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Behavioral healthcare à la Toyota

March 2, 2012
by H. Steven Moffic, MD
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There is no question that most of healthcare and behavioral healthcare has become big business. This situation escalated after the development of for-profit managed care over the past 20 years or so, and is likely to further increase if healthcare reform continues.

Accountable Healthcare Organizations (ACOs), after all, have been described as “HMOs on steroids." To keep costs in control and thrive financially, the ACOs and the managed care companies will have to have the best business processes, and hopefully the best business ethics, in place.

Coincidentally or not, over the same time period, my wife and I have been buying Toyota cars. These tended to be the middle-level minivans and Solera models, the former for my wife and the convertibles for me. Why did we do that? Their presumed reliability and value proved to be true, at least for us. Toyota has also been a pioneer in the transition to electric cars with the Prius, which our son bought. This addition supports one of my favorite activist causes, global warming, which was the focus of my very first blog for Behavioral Healthcare.

As Toyota was succeeding in the USA, the big American car companies almost went under with questions of quality, poor gas mileage, and lack of excitement. Even our usual distaste for negotiations with car salesmen were not so bad at Toyota. For our last purchase, last October, we even bought the salesman a carton of chicken soup as a thank you. Recently, we were reminded that this car needs its first servicing and “checkup”. Maybe we need to do more of the same at our clinics.

Of course, we were tempted to go elsewhere at times. Why not something fancier? We could afford that. Then, there was the more recent scare of the stuck accelerator in some Toyotas. Even though American cars seem to be catching up, thanks to a governmental bailout, Toyota seems to be recovering nicely on its own, even after the earthquake in Japan slowed production.

This has got me wondering. Can the success of the “Toyota Way” be generalized to our behavioral healthcare systems to make them more cost-effective? If so, what goes into this “Toyota Way?”

At least one psychiatric hospital has explicitly and publicly started to put this “lean methodology” of Toyota into place. This is the well-regarded Sheppard Pratt system in Towson, Maryland. The first focus was to save time and improve quality. This was applied even to such apparently mundane activities as to gather a discharged patient’s belongings when they were to leave the hospital, which was reduced from 2 hours to 2 minutes. And, to think that we psychiatrists have been complaining of the common reduction of medication checks from 60 minutes to 15 minutes!

Most highly trained professionals seem to resist the “Toyota Way”. Doctors often resist quality improvement processes, arguing that their judgment and expertise can’t be reduced to a set of rules. Are they right?

The Toyota Way

To answer that question, let’s review the history of the Toyota process and where it might have gone astray by 2009. First to understand is their production system of very specific rules, but rules that seem paradoxical. The production workers have been viewed as a “community of scientists” and their supervisors as “teachers.”

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Steve,

Very interesting ideas, Steve. Let me add a few more:

1) The Toyota Production System (TPS) is actually based on ideas developed by an American, Ed Deming (http://en.wikipedia.org/wiki/W._Edwards_Deming), about making a lean production system. Because wealthy US manufacturers were making plenty on mass-production, they wouldn't listen to Deming. But he's a hero in Japan. The Japanese mastered tis system in the postwar years because they couldn't afford not to. With so little postwar capital available, they needed a way to minimize inventory and maximize product output--e.g., make the most cars using the fewest parts. That's the "lean" part of lean production.

2) Another key part of the TPS is not that it is so much rigid and rules-driven, but that it is consistent. Work areas and standards are set up in identical ways so that there is a minimum of time required to consider the work situation and a maximum of time devoted to producing a consistent output. Having worked in lean environments (manufacturing, etc.) that stress such consistency, this approach actually frees a person up to focus on putting in a quality decision, a quality effort, rather than arguing about the circumstances.

3) There's another important benefit, too: given the consistency of work environment offered by a lean approach, the results offered by really excellent practitioners really do stand out--the consistent environment eliminates questions about 'fidelity' to a model and lets the practitioner's work speak for itself.

4) RE: EHRs. Change always hurts and no one fights change more than those who are skilled in the 'previous' system of operations. Keeping data on outcomes is essential to any systematic change in care quality and, as painful as it might be short-term, I believe that medical and clinical professionals are going to have to get used to providing systematic, electronic data, most likely with EHRs.

5) Continuity of care. Again here, a well-designed system leaves little room for chance or error--either in the delivery of care or in the interaction with the downstream "customer," whether that customer is a caregiver, another organization, etc.

I hope that the behavioral health profession, and all of medicine, will embrace the benefits of systems analogous to the TPS in their own work. If they do not, I worry that they will have it forced upon them by others (for-profit healthcare), with difficult consequences involving loss of jobs, pay cuts, and career difficulties.

Dennis,
Thanks so much for the informative elaboration on the Toyota process. I probably should have mentioned the main two references I used, which were from the Harvard Business Review, covering 1999 and 2011. They were "Decoding the DNA of the Toyota Production System" by Steven Spear and H. Kent Bowen, September-October, 1999 issue and "The Toyota Principles Can Also be Effective in Operations Involving Judgment and Expertise" by Bradley R. Staats and David M. Upton, October, 2011 issue. What business principles I learned from my own personal experience was from administering a not-for-profit managed mental healthcare system, called Luminous, from 1989-2003, and discussed in my book, "The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare" (Jossey-Bass, 1997).

While I agree with your prediction and warning, what is going to be especially challenging is to dovetail such production systems with the building recovery and consumer movements. What these latter movements desire is to take into account the particular life goals of each patient. Applying that to cars would be like some degree of customizing each car. How much can we do that in mental healthcare?

Refreshing discussion. I suggest the reader consider a review of the literature on practice- based evidence, which is an empirical assessment of the effect ongoing monitoring - and collaborative review- of client-reported outcomes has on treatment duration, client satisfaction and retention. The procedure is to periodically poll client outcomes in a reliable valid sensitive and rapid manner, and immediately report findings back to client therapist manager elegantly. See authors like Mike Lambert who have developed expected treatment response- based software that assesses, reports...this approach is specifically designed to customize on an ongoing basis, interventions to client values and circumstances . It has been demonstrated to relisbly improve the outcomes of our neediest 'customers' in multiple RCTs. It also provides a common metric to compare outcomes across heterogenous pathologies, which is a pre- requisite for CQA.
Not a solution by itself- but certainly part of it!
We are currently working to implement this system in Canada on a national scale within our Veterans clinic system , specifically to support dovetailing of network performance management and consumer-centered care.
Again, great discussion!
Respectfully
David Ross
David.ross@vac-acc,gc.ca

Concord Hospital in Concord NH has recently begun significant training with managers to embrace and adapt LEAN principles and strategies adopted by Toyota. We recenly hired a new Director of LEAN to facilitate the transition toward a lean health care environment. As Director of Behavioral Health Services, we have adpoted lean principles starting with small process improvements to reduce waste, unnecesary motion, over processing, and unsued employee creativity. Two other significant Lean projects are underway using the tools of lean.

Camille Kennedy MSN, RNBC
Director Behavioral Health Services
Concord Hospital
Concord NH 03301

A central tenet of ‘Toyota Way’ is Value Vs. Waste as defined from the point of view of the patient. So if a patient spends 8 hours in the ER or 30 min in a waiting room to see the physician for a 10 min visit, the rest of the time spent by the patient is considered non-value added time. And according to the ‘Toyota Way’ underneath every non-value added activity, there resides a quality problem. They study waste in all their processes very carefully. They have even classified waste into 7 different categories. Others have added more to that list of wastes.For instance, if during a 20 minute visit if you leave your office for 10 minutes because you are trying to look for a consent form, those 20 minutes in their entirety are not value added to the patient.

So if your question, “What gives your life meaning and how can our treatment here enhance that?” truly adds value to the patient’s life, even a 20 minute discussion can be very value added. So as an example a focus of a quality improvement activity could be looking at the entire experience of the patient from the time they make the first call to the time they actually get to see the physician and get their treatment, in order to see where are the pockets of wait in that entire ‘value stream’. One of the biggest areas of waste in psychiatry is access to providers, specially if one is looking for specialists, like a child and adolescent psychiatrist or an addiction psychiatrist. From the patient’s point of view, calling multiple providers on their insurance plan and having to wait for weeks to see someone in times of dire need can be utterly wasteful.

The New England Healthcare Institute has defined waste in Healthcare as “Healthcare spending that can be eliminated without reducing the quality of care”. So if ‘fast and cheap’ can ensure no reduction in quality or an ‘increase in quality’ then it is a totally worthwhile exercise in these financially strapped times.

The only variation in our care of patients should be attributable to what the patient brings to the treatment. As far as our response to them- our assessment and treatment of them should be standardized (another concept resisted by trained medical professionals), not rigid and inflexible, but one that ensures a certain well-defined and pre-planned level of basic and systematic care which will not vary by practitioner or the time of day they come to the hospital or the clinic. Today too often, even in prestigious institutions, the kind of care one gets is too often dependent on the quality of the practitioner. Ensure a certain basic standard, would eliminate that kind of variation. Too many errors are occurring today in medicine due to this kind of rampant variation due to provider-specific or system-specific reasons. Standardization actually frees the practitioner’s mind to focus on the more challenging or novel problems, because the ordinary or expected set of problems or issues have been dealt effortlessly by following these well-studied and clearly elaborated “rules of use”.

Sunil Khushalani, MD
Sheppard Pratt Health System

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H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...