A-10 Thunderbolts and Crisis: What Happens With Precision and Focus?

2016-01-28_20-32-08“Hey, look! It’s a pair of A-10 Thunderbolts!” The distinctive buzzing hum of the planes’ turbofan blades distinguished them as “Warthogs” well before I could make them out. The four of us stood in the parking lot of ConnectionsAZ Crisis Response Center and admired these marvels as they lined up in the sky above us for landing at Tucson’s nearby Davis-Monthan Air Force Base.

Hours later, during our return drive to Phoenix we reflected on our tour and the striking success that can be achieved when a group knows exactly what they want to do… and then just does that and little else.

The A-10 has one mission only: destroy tanks. Period. Its front landing gear offset from center, the plane was literally designed around the 30 mm Gatling rotary cannon, which sprays depleted uranium armor-piercing shells at rates of nearly 4,000 rounds per minute.

Targeting small, slow-moving targets is difficult for fast jets. The A-10 flies low and slow to accomplish its singular mission and this means absorbing significant amounts of damage. In order to stay focused on its mission, the A-10 engines and pilot are wrapped in 1,200 pounds of protective titanium armor. All so that it can… destroy… more… tanks. That’s it.

In Good to Great, business visionary Jim Collins describes the magic that occurs when a team crystallizes their reason for being and refuses to be distracted by anything else. He contrasts the fox, which is good at many things, and the hedgehog which is the master of one thing. Like the A-10.

Tucson’s Crisis Response Center

Dr. Margie Balfour is Chief Clinical Officer at the Crisis Response Center in Tucson and also serves as Vice-President for Clinical Innovation and Quality at ConnectionsAZ. Dr. Balfour graciously facilitated a tour of this state of the art facility which was opened in 2011.

The result of a $50 million community bond, the Crisis Response Center facility housed crisis stabilization, with 23 hour observation and sub-acute residential beds, and separate units for adults and children. A secure “sally port” facilitated transfers from law enforcement, and a covered walk-way connected the facility to Banner University Medical Center South Campus, which includes an emergency room and acute care psychiatric inpatient unit next door. In addition, a crisis call center and peer warm line was co-located in this fully integrated and coordinated model.

IMG_1677In the original approach all these different services were subcontracted through a single vendor, an approach that might be described as “foxy,” to borrow again from Jim Collins.

On April 1, 2014, ConnectionsAZ began operating the crisis stabilization programs inside the Crisis Response Center, and Dr. Balfour relocated from Texas to Tucson to provide the medical leadership. A circuitous career path that started off as a scientist prior to developing a passion for clinical in public sector behavioral health established a foundation for a new kind of precision and focus.

If the A-10 singular mission is dispatching tanks, what is it for crisis?

It seems self-evident that crisis services should be about getting the best care to people experiencing a psychiatric emergency… FAST. It’s an emergency, and the response should match. When the call comes in, the firefighters proverbially slide down the pole and roll the trucks. Remember the opening theme to the long running NBC hit ER… everyone is running! Lives depend on it.

Yet, the reality of crisis services is often the exact opposite. It can take hours or even days in an Emergency Department to be “medically cleared” before entrance is granted to many of the nation’s crisis stabilization programs. Law enforcement and first responders are expected to take the person in crisis to the hospital first, not the crisis unit.

The experience of the over 13,000 individuals that utilized the services of the Crisis Response Center each year had been uneven. There were often long delays in the clinical triage area while the patient awaited a decision on whether they would be admitted or discharged. Frustration abounded, which was compounded because the same questions were repeated several times during the process.

The result was a decrease in safety and increase in injuries and assaults. Individuals in crisis were sometimes left unattended for long periods of time and staff were spread thin between the crisis programs and interview areas. Security was frequently involved.

Lean Six Sigma in Action

There was a significant need to improve and speed the triage process, but there was a lack of agreement on the mission of the facility. Dr. Balfour and the ConnectionsAZ team met with the leadership and front line staff in a series of town-hall meetings, conducted rounds in the facility to interview patients and staff, and worked shifts providing clinical care to view the experience up close and personal.

2016-01-31_23-20-54The result of this process was an A-10-level singular mission: Meet the immediate needs of those in behavioral health crisis in a safe and supportive environment.

In order to reengineer the Crisis Response Center for this new mission, Dr. Balfour and team utilized Lean Six Sigma. Motorola and Toyota both revolutionized process improvement, by eliminating waste and improving the flow of manufacturing, and by building upon the pioneering work of Edwards Deming in the 1950s (think Plan-Do-Study-Act). Healthcare has been slow to catch the vision, and crisis care for behavioral health has been characterized by waiting in lines, for both the patients and the various internal and external agencies with whom these programs collaborate.

The team began by establishing some assumptions. They would achieve gains with the existing resources and staffing by standardizing the process and eliminating waste and inefficient practices. They also introduced a number of interventions, including improved dashboard tracking tools.

Next, they analyzed wasted time and function. What were the tasks that added value? What were the tasks that added little value but were nevertheless required (by licensure, contract, etc.)? And, finally, what were the tasks that were waste?

The value analysis found that the old process required almost 11 hours, and that nearly 40% of this time was simply unnecessary and non-value added. Wasted time. For individuals and family members dealing with a behavioral health crisis. Idly sitting in the waiting room was a significant portion of this time, but there were also inefficiencies in some of the other tasks that needed to be improved.

The Results

The outcomes were Thunderbolt! They decreased the “door to door dwell times.” The average time spent in the triage clinic decreased from seven hours to two hours, and the time in the 23 hour unit decreased 30%, improving not only the patient experience but also the capacity through improved through-put.

Even if you haven’t been in a psychiatric crisis, most everyone has been to the Emergency Room, and the key metric we all remember… how long did it take us to see the doctor? Dr. Balfour’s team reduced the waiting time by nearly 80%. These significant gains had other cascading benefits. For example, the facility reduced dramatically the time it spent on diversion so that it could better serve the needs of those in crisis in greater Tucson. Assaults to staff and calls to security were also dramatically reduced, and the changes in process yielded additional space. The building was remodeled to take advantage of these improvements and the capacity of the temporary observation unit was increased by 36%.

Dr. Balfour believes there were several key ingredients in their success. They engaged everyone from top leadership to the line staff. They kept compliance and quality functions separate, and obtained Lean Six Sigma green belt certification for quality staff. And, they built the IT and data system necessary to track and report accurately on the performance.

When I think of the A-10 level focus of the ConnectionsAZ culture, the metric that comes to mind most readily is law enforcement drop-off turnaround time. First responders don’t take people in crisis to the emergency room first. They drive straight to crisis facilities in Phoenix or Tucson where they spend between five and ten minutes before returning to their patrol.

Precision and focus. Business is changing healthcare, and lean six sigma has come to psychiatric crisis services. The results are in, and it’s time for us to re-model our own A-10 Thunderbolts.

We can measure our performance and progress through the levels below.

Levels of Accomplishment

Level 1 Everyone in the organization/department knows what the unit’s core processes are.
Level 2 Each core process is fundamentally documented.
Level 3 The primary customer requirements of each process are documented and conformance to spec is tracked.
Level 4 The primary control factors that drive desired performance for each process are documented and tracked.
Level 5 Each process can be documented to be behaving as intended (e.g., is “in control”).
Level 6 Each process is completely standardized, in control, and has an on-going continuous improvement plan.


Note: Dr. Margie Balfour will be one of the presenters at the National Council for Behavioral Health conference in Las Vegas on March 7 – 9. Also, check out her article: “Crisis Reliability Indicators Supporting Emergency Services (CRISES): A Framework for Developing Performance Measures for Behavioral Health Crisis and Psychiatric Emergency Programs,” Community Mental Health Journal, 2015 (download here), which includes the outcomes model below. 


Originally posted on by

Defend the Alamo: Crisis Mental Health Care Must Be Transformed

shutterstock_9835540Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s Emergency Departments are the Alamo of mental health access and care.

The recent headline was not surprising: “8 in 10 ER Docs Say Mental Health System Is Not Working for Patients.” The survey by the American College of Emergency Physicians (ACEP) of 32,000 physicians, residents and medical students working in hospital emergency departments concluded that “boarding” wait times for psychiatric inpatient needed to be reduced and more training and education of staff about psychiatric emergencies was required.

Sheree Kruckenberg is Vice President Behavioral Health for the California Hospital Association, which represents 400 hospitals and health systems. Her April 2015 open letter drew similar conclusions:

“The increasing dependence on… hospital EDs to provide behavioral evaluation and treatment is not appropriate, not safe, and not an efficient use of dwindling community emergency resources. This includes not only hospitals, but emergency transportation providers and law enforcement. More importantly, it impacts the patient, the patient’s family, other patients and their families, and of course the hospital staff.”

The Emergency Nurses Association (ENA) has reported similar challenges with a shortage of tailored education and training. According to the National Alliance on Mental Illness (NAMI), many patients and families are displeased with their experience in the ED because of wait times and a lack of respect.

Everyone seems to agree with the problem.

The solution doesn’t seem as clear. ACEP is leading a response with a larger group of partners to form the Coalition on Psychiatric Emergencies, also known as “COPE,” with the goal of improving mental health and addiction care in EDs.

History would suggest those reinforcements aren’t coming in the numbers necessary. By the time the mental health crisis reaches the Alamo, the battle is already lost.


Our country’s approach to crisis mental health care must be transformed. It is the time, and we have the tools to prevent tragedies like these:

  • Unspeakable family pain: In November 2013, Virginia State Senator Creigh Deeds told CNN that he was alive for just one reason: to work for change in mental health. Just a week earlier, his son “Guss” stabbed him 10 times and then ended his own life by suicide. This happened only hours after a mental health evaluation determined that Guss needed more intensive services, but unfortunately, he had to be released from custody before the appropriate services could be found.
  • Psychiatric “boarding”: The month prior, the Seattle Times concluded their investigation of the experience for individuals with mental health needs in Emergency Departments. “The patients wait on average three days [emphasis mine] — and in some cases months — in chaotic hospital EDs and ill-equipped medical rooms. They are frequently parked in hallways or bound to beds, usually given medication, but otherwise no psychiatric care.” In 2014, the state supreme court ruled the practice of “psychiatric boarding” unconstitutional.
  • The wrong care, in the wrong place, compromising other medical urgent care: In April 2014, California approved $75 million for residential and crisis stabilization and mobile support teams. This investment was based on the belief that 3 out of 4 visits to hospital emergency departments for mental health and addiction issues could be avoided with adequate community based care.
  • Thousands of Americans dying alone and in desperation from suicide: And, in 2015, the National Action Alliance for Suicide Prevention launched the Crisis Task Force, with the goal to provide stronger 24/7 supports to the 9 million Americans at risk each year. Over 115 people per day in the US die alone and in despair.

Four different compelling reasons. Public safety. Civil rights. Extraordinary and impactable waste of public funds. And, the opportunity to address one of our most intractable human problems. The time is now, and the burning platform is clear.

It does not have to be this way. In a few states and communities across the U.S., solutions are in place. But until now we do not have the vision or will to approach crisis care with national resolve and energy.

Three examples highlight what can be done differently.

  • Power of Data and Technology. The Georgia Crisis and Access Line utilizes technology and secure web interfaces to provide a kind of “air traffic control” that brings big data to crisis care and coordination in real time.
  • Power of Peer Staff. People, Inc.’s Living Room, peer staffing and retreat provide safety, relief and recovery in environment more like the home than the institution.
  • Power of Going to the Person. Colorado Access’ mobile crisis teams don’t wait for law enforcement to transport a person in need to the hospital. They go to the person. Colorado is the first state to prove this can be done in urban, rural… and yes, even frontier areas.

Now is the time for a new approach.

crisis services graph

California, Colorado, Georgia and Washington State were driven to new approaches because of vastly different primary drivers, but five key elements stood out.

  1. The Expansion of Community Based Mobile Crisis Services to a 24/7 outreach and support with a contractually required response time (Colorado and Georgia)
  2. The introduction of Crisis Stabilization Programs that offered 23 hour observation and sub-acute short-term stays, at lower costs and without the overhead of hospital-based acute care
  3. Crisis triage call centers with strong use of technology and information across a system of care, leveraging big data for performance improvement and systems accountability while providing high touch support informed by suicide prevention best practices
  4. The engagement of peer staff, trauma informed care principles and recovery cultures to improve the experience and outcomes
  5. The involvement of government leaders, with activating legislation in California and Colorado, key engagement of the governor in Colorado and Georgia, and the judicial branch (DOJ, Supreme Court) in Georgia and Washington State2016-01-19_14-45-49

Now is the time for crisis, and we can do far better.

Our society takes for granted a national emergency medical response system. 911 centers with high technology to assure individuals with other medical problems do not fall through the cracks. These have transformed stroke and heart attack care. Ambulance services go to the person directly to assure immediate life-saving care, with  emergency medical services in every area of the country, urban, rural and frontier. We can do the same for other brain health crises. We must.

Defend the Alamo.


Note: In 2015, the National Action Alliance for Suicide Prevention launched a consensus expert task force on crisis that I have co-led with Dr. Mike Hogan. He and I co-authored the majority of the blog above and this content will appear in the foreword to the upcoming white paper, “Crisis Happens Now: Transforming Services is Within Our Reach.” 

Also, the #NatCon16 conference in Las Vegas March 7 – 9 will host its 3rd annual crisis track, featuring a stellar line-up including Carolina Healthcare’s Dr. John Santopietro, Beacon Health Options’ Dr. Chris Carson, ConnectionsAZ’s Dr. Margie Balfour and Community Health Network’s Dr. Marlon Rollins and Suzanne Clifford and others. Click here for more info.

Finally, I would like to credit the leader of RI Crisis Leon Boyko, who developed the “Defending the Alamo” metaphor. Since beginning with RI International in 2014, he has partnered with health leaders in Arizona, California, Delaware, North Carolina and Washington State to launch half a dozen new recovery-based crisis stabilization and crisis respite programs. 


Originally posted on by

The Bugs and the Bees: Mental Health Really Matters for All of Us

beesAs we kick off 2016, it’s time to sit down and have that awkward “bugs and bees” talk. We cannot put it off any longer. It’s time to explain why mental health really matters for all of us.

Business leaders are not unacquainted with the negative impact of mental health. In any given week, nearly half a million Canadians are unable to work due to mental health problems. One in three disability claims are related to mental health, and the cost of claims and lack of productivity is exorbitant (70% of disability costs are attributed to mental illness). Despite this, many of us view mental health as something that pertains to other people.

Perhaps a story from nature will help us understand why mental health matters, and help us better connect with how life works. Believe it or not, we humans have a lot in common with ants and bees, as well as other eusocial species like mole rats. These groups all share intergenerational and cooperative care of their young, and division of labor is critical to their survival. Just like humans.

Dr. Thomas Joiner’s team at Florida State University has been studying the “bugs and the bees” to look for parallels with the Interpersonal Model of Suicide. This breakthrough concept, introduced just over a decade ago, suggests that people end their life by suicide because of two dominant intrapsychic pains:

  • They believe they are a burden to others
  • They have a sense of thwarted belongingness

When this happens to a bee or ant (because of injury or disease, for example), three things occur. First, it becomes very agitated. Next, it separates itself from the group. Lastly, it dies. Joiner’s team suggests that suicide among humans is a derangement of this self-sacrificial process observed among other eusocial species.

Feeling alone. Feeling that others would be better off without them. On the continuum of mental illness, this represents the darkest side and generates tremendous emotional pain and thoughts of death.

But consider the flip side of these two coins: contribution and connection. Two words. What do these words tell us about mental health? That instead of feeling like a burden to others, one perceives they are making a difference for their family, friends, and/or community. And this belief is inextricably tied to an engagement to others in the “colony.”

It’s early in 2016, which means that about a third of us are still thinking about our New Year’s resolutions. Perhaps you want to improve your health. You’ve committed to losing weight. Exercising more. Quitting smoking.

If you’re a smoker, giving up cigarettes is only the second most powerful thing you can do to improve your health. You’ll never guess what the best thing is.

Strengthening social supports.

In 2010, Julianne Holt-Lunstad performed a meta-analysis of nearly 150 scientific studies on morbidity and mortality. She concluded that the most powerful predictor was strengthening social supports. Being alone and feeling lonely increased the likelihood of death by 30%. By contrast, having friends and strong social connections will help you live longer and live better.

This isn’t a feel-good theory. It’s science. We thrive in work and life when we feel connected and are making a contribution. We despair when we feel alone and feel others would be better off without us. There is a long continuum in between the two.

The Mental Health Commission of Canada has created a simple continuum model to help explain how this works. There are four categories, ranging from healthy to ill, and the model describes the symptoms and states for each, as well as important actions to take at each phase. We are all on this line, moving back and forth along it throughout our lives.

mental health continuum modelSurprisingly, this continuum can be a hard concept for those individuals who have spent most of their days in the green, feeling like they are on top of the world. What they don’t realize is that they feel that way largely because of their social support network and the influence and impact they perceive they are making.

But we are all part of the colony. Life happens. The marine who has no memory of a time that wasn’t green gets injured, is discharged, and finds himself in the red very quickly. Same for the senior executive who for years has had thousands depending on her and when she retires, she suddenly perceives her life more of a burden than a benefit.

Now imagine how a serious mental illness such as schizophrenia, bi-polar disorder, major depression, or an addiction might skew a person’s view of their role in the colony. We tend to view suicide risk as a symptom of the mental illness, but the real threats are lack of contribution and connection.

The Harvard Business Review agrees. The recent article “Proof That Positive Work Cultures Are More Productive” by Seppälä and Cameron describe the negative outcomes of high-pressure companies. Healthcare costs are doubled and productivity is siphoned away. There is a 50% increase in voluntary turnover in these environments and errors and defects are 60% more likely.

Their answer for managers is simple. Go out of your way to help. Show empathy. Encourage people to talk to you. And most importantly, foster social connections.

In “First, Break All the Rules: What the World’s Greatest Manager’s Do Differently,” authors Marcus Buckingham and Curt Coffman show us that the best managers have staff who can answer yes to all the following key questions:

  • Do I have a best friend at work?
  • Does my work matter?
  • Does my supervisor or someone at work care about me?
  • Do I get to do what I do best every day?

I’m not naïve. The challenges of work can be intense, but they’re much more manageable when the work is shared and the worker is valued. It’s a little like charging into my first mud runner event a few years ago. Seemed like a great idea as I was sprinting along at front of the pack, and at the very first obstacle, our group came to a sloshing stop in muddy water. The person immediately to my right stumbled full up to their neck.

None of us could find a way to scale the muddy hill in front of us. We slipped and slid with others piling into the muddy pool, pressing us from behind. The guy next to me found a small stick and tried to claw his way out, but he failed. I grabbed the stick from him and forced it into the dirt so that he could plant his foot and lunge to the top.

My fellow ant looked back ever so briefly to express his thanks, and I yelled for him to reach down and help pull me up, too. He hesitated for an instant, and then leaned over, extending his hand and working to pull me up the mudslide, but our grip failed.

I urged him to give it one more try. He did and a moment later, I was up and over the top and the two of us were on to the next obstacle.

No, I didn’t win a Nobel prize and he didn’t cure cancer. But those brief moments demonstrate the essence of how life works, and why mental health matters for everyone. We’re part of a community. We work together to care for each other across generations. We divide labor to survive. We thrive when we are connected, and when we realize what we do helps others.

Ants do it. Bees do it. Humans do it, too.

Let’s stop putting it off. It’s time to talk about the bugs and the bees.


Note: I’m posting this blog from Washington DC participating in tomorrow’s The White House Dialogue on Men’s Health, an unprecedented event featuring the U.S. Surgeon General and Cabinet Secretary Broderick Johnson. Speakers include international leaders like Dr. Sally Spencer-Thomas and Kevin Hines.