Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Lean Perspectives: A Case for Implementing Parent–Child Relational Problem Screening

Bryson C. Okeoma, DNP, RN


The purpose of the current study was to make a case for instituting parent–child relational problem (PCRP) screening as a standard of care in pediatric inpatient psychiatric units due to increasing evidence that PCRP may be an underreported problem that affects more adolescents than currently realized. Adolescents who are admitted to the hospital for mood exacerbation, suicidal ideation, self-harm behavior, or behavioral escalation may improve and be discharged. However, these adolescents often are readmitted, which may be associated with parent–child relational factors. By identifying adolescents with PCRP and initiating holistic therapy/intervention that addresses the underlying cause of their PCRP, it may be possible to improve the parent–adolescent relationship and break the cycle of admission, discharge, and readmission. PCRP is increasingly recognized as a risk factor for development and progression of childhood mental illnesses. Investment in screening and treatment for PCRP may result in significant cost savings from prevention or reduction of rehospitalization and/or amelioration of disability. [Journal of Psychosocial Nursing and Mental Health Services, 56(9), 27–32.]


The purpose of the current study was to make a case for instituting parent–child relational problem (PCRP) screening as a standard of care in pediatric inpatient psychiatric units due to increasing evidence that PCRP may be an underreported problem that affects more adolescents than currently realized. Adolescents who are admitted to the hospital for mood exacerbation, suicidal ideation, self-harm behavior, or behavioral escalation may improve and be discharged. However, these adolescents often are readmitted, which may be associated with parent–child relational factors. By identifying adolescents with PCRP and initiating holistic therapy/intervention that addresses the underlying cause of their PCRP, it may be possible to improve the parent–adolescent relationship and break the cycle of admission, discharge, and readmission. PCRP is increasingly recognized as a risk factor for development and progression of childhood mental illnesses. Investment in screening and treatment for PCRP may result in significant cost savings from prevention or reduction of rehospitalization and/or amelioration of disability. [Journal of Psychosocial Nursing and Mental Health Services, 56(9), 27–32.]

Mental health of adolescents with mood disorders often improves when adolescents are admitted to the hospital. Adolescents are subsequently discharged but may be readmitted for another episode of mood exacerbation, behavioral escalation, suicidal ideation, or self-harm behavior (Tossone, Jefferis, Bhatta, Bilge-Johnson, & Seifert, 2014), creating a cycle of admission, discharge, and readmission. This assessment pattern was evident during a group therapy session in an inpatient pediatric unit in which some adolescents identified their relationship with their parents as the major contributor to their mood exacerbation, behavioral escalation, suicidal ideation, and self-harm behaviors (Okeoma, 2017). Therefore, there is a need to identify adolescents at risk for PCRP and implement appropriate interventions. A field trial conducted at a Midwestern children's hospital found a 34% prevalence rate of parent–child relational problems (PCRP) in the patient population screened (Wamboldt, Cordaro, & Clarke, 2015). Furthermore, a quality improvement project at a metropolitan children's hospital in southeastern Florida found 75% PCRP prevalence in the sample population, although this finding was limited by a relatively small sample size (Okeoma, 2017).

The current article makes a case for instituting PCRP screening as a standard of care in inpatient psychiatric units based on increasing evidence that PCRP may be an underreported problem that affects more adolescents than currently recognized (Okeoma, 2017; Wamboldt, Cordaro, et al., 2015). In the lean business model, screening for and treating PCRP constitute a “value” identification, which, when addressed, may have the potential to eliminate waste arising from rehospitalizations, financial cost, and/or burden of disability imposed by functional deterioration from untreated mental illness attributable to PCRP. The lean business model provides the framework for implementing PCRP screening as a standard of care in pediatric inpatient psychiatric units. The lean business model has been credited with improvement in patient outcomes, patient satisfaction, and health care cost savings (Belter et al., 2012; Hwang, Hwang, & Hong, 2014; Kates, 2014; LaGanga, 2012; Magalhães, Erdmann, da Silva, & dos Santos, 2016).


Lean is a business model with a primary focus to remove waste or anything not required to produce a product or service (Joosten, Bongers, & Janssen, 2009; Lawal et al., 2014; Teich & Faddoul, 2013; Womack, Jones, & Roods, 1990). By eliminating waste or redundancy in the manufacturing process, flow time is improved, variation is reduced, and standardization is achieved, resulting in reduced risk of errors and improved efficiency, productivity, and profitability. The lean model achieves these goals by focusing on five essential steps (Nave, 2002):

  • Identify value. Which features of the production process create value for consumers in terms of meeting customer needs, product availability, and cost of product?
  • Identify value stream. Determine the sequence of activities that contribute value as well as the activities that do not contribute value. For activities that do not contribute value, determine whether they are necessary. If they are necessary, reduce their impact to a minimum.
  • Flow. Improve flow of activities after clarifying value-added and non-value-added activities; minimize interruption between activities.
  • Pull. Let health care consumers pull services or products through the system by making products and services available to consumers when they are needed.
  • Perfection. Perfect the process through iteration driven by ongoing needs to remove waste, improve flow, and satisfy needs of the customer.

The lean philosophy of removal of waste fits the overall objective of identifying patients with PCRP and treating the underlying cause. Identification and treatment of adolescents with PCRP may help reduce waste associated with cost of rehospitalizations and indirect costs of mental health exacerbation and associated disabilities.

Evidence-Based Research

The lean business model is credited to the Japanese automaker Toyota®, and its evolution and adoption in the manufacturing and service industries are well documented (Ruffa, 2008; Teich & Faddoul, 2013; Womack et al., 1990). The model has been used in manufacturing and service industries as a tool to eliminate waste and increase efficiency, productivity, and profitability (Ruffa, 2008). In health care, organizations wishing to eliminate waste, improve patient outcomes, reduce costs, and improve patient satisfaction are increasingly adopting the lean model or other competing business models (Belter et al., 2012; Hwang et al., 2014; Joosten et al., 2009; Kates, 2014; Lawal et al., 2014; Lighter, 2014). There is recognition of the uniqueness of implementing lean practices in health care compared to manufacturing and service industries (Hwang et al., 2014). The imperativeness of deploying lean is driven by unique challenges in health care, such as demographic changes (e.g., the growing older adult population), cost and quality of care, and reimbursement considerations (Hwang et al., 2014). Thus, health care organizations are increasingly looking for opportunities to improve health care quality and reduce cost.

To address ongoing systemic challenges in the hospital setting, lean principles have been used as tools to improve interdepartmental interactions, employee satisfaction, and quality of patient care by reducing errors and waiting times (Graban, 2008). For example, the Denver Health Medical Center used lean principles to streamline its operations and eliminate waste (Nuzum, McCarthy, Gauthier, & Beck, 2007), and in the process reportedly saved $2.8 million without cutting back on patient care or reducing staffing (Shanley, 2007). Likewise, a savings of $10 million in 2005 was attributed to the Wisconsin-based ThedaCare Hospital Systems' lean programs (Matzek, 2006). At Prairie Lakes Health Care, lean approaches were used to reduce time to admission (Homolo & Fuller, 2008), and the University of Pittsburgh Medical Center used lean to improve patient flow and reduce wait times by focusing on the emergency intake process (Martin et al., 2009). Two other projects within the University of Pittsburgh Medical Center demonstrated lean-enabled improvements in the discharge of in-patient cancer patients to ambulatory services, as well as improvement in patient flow and reduction in unnecessary paperwork in the outpatient foot and ankle clinic (Martin et al., 2009). Similarly, St. Luke's Hospital in Houston, Texas, credited lean approaches with variability reduction, standardization in health care, and improvement in quality that met national health care standards (Cook, 2008).

Other applications of lean approaches in nursing and health care in general have been reported. More recently, the lean model was used to reduce waste and unnecessary hospital stays while enhancing customer values and deploying resources judiciously (Hwang et al., 2014). The model was used to simultaneously achieve improvement in quality and reduction in cost of care in a geriatric fracture center (Kates, 2014), and was credited with eliminating waste, reducing cost, and improving quality and safety at Virginia Mason Medical Center (Belter et al., 2012). The University of California Los Angeles Health integrated lean methodology in a clinical project to reduce readmission and achieved readmission reduction from 12.1% before the project (September 2010 to December 2011) to 11.3% after project initiation (January 2012 to June 2013) (Afsar-Manesh, Lonowski, & Namavar, 2017).

In the psychiatric setting, although not directly identified as a lean project, Schaumberg, Narayan, and Wright (2013) recognized long waiting times as a risk factor for poor adherence with initial psychiatric evaluation (IPE) appointments, and the authors demonstrated through a bridging program how advanced practice nurse–driven intervention could improve IPE outcomes in patients with depression. At the Mental Health Center of Denver, patient no-shows for initial intake appointments were recognized as a persistent problem, and lean was sub-sequently used as a tool to improve capacity, with a resulting 27% increase in completed intake appointments in the first year of project implementation (LaGanga, 2011). ConnectionsAZ reported the application of lean principles in transforming clinical operations in a behavioral health crisis facility and concluded that lean can be used to improve safety and throughput (Balfour et al., 2017).

As health care providers face the challenges of improving health care outcomes and lowering cost, business models such as lean provide attractive opportunities for improving quality of care, health care outcomes, and cost reduction. In the current article, a screening and referral process is addressed via the lean framework.

Process Considerations Pertinent to PCRP

A typical production system has input, process, and output components. In health care, the input component comprises providers, patients, and resources used in the process of care. Although health care providers cannot choose the quality of patients who seek their care, they may improve the quality of providers and processes of care by ensuring adequate training, skillset proficiency of providers, and use of the best available tools in the processes of care. Waste can be minimized by ensuring judicious use of resources in the processes of care, avoiding unnecessary testing/procedures (Kerr & Ayanian, 2014), minimizing wait times (Jackson & Woeste, 2008), and reducing rehospitalizations (Breslin, Hamilton, & Paynter, 2014).

Within a health care system, the processes of care can be a complex network of processes and interactions—from patients presenting for an office or emergency department (ED) visit through discharge to home as an outpatient or admission to an inpatient unit. The interactions between the patient and various units of the health care system and processes of care comprise a complex network fraught with risk for error and waste. However, by using evidence-based care and standardized processes of care with protocols, bundles, and checklists, there are opportunities to eliminate or minimize waste, improve patient outcomes, and reduce cost (Kates, 2014; Kerr & Ayanian, 2014).

The output of a health care encounter is discharge to home, discharge/transfer to another facility, or discharge to the morgue. Patients discharged home may stay healthy at home without need to return to the hospital with complication or relapse. However, patients frequently return to the hospital with a relapse of the condition for which they were previously hospitalized. As many as 19% of patients may be readmitted within 30 days of discharge (Axon & Williams, 2011; Rau, 2012). Given value-based purchasing legislative mandates, and changes in Medicare/Medicaid reimbursement policy, patients who develop complications during hospitalization or are readmitted within a specified time period may not be reimbursed for care related to complications or rehospitalizations (Cassatly, 2012). For example, Medicare no longer reimburses for treatment of catheter-associated urinary tract or blood stream infections developed after 48 hours from date of admission (Wald, Richard, Dickson, & Capezuti, 2012). These infections are regarded as hospital-acquired infections. Likewise, reimbursement for readmission of patients with pneumonia, myocardial infarction, or heart failure discharged within 30 days will be based on scoring that considers excess versus expected readmission (Axon & Williams, 2011). These provider reimbursement shortfalls, and in some cases penalties, have incentivized hospitals to minimize complications and optimize outcomes, often through evidence-based care and use of protocols, bundles, and checklists (Wald et al., 2012).

Imagine a futuristic health care environment, where providers will no longer receive reimbursement or will be penalized for failure to identify and treat PCRP as the underlying reason for recurrent psychiatric hospitalization of adolescents with mental illness. In this environment, the usefulness of instituting PCRP screening as a standard of care for in-patient pediatric psychiatry becomes apparent. Given that family relational variables play an important role in the development, mediation, and moderation of childhood mental illnesses (Wamboldt, Cordaro, et al., 2015; Wamboldt, Kaslow, & Reiss, 2015), the opportunity cost of failure to identify and address the predisposing risk factors is mental health exacerbation and rehospitalization. The financial cost of instituting PCRP screening is the cost of resources consumed during its implementation, such as cost of acquiring the assessment tool, space and infrastructure, and labor needed to implement the tool (Crowley, Jones, Greenberg, Feinberg, & Spoth, 2012). In contrast, the opportunity cost is the cost that will be incurred if this diagnostic tool and subsequent intervention is not pursued (Crowley et al., 2012). This cost will manifest in rehospitalization, mental health exacerbation, and associated disability. Although the direct financial cost of hospitalizations can be evaluated, the indirect cost of untreated mental illness or mental health exacerbation may be estimated in terms of the projected cost of the inherent disability. Such detailed financial cost analysis is beyond the scope of the current article.

PCRP and the Lean Framework

First, screening adolescents for PCRP and referring them for therapy in a pediatric psychiatric inpatient setting is a value identification. Next, the value stream comprises processes that contribute to the identified value. With patients and families as the customers, providers (e.g., psychiatrists, psychologists, advanced practice nurse prescribers, psychiatric nurse practitioners, psychiatric clinical nurse specialists, therapists and counselors, social workers/case managers, staff nurses, behavioral health technicians) participate in a variety of care processes to meet the needs of patients and their families (Figure). Each admitted patient is evaluated by a licensed psychiatric provider within 24 hours of admission. During this time, psychosocial evaluation is performed and it is expected that PCRP assessment can be performed within the context of psychosocial assessment. According to one quality improvement project, approximately 45 to 65 minutes were required to administer PCRP assessment, and 73% of adolescents screened (n = 15) had PCRP (Okeoma, 2017). The screening tool may be used with permission from the author/publisher (Wamboldt & Cordaro, 2013; Wamboldt, Cordaro, et al., 2015). Those meeting criteria for diagnosis will have their problem lists updated with PCRP. Using a multidisciplinary approach, the patient's care plan should be developed and each member of the team should play his/her professional roles in meeting the needs of the patient until discharge and possibly transitioning care to outpatient, as indicated.

Schematic of value chain and support activities for parent–child relational problem (PCRP) screening at a pediatric inpatient psychiatric unit.


Schematic of value chain and support activities for parent–child relational problem (PCRP) screening at a pediatric inpatient psychiatric unit.

As in other health care environments, many professionals are involved in the delivery of care for patients with PCRP (Figure). Therefore, improved flow of communication, interaction, and collaboration between and among individual providers (Cain & Haque, 2008) is essential in the overall success of a quality improvement project. Staff buy-in is widely recognized as an important factor in the success of quality improvement projects (French-Bravo & Crow, 2015). Lack of staff buy-in can impede flow, and may be evident in poor interaction and collaboration among individual players whose roles are essential for the success of a quality improvement project, and may ultimately diminish the usefulness of the project. To avoid this, staff buy-in should be rigorously pursued by soliciting the support of all potential players in implementation of the project.

In manufacturing processes, letting customer preferences determine what is being produced, when it is being produced, and the amount being produced (Teich & Faddoul, 2013) can be straightforward. However, “pull” takes a slightly different connotation in a health care environment. In the context of PCRP, screening all eligible patients and referring only those who have PCRP satisfies the criteria for letting patient needs detect service. Lastly, perfection is achieved through monitoring outcomes (i.e., identifying outcomes and changes needed to improve outcomes), making constant effort to improve flow, eliminating non-value activity, and satisfying patient care needs (Lawal et al., 2014).

The opportunity cost of failure to screen and treat PCRP may be mental health exacerbation and associated rehospitalization and/or disability; however, it is difficult to determine how many rehospitalizations may result from failure to assess PCRP and the consequent lack of treatment. Nonetheless, untreated mental illness may ultimately result in functional disability (Murray & Lopez, 2002). It has been estimated that major benefits of intervention in young individuals with mental, emotional, and behavioral (MEB) disorders include reduced disruptions in education and reduced involvement in the criminal justice system (Hahlweg, 2013). Other benefits of intervention accrue from the association between MEB disorders and increased morbidity, reduced quality of life arising from patients' psychosomatic problems, and increased risk for physical illness (Hahlweg, 2013). Moreover, close acquaintances of these individuals may be affected, as family members, peers, and victims of crimes committed by these individuals may have negative health consequences (Hahlweg, 2013).

At the society level, a 2007 Institute of Medicine report estimated the direct and indirect cost of MEB disorders to be $247 billion annually (O'Connell, Boat, & Warner, 2009). This report argues that billions of dollars can be saved by investment in evidence-based strategies that would prevent or ameliorate the effects of these disorders (O'Connell et al., 2009). Given the association between genetic and relational variables in the development of mental illness (Brett et al., 2015; Davies & Cicchetti, 2014; Douglas et al., 2011; Drury et al., 2012; Drury et al., 2010; Wamboldt, Kaslow, et al., 2015), and given that mental illness in adults may have childhood origins (Merikangas, Nakamura, & Kessler, 2009; Reef, Diamantopoulou, van Meurs, Verhulst, & van der Ende, 2009), a genuine effort at mental health promotion and treatment in adults should also aim for early detection and prompt treatment in children and adolescents.


PCRP is an emerging area in psychiatric nursing research. The subject itself may be more developed in the practice of psychology than nursing. Hence, from a nursing perspective, this article helps bring into focus elements of PCRP that may be important in holistic psychiatric nursing. The availability of a reliable and validated screening tool for PCRP may help nurses, particularly psychiatric, ED, outpatient center, and advanced practice nurses, at various points of contact with patients to screen for PCRP and initiate appropriate interventions.


Treating PCRP may improve the mental health outcomes of the parent/caregiver, but more importantly, the mental health outcomes of the child who is developmentally vulnerable. Interventions targeting PCRP may alleviate complications of untreated PCRP and ultimately result in decreased development, progression, and exacerbation of mental illness associated with PCRP. Although financial analysis of the cost of implementing PCRP is beyond the scope of this article, small investment in screening and treatment for PCRP may result in significant cost savings from prevention or amelioration of the consequences of untreated PCRP-mediated mental illness.


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Dr. Okeoma is RN, Stony Brook Medicine, Stony Brook, New York.

The author has disclosed no potential conflicts of interest, financial or otherwise.

The author thanks Dr. Gonzalez and Dr. Hooshmand, University of Miami, School of Nursing and Health Studies, and Emmanuela Ojukwu, Graduate Assistant, for their constructive criticism.

Address correspondence to Bryson C. Okeoma, DNP, RN, Stony Brook Medicine, 100 Nicolls Road, Stony Brook, NY 11794; e-mail:

Received: October 15, 2017
Accepted: February 22, 2018
Posted Online: April 19, 2018


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