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Improving access without adding resources at Utah State Mental Health Hospital 


Utah State Mental Hospital (USH) in the USA is a forensic and civil mental health hospital that was facing a challenge that seemed insurmountable and yet unavoidable.  Patients accused of crimes and deemed incompetent to stand trial until receiving services were waiting an average of six months to be admitted to the hospital, with some patients waiting up to 18 months. 

A lawsuit had led to a settlement agreement, whereby USH was required to quickly and significantly reduce waiting times or face a $25 million fine. The settlement agreement mandated that USH reduce waiting times to 60 days within three months, further reducing waiting times to 30 days within eight months, and 14 days within 15 months, and then maintain this for five years without a breach.


USH implemented the Flowful approach to create a breakthrough in patient flow, in order to free up capacity and improve patient care and timely access without any additional resources.

The Flowful implementation involved an initial analysis of the total delayed bed days. Within a few weeks, the few underlying causes had been identified and had started to be resolved. Through a highly focused and systematic approach based on live data from the Flowful system, a rapid cycle of continuous improvement was initiated. The implementation was led throughout by the Superintendent and Medical Officer and Assistant Superintendent/Forensic Director, with the IT team providing the initial support to facilitate rapid and successful implementation.

The results were achieved through a reduction in length of stay in a patient-centered and clinically led way, freeing-up capacity and enabling better patient throughput for better access. This was achieved through improved synchronization of work across the system and through a focused process of ongoing improvement.


USH was able to improve access and reduce waiting times much faster than required by the settlement agreement. Waits for admission were reduced to 30 days within three months and 14 days within nine months without any breaches, and without adding any resources. These results have been sustained for over five years and throughout the Covid pandemic.

This was achieved by improving patient flow – first within the USH forensic department, and then by spreading the approach to their wider community of actors, before expanding the approach to the USH’s civil mental health department.

The Flowful system is now at the heart of daily activities enabling patient plans to be seen and acted upon both within the hospital, the wider health authorities, and out-of-hospital care providers. For forensic patients, the court diary system was also resynchronised to align with the patient’s actual care plan, resulting in fewer delays and fewer missed court hearings.

The approach has decreased disruptions and delays, improving patient satisfaction, care quality, and safety. It has also led to increased transparency and clarity, benefiting personnel and leadership, and resulting in more efficient decision-making. Overall, the approach has transformed the Utah Mental Health system, with successful implementation across the whole system.

“Our ‘Flowful’ journey has taken our hospital that was facing a crisis of demand exceeding capacity to an efficient, patient-centered system by improving flow.  ‘Flowful’ taught us to challenge assumptions and change behavior to deliver breakthrough results. The principles of the Theory of Constraints work in the mental health field and have applications for effective, safe, and quality-focused system-wide management.”

Dallas Earnshaw, Superintendent, Utah State Hospital
Dr. Gundlapalli, Medical Director, Utah State Hospital

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