Being Well, Being Agile

Kalen walks into a meeting room at Monash Hospital with confidence. He is here to talk about his experience with the Agile Psychological Medicine Clinic, a mental health clinic run by Monash Health, the largest public health service provider in Melbourne, Australia. “I have been misdiagnosed and mis-medicated for ten years with no improvement. I came through [the clinic] and I am now fixed," he declares, with a satisfied smile on his face.

Only a few months ago, Kalen’s anxiety at the very thought of entering a hospital, even for the most minor procedure, would have made this encounter almost impossible. His apprehension may come as no surprise. For more than a decade Kalen, a transgender person now in his thirties, went from treatment to treatment and had been given just about every possible mental illness label. Despite opening up and exposing his vulnerabilities, Kalen became convinced that no one was truly listening. Many years of perseverance resulted in little progress toward the meaningful life for which he so desperately longed. He felt the system had failed him.

Last January, in the midst of a crisis, things took a different turn. Kalen was admitted to the hospital for uncontrolled twitches and body movements. The initial assessment conducted by the neurological unit could not find a neurological cause, which left the possibility of a psychological explanation. The unit referred him to the team at the Agile Psychological Medicine Clinic. 

The treatment that awaited him was unlike anything he had experienced before. “All the other mental health people I had seen had just been like, ‘Let’s slap a label on you and medicate you for that label, and who cares if it really fits. Let’s just get you in and out the door,’” Kalen recalls. 

This clinic’s approach, inspired by the agile ethos, was different. Here, interactions are valued over processes, the collaboration between clinicians and patients is at the core of the treatment, and clinicians have the ability to respond to change rather than being bound by rigid plans. 

Building from the ground up

In Australia, one person takes their life every three hours. This alarming number is on the rise and is one of the reasons why Dr. Melissa Casey, Director of Psychology at Monash Health, feels so passionate about change in the health system. “We know that mental health is a significant issue. We know, when we look at suicide rates and people presenting in great distress, that what we are doing currently in terms of clinical services is not meeting our community’s needs,” Dr. Casey says. 

Dr. Casey has led the innovative service reform that gave birth to the Agile Psychological Medicine Clinics. They are challenging the traditional means of care in the public health system by adopting the agile framework to improve the health and well-being of the community. 

Monash Health had been struggling to meet new KPIs for their emergency care, and the issue was brought to Dr. Casey’s attention. The pivotal moment in her thinking, however, came when she and her colleagues looked at the staggering increase in the number of people presenting in crisis to emergency care. In her mind, it was a clear sign of a broken system.

During the data analysis for design phase, user journey mapping — a technique borrowed from UX design — was used to demonstrate how patients currently engage with the system. Dr. Casey recalls one example in particular. Tom, a middle-aged man who had attempted suicide, had several contacts with Monash Health clinicians. Over a couple of months, he went through 13 case managers who updated his record 70 times. In total, Tom’s case was handed off 18 times, but he only saw a clinician three times. What surprised Dr. Casey even more was that information relating to Tom’s clinical care was scattered through five different IT systems and 15 paper records. Was this really the best clinical care for Tom?

Armed with evidence and a better understanding of the problem, Dr. Casey started to consider whether the agile approach could be part of the answer to delivering better quality and faster, more responsive mental health care.

The new solution needed to be more human-centric and had to deal explicitly with the complexities of both human clinical needs and the health care system. It needed to broaden its focus on delivering services efficiently to include consideration of its effectiveness as experienced by the patients.

That’s where agile came in —to address a complex problem that more traditional, planned approaches had consistently failed to solve. Adopting agile principles as a foundation for reforming clinical care would not just enhance the customer experience; it would enable clinicians to adapt quickly to feedback and allow them the agility they needed to be effective and efficient. 

“It’s the patients who are at home that know whether they are functioning well and whether they are improving as they go through clinical treatments. That’s how we know whether we are making a difference,” Dr. Casey says.

In 2013, after several weeks of co-design and workshops with other clinicians and agile coach consultants to create the new model of care, the prototype Agile Psychological Medicine Clinic opened in Berwick.

Berwick: Only the beginning

From the moment you set foot in the original clinic in Berwick, there is an immediate sense of calm. The fact that the clinic is in a separate building, but within a short distance from the hospital, is no coincidence. As it turns out, taking the clinic out of the hospital setting was one of the first things addressed in developing the concept. This shift allowed Dr. Casey's team to test their hypothesis in a measured environment, independent from the rest of the hospital system. However, it remains within a general practice medical clinic, so patients can receive their ongoing care here in a seamless transition after they have received their specialist care within the agile clinic. 

The difference in the approach is immediate and obvious. Friendly receptionists seated behind a table greet patients as they arrive for appointments. It's a stark contrast to the security glass enclosure one would expect to see in a clinic that regularly deals with high-risk patients. There are no bright lights or loud noises to remind patients of their journey through ER. Instead, the reception area is furnished with colorful seats in many different shades and walls are painted in soft tones, adding to the peaceful environment. 

The consultation rooms seem plain and minimalist at first glance. There is a desk with a computer and two identical armchairs, on each side of a coffee table, slightly angled so that they aren’t completely facing one another. There was a deliberate intention to move away from a more traditional therapy seating arrangement to one that is less confronting. It tries to create a more inviting setting that inspires dialogue between the clinician and the patient, which is in line with the agile philosophy of valuing collaboration. 

Within the first year of opening the prototype clinic, Dr. Casey and her team won a state award for delivering innovative mental health care in the state of Victoria. The overall approach of the clinic, its physical setting, flexible treatment programs, and streamlined processes were quickly recognized as groundbreaking. They are regarded as progressive solutions for seemingly intractable problems in a health system under mounting pressure. Its success also meant that four more clinics have since opened near other hospital emergency departments in the region.

Putting it all in practice

Most people coming through the agile clinics are in a crisis state. They are either referred by a hospital emergency department or via a telephone triage service. The importance of being responsive and acting quickly can make a big difference to the patient’s immediate safety and future recovery. For this reason, every effort is made to eliminate waiting lists so that all patients are seen within 72 hours. This response makes each patient feel as though his or her case is taken seriously.

The clinics have a strong collaborative treatment focus, as it is acknowledged that patients are the experts in their life, their struggles, and their goals. From the first appointment, patients receive tools that help them stay safe and build the resilience they need to manage any future crisis. “We try to give people practical strategies. Even from the first session, you are at least given something to go home with,” psychologist Kirsten Yates says. Those practical strategies are tailored to each individual and can range from simple breathing and self-soothing techniques to enlisting social support to help them through the journey. “It’s not just an assessment process where it feels like the client is having to give everything. We try very hard to make sure that there is always something that is practically useful.” 

Patients are active participants throughout their treatment. They are involved in every step of the process, from diagnosis to the treatment they receive. They even have the opportunity to rate their clinicians after every session to ensure mutual understanding and to influence future outcomes. This alone would be enough to scare most psychologists and medical doctors, who aren’t usually the ones in the firing line, but the collaborative and adaptive culture drawn from agile principles means that clinicians see this as an opportunity to learn and improve the services they offer every patient. They all agree there is no point to hammering away in a manner that's not working for the patient.

Clinicians spend time developing and nurturing relationships with their patients to create a continuity of care that is so obviously missing in most other areas of the health system. “We try to maximize the relationship and minimize the handovers. That’s a core part of the agile philosophy,” Yates says. It's a recognition of the importance of human relationships to good mental health and strikes at the heart of the clinic's mission.

Depending on the diagnosis, patients are typically seen for a dozen sessions over three or four months. Such rapid delivery of care is in line with the key agile principle that time is of the essence.

The high success rate of the clinics is heavily influenced by what happens behind the scenes. Each week, clinicians discuss cases together during team meetings in a way that would be familiar to anyone who has participated in an agile ceremony. They evaluate cases to see what could be done differently to ensure the continual progress of treatment. This fluidity gives clinicians the freedom to notice any emerging issues. They then have the ability to be more responsive, which isn’t necessarily the case when there are too many constraining plans and processes or where things might go unnoticed until it is too late. The meetings also provide a forum for ideas that draw upon the full depth of expertise and experience in the room.

Making a difference

Approximately 1350 patients have been treated through the clinics. But what matters for Dr. Casey is whether there are significant improvements that are actually noticed and reported by the individual patients themselves. “Patients are actually getting better,” she says. “We can see a marked improvement from their point of view, because we ask them. We work with them right from the start in terms of their understanding of the problem. In mental health, it is not just a biological phenomenon — it’s a biological, social, and psychological phenomenon. So we really need to understand, as clinicians, what it is like for them.”

Over a period of 12 months, data was obtained from 222 patients who used the services offered at the original Berwick clinic. The trend showed a 23 to 46 percent improvement on several standardized measures following treatment. This included measuring clinical outcomes from a range of symptoms such as anxiety and depression, as well as scales tracking the patient‘s level of demoralization, improvement in social functioning, and their satisfaction with care received.

The data collected also showed a significant decrease in the number of clinicians involved in each patient‘s care. Stubbornly high handover rates of patients to clinicians plagued previous approaches, as demonstrated in Tom‘s journey. Psychologists and psychiatrists who delivered the services also contributed to the evaluation. Overall, they reported high job satisfaction. This was backed up with evidence showing minimal rates of sick leave.

Agile in health care

The adoption of agile outside of software development is growing and less mature than in tech. But, worldwide, an increasing variety of industries are turning to its principles to instigate workplace change. What the Agile Psychological Medicine Clinics in Australia show is just how versatile the concept can be. In health care — an industry that is constantly under pressure and notorious for its resistance to change — agile could play a powerful role in overcoming institutional inertia in order to deliver innovative approaches. 

For Dr. Casey, the same principles that led to the creation of the clinics in the mental health space could be part of the answer to improving the broader health system. “We need to be responsive to new trends, looking at the behavior of the system and using the retrospective-type processes that are quite consistent with what we do as psychologists — be psychologically agile. To achieve this, leaders must create a psychologically enriched environment that fosters creativity and adaptation. This is critical." 

While the success of the clinics has been received positively by many practitioners and leaders, Dr. Casey admits that it wasn’t always easy to break through the bureaucracy.

“It’s a continuous learning activity,” she concludes. “We are learning and improving all the time, and that is the point. There is never an end. It’s a constant learning and improving cycle. And that is quality care.” 

Kalen is only one of many success stories coming out of the clinics. In the end, he was diagnosed with post-traumatic stress disorder and treated with evidenced-based trauma treatment and cognitive processing therapy. This diagnosis was only touched upon in his earlier contacts with the health system, despite its ultimately proving to be the underlying condition responsible for the wide range of symptoms he suffered over many years. 

Six months after completing treatment with the agile clinic, Kalen has his life back. He is studying at university and is able to function effectively and happily within the community. 

“I am awake, I am completely different,” he says. “[Before treatment] I was depressed and hyper vigilant and miserable, and now I'm not. It’s great!”