencies to deliver what was required by the many policies and procedures that were produced or reviewed and revised to attain compliance. As the senior team was assembled, every former clinical discipline director eventually was replaced with new leaders. Surprisingly, the negative publicity about Kings County seemed to attract, not deter, exceptional leaders and staff, especially when during interviews the senior team displayed openness and a lack of defensiveness about the past, the current challenges and the vast potential for the Behavioral Health Service’s future. It was gratifying to hear the newly recruited leadership speak passionately about their desire to join the challenge of redefining the mental health care system for a population as large as central Brooklyn, seeing it as a once-in-a-career opportunity. Most of our new leadership came from other inner-city hospitals and were familiar both with our community culture and with the many challenges presented in such settings.

We have learned that even if you invest in the right number of sufficient staff, if your processes are faulty your people will fail. Ultimately, we needed to integrate each of the many fragmented services into one seamless continuum that improved access to care and delivered state of the art care in a timely and cost-effective way: better health, better quality care, and reduced overall cost.

Kings County Hospital Center Behavioral Health Services now has the tools, experience, and mentoring to achieve and sustain our gains, utilizing the philosophy and methodology of lean. We will continue to add value, decrease waste, improve performance, and become a center of excellence for our community.

Joseph P. Merlino, MD, MPA is the chief executive for behavioral health services and Director of Psychiatry at Kings County Hospital Center, where he leads the transformation efforts of one of the largest public hospitals in New York. He is the co-editor of Lean Behavioral Health: The Kings County Hospital Story with Joanna Omi and Jill Bowen.

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