Lean Behavioral Health: The Kings County Hospital Story

With ever increasing pressure on budgets and an emphasis on quality, safety and efficiency of healthcare services, quality improvement has become part of everyday practice in the UK, making this book a particularly topical read. Lean is a way of thinking derived from the Toyota car industry, which looks to define value from a customer's perspective and create value by eliminating waste throughout the chain of processes required to deliver a product. The idea of continuous improvement is inherent within a lean system. Lean systems have been utilised in the manufacturing sector with varying degrees of success, but more recently the principles and techniques of lean have been transferred to other sectors, including healthcare. This book outlines how lean principles and tools were utilised to lift psychiatric services at The Kings County Hospital out of crisis and promote a culture of continuous improvement in the quality of services delivered. 
 
The book was not always the easiest read and there were several sections where a further copy-edit would have been beneficial. It took time to become familiar with the language of lean and the acronyms used, although a glossary at the start of the book assisted in the learning process. Earlier chapters set the scene, explaining lean and the background to the crisis facing the hospital, and gave brief details of many improvement projects that were undertaken. However, at this point the exact nature of problems within different departments, solutions identified and how lean methodologies had assisted the process were not always clear. Later chapters revisited some of the examples on a department-by-department basis and gave a better sense of the value of lean tools in identifying and solving problems with the aim of sustainable change and creation of a culture of continuous improvement. Figures supplementing the text gave an indication of the scope of various lean events but it was impossible to read the detail of what had been discussed due to their small size. Although this book was not aiming to act as a manual for the application of lean in a healthcare setting, at times it was frustrating that detail in examples and figures was lacking because this would have strengthened understanding of the difficulties facing the organisation prior to and during change events and the value of lean in helping to identify solutions and guide teams through the change process. 
 
At The Kings County Hospital, application of lean thinking typically involved initial work to establish the current state of all activities in a process requiring improvement, creation of a target state, and corresponding gap analysis between the two states. Identified problems were then addressed through rapid improvement events (during the course of a 4.5-day event waste was identified, solutions tested and improvements made), longer projects and immediate ‘just do its’. Evidence was provided that where lean principles were successfully implemented within the organisation, there were consequent benefits: financially, to staff productivity and morale, to the quality, safety and efficiency of clinical services delivered, and in the experience of patients. For example, in the psychiatric emergency room, the physical flow of patients through the department and collection of patient data were streamlined, with clear standards of work developed for staff involved in each step in the process. This led to elimination of previous duplication of work, shorter nursing and psychiatric triage times and improved standards of patient care. 
 
Overall, the book did provide a thought-provoking and, at times, inspirational commentary on real-life and wide-ranging changes to working practices across the hospital's psychiatric emergency, in-patient and out-patient services. It demonstrated how improvement methodologies can help to establish a new organisational culture, reduce waste and improve quality in any process pathway. As well as commenting on successful changes, the book also offered insights into changes which had not worked so well and reasons for that, acknowledging that the process of improvement is ongoing and that the organisation continues to strive towards an ideal state. The book offers a good case study as a starting point for anyone interested in incorporating improvement methodologies at any level of an organisation, demonstrating the benefits of thinking outside of the healthcare box and utilising successful quality and value improvement strategies developed in other sectors.

This is a self-help book directed at those who experience voices. It is written in a format seen in a number of other previous self-help books. Its aims are simple -to increase understanding of the experience of hearing voices and reduce distress this causes.
The book is structured in five parts. The first part provides background knowledge about distressing voices by exploring topics such as the relationship between hearing voices and mental disorder, the common types of voices experienced by people and the relationship between voices and low self-esteem. The second and third parts provide strategies to reduce distress occurring as a consequence of voices. Examples include helping the reader to develop relaxation techniques and encouraging socialisation. This section also covers core aspects of cognitive-behavioural therapy such as identifying core beliefs and helping the reader to start to challenge these. The penultimate part encourages the reader to make plans for the future, and the last part explores the impact of voices on those close to the reader, such as friends and family.
The major strength of this book is its readable style. The introduction highlights that a number of individuals are reluctant to seek help regarding distressing voices. The narrative style and the effective use of case histories throughout add a personal feel to the book and perhaps help to reduce the sense of isolation that can occur as a consequence of hearing voices. A number of practical homework tasks are set. These help to support the reader to develop greater knowledge and awareness of their voice-hearing and develop the ability to manage distress.
A minor criticism of this book might be its relatively small dimensions. Although this makes it portable and approachable, the practical exercises contained within are on the small side. As a consequence, one would suspect that someone working through the book would need to keep some of the exercises separate from the book. This might make review of the knowledge and skills gained a little disjointed. The book is laid out clearly and logically, with short paragraphs that encourage the reader to work through short sections, as and when the opportunity arises, rather than reading the book in one go. However, I wonder if some readers might benefit from guidance in approaching the book, for example working alongside a carer or mental health professional.
On the whole, this book achieves its objectives. It would be of value to those suffering from distressing voices, as well as friends and family members who may seek greater understanding of these experiences. Open University Press, 2014, 22.99, pb, 256 pp. ISBN: 9780335242085 This highly accessible book is pitched at healthcare professionals in primary and secondary care working with persons with anxiety and depression, with the aim of introducing and promoting the theory and practical applications of cognitive-behavioural therapy (CBT). This review coincided with my own supervised CBT case as part of my core training, and I found the book a helpful guide for practically applying cognitive and behavioural theoretical principles. Perhaps not surprisingly for a book on CBT, each chapter has clearly structured introductions, subheadings and summaries with recommended further reading. The contents are logically laid out, with succinct sections exploring initial assessment, problem identification, applying therapies to specific conditions and maintaining recovery. The subsections regarding session structure, goal-setting and maintenance models are especially useful, along with a most helpful chapter on applying the covered principles to difficulties with sleep. The book has a practical flavour throughout, with appropriate use of case vignettes, online materials to recommend to patients, and a wealth of resources within the appendices.

By Colin Hughes, Stephen Herron and Joanne Younge
Reassuringly, the book is very clear that its main goal is not to act as a substitute for formal training or supervision, but rather to introduce the reader to the ideas and means to be more psychologically minded in one's practice. With this in mind, perhaps the main strength of the book is its awareness of its own limitations; it clearly signposts to further reading where appropriate, and emphasises the importance of supervision, and indeed how to optimise it.
In pitching to such a wide range of practitioners there may be some aspects of the book which some will find more relevant than others. Nonetheless, I feel the authors have produced a valuable guide to exploring the delivery of low-intensity CBT for depression/anxiety at a time when awareness of the importance of these therapies is increasing beyond psychiatric practice. Given this, I would recommend it as an introductory reference text. This book has a rather interesting back story. In 1946, a young man recently demobbed from the army took up a position as hospital artist at Netherne Hospital in south London. His only previous experience in such a role had been at a tuberculosis sanatorium, where the patients' goals were focused on mastering technique. In a psychiatric hospital 2 years before the birth of the National Health Service, his role seemed ill-defined and slightly overwhelming: not an occupational therapist, not an art teacher, but a hospital artist. Over time the patients' obvious enthusiasm and gratitude helped Edward Adamson crystallise an approach to his task that was non-patronising, respectful and unobtrusive, valued autonomy, and was probably very therapeutic. Arguing against the use of tranquillisers in favour of a solution originating from within, his view was that 'art places the central responsibility for change upon the individual, rather than making him rely exclusively upon imposed treatment from outside'. Years later, he was founder chairman of the British Association of Art Therapists, and his pioneering work at Netherne is regarded as central to the emergence of art therapy.
This slim A4 book reads partly as an exhibition catalogue (the Adamson Collection hangs at Lambeth Hospital in London) and partly as an art therapy manual, setting out clear treatment maxims. 'My own method is to be as passive as possible', he explains. 'I never attempt to interpret a person's work, particularly when he or she is painting. There is a great temptation to ascribe all sorts of psychological meanings to the paintings, quite independently of their originators. I do not even show a great deal of curiosity about the medical history of those who come to paint. It is so easy to prejudge people by labelling them'. Avoiding displaying patients' paintings on hospital walls in order to respect their privacy, Adamson invited selected visitors to a dedicated gallery, where he used the works to teach professionals how to understand and absorb the patient's point of view.
Adamson died in 1996, having spent the last years of his life in private practice in his Chelsea studio. Art as Healing was originally published in 1984, and was the UK charity Mind's book of the year in 1985. It has been reissued in 2014 in an unedited form, the only change being a preface to summarise Adamson's life's achievements. It is an enjoyable read, but the brief chapters are slightly disjointed, and I would have liked to have read an annotated version in which art therapists commented on the works or on Adamson's approach, adding their own contemporary examples. The chapters are categorised by theme, artist, and materials. Not all the works are accompanied by a clinical story but some spell out the distinct therapeutic advantage afforded to the patient in the act of its creation. It is not always clear if the labels represent the accounts of the artists or Adamson's own interpretation, and at times the role of a particular work in rerouting a patient's prognosis feels overplayed. The text also includes poems, but it is only apparent from the acknowledgements that these too are the work of patients, and it is not clear whether they are the work of one or more authors.
These are minor criticisms. Although the book feels a little dated in relation to its gendered language, the clinical material remains fresh. In the 1980s, as now, it reveals to psychiatrists how their patients view them, underlining the importance of empathy and intelligent kindness. Thirty years on, in the wake of the Matisse trial and its finding of no benefit of art therapy on negative symptoms or global functioning in schizophrenia, and in the context of draconian cuts in mental health services, it feels that a revised version would provide a fascinating account of how contemporary art therapists view the work of Adamson, setting the historical roots of art therapy in the context of an uncertain future. I would recommend this book to anyone interested in clinical stories, the history of asylums, techniques for communicating with disturbed patients, the Jungian approach to 'letting things happen' in art, the field of Outsider Art and what constitutes its boundaries, and individual-level interventions to challenge stigma. I would also suggest it to anyone who needs persuading that we all possess a creative energy that we may not have yet released.

Lean Behavioral Health: The Kings County Hospital Story
Edited by Joseph P. Merlino, Joanna Omi and Jill Bowen Oxford University Press USA, 2014, £35.00, pb, 288pp. ISBN 9780199989522 With ever increasing pressure on budgets and an emphasis on quality, safety and efficiency of healthcare services, quality improvement has become part of everyday practice in the UK, making this book a particularly topical read. Lean is a way of thinking derived from the Toyota car industry, which looks to define value from a customer's perspective and create value by eliminating waste throughout the chain of processes required to deliver a product. The idea of continuous improvement is inherent within a lean system. Lean systems have been utilised in the manufacturing sector with varying degrees of success, but more recently the principles and techniques of lean have been transferred to other sectors, including healthcare. This book outlines how lean principles and tools were utilised to lift psychiatric services at The Kings County Hospital out of crisis and promote a culture of continuous improvement in the quality of services delivered.
The book was not always the easiest read and there were several sections where a further copy-edit would have been beneficial. It took time to become familiar with the language of lean and the acronyms used, although a glossary at the start of the book assisted in the learning process. Earlier chapters set the scene, explaining lean and the background to the crisis facing the hospital, and gave brief details of many improvement projects that were undertaken. However, at this point the exact nature of problems within different departments, solutions identified and how lean methodologies had assisted the process were not always clear. Later chapters revisited some of the examples on a department-by-department basis and gave a better sense of the value of lean tools in identifying and solving problems with the aim of sustainable change and creation of a culture of continuous improvement. Figures supplementing the text gave an indication of the scope of various lean events but it was impossible to read the detail of what had been discussed due to their small size. Although this book was not aiming to act as a manual for the application of lean in a healthcare setting, at times it was frustrating that detail in examples and figures was lacking because this would have strengthened understanding of the difficulties facing the organisation prior to and during change events and the value of lean in helping to identify solutions and guide teams through the change process.
At The Kings County Hospital, application of lean thinking typically involved initial work to establish the current state of all activities in a process requiring improvement, creation of a target state, and corresponding gap analysis between the two states. Identified problems were then addressed through rapid improvement events (during the course of a 4.5-day event waste was identified, solutions tested and improvements made), longer projects and immediate 'just do its'. Evidence was provided that where lean principles were successfully implemented within the organisation, there were consequent benefits: financially, to staff productivity and morale, to the quality, safety and efficiency of clinical services delivered, and in the experience of patients. For example, in the psychiatric emergency room, the physical flow of patients through the department and collection of patient data were streamlined, with clear standards of work developed for staff involved in each step in the process. This led to elimination of previous duplication of work, shorter nursing and psychiatric triage times and improved standards of patient care.
Overall, the book did provide a thought-provoking and, at times, inspirational commentary on real-life and wideranging changes to working practices across the hospital's psychiatric emergency, in-patient and out-patient services. It demonstrated how improvement methodologies can help to establish a new organisational culture, reduce waste and improve quality in any process pathway. As well as commenting on successful changes, the book also offered insights into changes which had not worked so well and reasons for that, acknowledging that the process of improvement is ongoing and that the organisation continues to strive towards an ideal state. The book offers a good case study as a starting point for anyone interested in incorporating improvement methodologies at any level of an organisation, demonstrating the benefits of thinking outside of the healthcare box and utilising successful quality and value improvement strategies developed in other sectors. This book is about passion for teaching and learning. The word 'curriculum' is used as a metaphor for education at any academic level. The book is composed of 12 chapters containing theoretical background and discussion about specific approaches to the development and delivery of a teaching curriculum, ranging from science and mathematics to fine arts and philosophy. These theoretical discussions focus on both traditional (or conservative) and progressive approaches to education and are accompanied by useful 'reflective activities' that help the reader deconstruct and apply underpinning pedagogical concepts and theories to their local context and circumstances. Moreover, each of the chapters contains a set of 'personal reflections' that give a human touch to teaching and learning activities in 'a real life' setting.
Although the book has a focus on the Australian context and curriculum, its messages are universal and applicable to all those who love conveying knowledge or imparting skills to younger generations.
The book also contains an interesting chapter on Indigenous education that focuses on the experiences of a young non-Indigenous teacher who lived and taught in a remote Aboriginal community school in the Northern Territory. Her personal reflections on this unique intercultural encounter and challenging teaching environment make the book relevant to any other multicultural corner of the world. This can be exemplified by the following quote: 'Understanding multiple ways of knowing becomes increasingly important, as we acknowledge that differing standpoints inform how we human persons think and experience the world'.
Academics involved in medical education rarely have any formal training in teaching. We learn how to teach on the job and in the field and make up for pedagogical shortcomings by an abundance of energy and enthusiasm. Universities around the world are moving towards 4-year graduate medical courses, resulting in a significant reduction in disciplinespecific teaching time. With shorter rotations, we need to use our time with students judiciously to ensure that they learn what is needed to cover the core components of the curriculum. Importantly, for an unpopular specialty such as psychiatry, we must also develop more creative and innovative teaching strategies to attract medical students to the 'endangered' discipline of psychiatry. The combination of reflective activities and discussion of contemporary educational topics allow this book to serve as a suitable guide for improving psychiatric education that will assist in the survival of psychiatry as a respected career choice and profession.