Applying Lean across a Mental Health System

System diagram by  jscreationzsAn Australian service provides an good example of using Lean principles across a mental health system.

The description of the changes, available here, includes many Lean techniques to which I will return in future posts.

There are some readily identifiable themes: there was training for staff in Lean approaches, and staff directed subsequent changes. Examples of work include 5S – there are some good before and after photos available at the web link above – and value stream mapping. Again, the weblink shows a good photographic example of their present state and desired future state pathway. The set of administrative steps in their initial state, shown in blue in their photographs, is particularly striking. By my count, they appear to have decreased from over 100 administrative steps in a patient journey, to about 15.

This is an example of reducing non-value added activity. All health and social care staff struggle with the idea that some of their work might not add value to their patients or clients. I attended a meeting recently in which a doctor was angry at the suggestion that there was waste in their clinical system, declaiming in frustration, ‘what do these people think I’m doing with my time?‘. The doctor knew they worked long hours that ate in to their personal time – how could there be waste in that?

I’ll return to the idea of waste in a future post, but it’s worth keeping in mind the distinction between processes that add no value at all, and those that don’t get the patient nearer to their goal, but which are necessary in the current system. So, for example, at a recent Improvement Workshop, I saw staff in a service tease out why a particular step occurred in a process in their service. They all had examples of the problems it caused for them, but why had it been introduced in the first place? After some discussion, they decided that it had been introduced as a check before a later computerised process was put in place. The new system was in operation, but the previous step had never been removed.

This is a good example of waste on which everyone is able to agree – there’s no value to the process at all. In some textbooks this is called Type II waste – waste than can be removed at once. Other processes fall in to Type I – processes which have no real benefit to the patient, but are necessary because of the way the system works at present. For example, in a recent local Workshop, a service talked over an investigation needed by many patients, that was conducted in a different part of the hospital. The investigation was, at present, necessary, but the journey to and from the second department took time, and introduced considerable delays. The equipment needed to undertake the investigation could not be duplicated. The journey itself added no value to ill patients – it was the results of the investigation that mattered to them – but because of the lay out of the hospital, the step could not be removed, making this a Type I waste. Even within this, the staff identified some ways to speed up the process and decrease waiting. Waste like this may be unavoidable, but it is good practice to keep returning to it to see if it is still necessary, or if there are ways to reduce it.

Other examples in the Australian case study include developing a pull system with kanban; using visual signals (called an ‘andon‘) and increasing standardised work. It would be useful to know more about whether and how the changes have been maintained. All the work described sounded well worthwhile, and the changes described were impressive: keeping change going is also a significant challenge.

Image courtesy of  jscreationzs at

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