The Spirit of Kaizen to Improve Detection and Prevention of Delirium in the Hospital

I received an email by mistake from the psychiatry clinic manager, which may turn out to be one of the advantages of being left on an outdated email distribution list. The message described the “mini-kaizen” to be conducted at the next clinic meeting with the goal of improving processes in the clinic. The concept of kaizen comes from the Japanese concept for continuous quality improvement (CQI) in industry. You may recall that this concept was popular in the late 1980s and into the 1990s and there have been articles about it being applied in the health care industry published in the medical literature as recently as a couple of years ago.

Along with the message was an attached article published in 1992 in Psychiatrist (formerly the Psychiatric Bulletin) by M.M. Feldman, entitled “Audit in psychotherapy: the concept of Kaizen”. Feldman points out that any pressure to change an organization causes a lot of anxiety and defensive push-back. I immediately thought of the current challenges facing our Delirium Early Detection and Prevention Project. The result can be the loss of focus on the central problem and the mobilization of defensive mechanisms leading to staff withdrawal, passivity, and hopelessness. The difficulty is caused by the view that the solution for the problem is being imposed from above and ignores the anxiety caused by management’s pressure to change existing structures and processes without involving all stakeholders. Inertia results and change is prevented.

The concept of Kaizen incorporates a spirit of collaboration between all stakeholders in the process of change. It involves allaying fear of change by measuring the present state and mapping out the steps for changing it. In the case of improving the recognition and measurement of delirium, this might take the form of either relying on the International Classification of Diseases-9 (ICD-9) codes in our electronic database or setting up an alternate database to measure the prevalence of delirium that involves psychiatric consultants diagnosing delirium rather than internists (who typically lack the awareness and skill sets to properly identify delirium and which could  be enhanced by focused education). Then the group of stakeholders identifies the steps in the process that can be improved, institute changes, and again measure the incidence of delirium after changes have been made.

The speed of the Kaizen process also appeals to me. The concept of Kaizen has been more recently applied in the emergency room (ED) at Vanderbilt University Medical Center. The emphasis is on small, low-cost, low-risk improvements. They developed a CQI program which included an innovative Web-based tracking device called a Kaizen Tracker, which aids in the submission and implementation of suggestions that are called kaizen initiatives (KIs)[1]. Over the past 4 years, it has resulted in over 400 changes in the processes used in Vanderbilt’s ED, although patient outcomes have not been tracked.

Interestingly, Vanderbilt is also where some of the most exciting research and process improvement in assessment, treatment, and prevention of delirium are going on in the U.S. Check out their web site at icudelirium.org.

1.            Jacobson, G.H., et al., Kaizen: A Method of Process Improvement in the Emergency Department. Academic Emergency Medicine, 2009. 16(12): p. 1341-1349.

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