Using Lean to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety  Margaret E. Balfour, MD, PhD, Kathleen Tanner, MA, LSSBB, Paul J. Jurica, PhD, Dawn Llewellyn, BA, Robert G. Williamson, MD, Chris A. Carson, MD, MBA  Joint Commission Journal on Quality and Patient Safety  Volume 43, Issue 6, Pages 275-283 (June 2017) DOI: 10.1016/j.jcjq.2017.03.008 Copyright © 2017 The Author(s) Terms and Conditions

Figure 1 These X-bar charts depict improvement in throughput measures. Each data point represents the mean of a random sample of up to 100. The center line (X-bar) represents the process mean. Upper control limits (UCL) and lower control limits (LCL) are set at three standard deviations above and below the mean, respectively. S-charts plotting the standard deviation verified that the processes were in control and are not displayed. Clinic door-to-door dwell time decreased following Phase I interventions, and this improvement was sustained during Phase II (Figure 1a). There was an increase in observation unit door-to-doctor time following Phase I, as more patients were required to be evaluated by the behavioral health medical professional (BHMP), then a reduction after the implementation of Phase II interventions targeted at BHMP staffing (Figure 1b). Figure 1a is reprinted with permission of Springer SBM US, from Balfour ME, et al. Crisis Reliability Indicators Supporting Emergency Services (CRISES): a framework for developing performance measures for behavioral health crisis and psychiatric emergency programs. Community Ment Health J. 2016;52:1–9. Joint Commission Journal on Quality and Patient Safety 2017 43, 275-283DOI: (10.1016/j.jcjq.2017.03.008) Copyright © 2017 The Author(s) Terms and Conditions

Figure 2 The number of staff injuries steadily decreased and were eliminated from the clinic setting altogether (see Table 1 for statistical analysis). Joint Commission Journal on Quality and Patient Safety 2017 43, 275-283DOI: (10.1016/j.jcjq.2017.03.008) Copyright © 2017 The Author(s) Terms and Conditions

Figure 3 Before the Phase I interventions, staff were spread out over a large area, with mixing of patients with unclear risk profiles (blue arrows), who often slept overnight in unmonitored, non-ligature safe assessment rooms. After the new process, risk level is determined early. Green arrows show the flow of low- and moderate-risk patients, and red arrows show the flow of high-risk patients, who may arrive via the waiting room (walk-ins) or the gated sally port (law enforcement drops). Staff are consolidated with the high-risk patients on the observation unit. More efficient flow resulted in unused space that was converted to an overflow observation unit. The process improvement team developed the new flow using an enlarged laminated floor plan and dry erase markers; their final product looked much like this electronic version. Joint Commission Journal on Quality and Patient Safety 2017 43, 275-283DOI: (10.1016/j.jcjq.2017.03.008) Copyright © 2017 The Author(s) Terms and Conditions

Figure 4 Alignment of Lean concepts with behavioral health clinical goals improves both safety and experience for this specialized population. Obs unit, observation unit; pt, patient. Joint Commission Journal on Quality and Patient Safety 2017 43, 275-283DOI: (10.1016/j.jcjq.2017.03.008) Copyright © 2017 The Author(s) Terms and Conditions