Toyota's Quality Principles Drive Hospital's Reform Effort

A major psychiatric hospital—Sheppard Pratt in Towson, Md.—has decided to adopt "lean methodology," which has been primarily developed and refined over the years by Toyota to improve the way it manufactures vehicles.

It is not just a performance-improvement methodology, but a well-thought-out philosophy that looks at waste within an organization and tries to improve the quality problems hidden under each wasted step, according to Sunil Khushalani, M.D., chair of the Medical Executive Committee at Sheppard Pratt.

Many general hospitals have successfully used this methodology to solve vexing problems such as medication errors or infections. Sheppard Pratt wanted to use it to create a widespread culture of problem-solving in its operations and thus enhance the quality of care.

Three leaders at Sheppard Pratt—President Steven Sharfstein, M.D.; Vice President and Medical Director Robert Roca, M.D.; and Khushalani—discussed this project at the APA annual meeting in Honolulu in May. "Khushalani is particularly involved in bringing Toyota's lean methodology to bear at Sheppard Pratt," Roca pointed out. "We call him Captain Toyota."

Pittsburgh Whetted Their Interest

In 2009, Roca said, he and some of his Sheppard Pratt colleagues heard about a program called the Pittsburgh Regional Healthcare Initiative (PRHI), which was formed to improve complex health care system problems by harnessing certain of Toyota's lean methodology principles. They invited PRHI consultants to visit Sheppard Pratt and explain how Toyota principles might be used there.

One of the basic Toyota ideas was the need to approach continuing problems as process problems rather than as people problems. Another was to get the people who are involved in a problem to participate in discussion of how to solve it. The problems in the medical setting may range from waste to errors in providing care. As these problems are solved, the result should be that patient care improves and money is saved.

Sheppard Pratt officials decided to adopt some of the methodology under operation "SPIRIT" (Sheppard Pratt Improvement Resources Inspired by Toyota).

One of the projects was to reorganize the equipment in the observation room next to the seclusion room to make the observation room more efficient. "A mental health worker was especially instrumental in doing all this, and she was very excited that her ideas were adopted as solutions," Roca said. "Before the reorganization, it took 108 seconds to find the needed object; afterward, only 16 seconds."

This time differential is critical, Khushalani explained, "because if it takes as much as two minutes to find the necessary things, it can endanger a patient's safety."

Discharge System Reformed

Another project that they tackled, Roca said, was streamlining the hospital discharge system. Staff were unclear about their roles, or in some cases individuals were duplicating tasks. So the responsibility of each person was clearly defined. Communication among the discharge staff was also improved by putting certain critical items of information in patients' electronic health records that would be transmitted to the next level of staff in the discharge process.

Before the new system was implemented, it could take two hours to find a discharged patient's belongings, Khushalani said. Now it takes only two minutes.

A third project, Roca continued, was reducing the chances of patients' getting the wrong food trays, which could harm those with food allergies. The Performance Improvement Team met for four days, discussed the problem, and worked out an action plan for solving it. Twelve percent of patients had gotten the wrong tray before the action plan was initiated; less than 1 percent did after the plan was in place.

"We are just two years into the process," Khushalani told Psychiatric News during a later interview, "and we need to learn from others who are ahead of us in this regard, for example, Seattle Children's Hospital and Virginia Mason Hospital in Seattle." But he is proud of what they have accomplished at Sheppard Pratt so far and recommends that other psychiatric hospitals and outpatient clinics consider adopting similar approaches.

He is convinced that psychiatrists in private practice could profit from some of these concepts by making their offices less wasteful and more efficient and thereby enhancing the quality of patient care and saving money. Two good resources, he said, are the books Lean Hospitals, written by Mark Graben and published by CRC Press, and The Pittsburgh Way to Efficient Healthcare, by Naida Grunden and published by Healthcare Performance Press.

"We have superbly competent and brilliant team members, but our consistency in delivering high-quality care is far from great," Abhilash Desai, M.D., medical director of geriatric psychiatry at Sheppard Pratt, told Psychiatric News. "Through the SPIRIT project, we can make high-quality care routine." Desai is not directly involved in the project.

"We at Sheppard Pratt would love to hear from other psychiatric institutions that are using Toyota's lean methodology or similar methodologies so that we can share information with them and learn from each other," Khushalani said. His e-mail address is skhushalani{at}sheppardpratt.org.