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Jt Comm J Qual Patient Saf. 2009 Sep;35(9):439-48.

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.

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Adult Psychiatry Clinic, Langley Porter Psychiatric Hospital and Clinics, San Francisco, CA, USA.



Health care organizations have increasingly embraced industrial methods, such as the Toyota Production System (TPS), to improve quality, safety, timeliness, and efficiency. However, the use of such methods in psychiatric hospitals has been limited.


A psychiatric hospital applied TPS principles to patient transfers to the outpatient medication management clinics (MMCs) from all other inpatient and outpatient services within the hospital's system. Sources of error and delay were identified, and a new process was designed to improve timely access (measured by elapsed time from request for transfer to scheduling of an appointment and to the actual visit) and patient safety by decreasing communication errors (measured by number of failed transfers). Complexity was substantially reduced, with one streamlined pathway replacing five distinct and more complicated pathways. To assess sustainability, the postintervention period was divided into Period 1 (first 12 months) and Period 2 (next 24 months).


Time required to process the transfer and schedule the first appointment was reduced by 74.1% in Period 1 (p < .001) and by an additional 52.7% in Period 2 (p < .0001) for an overall reduction of 87% (p < .0001). Similarly, time to the actual appointment was reduced 31.2% in Period 1 (p < .0001), but was stable in Period 2 (p = .48). The number of transfers per month successfully processed and scheduled increased 95% in the postintervention period compared with the pre-implementation period (p = .015). Finally, data for failed transfers were only available for the postintervention period, and the rate decreased 89% in Period 2 compared with Period 1 (p = .017).


The application of TPS principles enhanced access and safety through marked and sustained improvements in the transfer process's timeliness and reliability. Almost all transfer processes have now been standardized.

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