11

NYS OMH Learning Collaborative NYS OMH Learning Collaborative Preventing the Need for Preventing the Need for

Restraint & SeclusionRestraint & Seclusion

Summation of Key Results of Summation of Key Results of SAMHSA’s National Initiative SAMHSA’s National Initiative

November 30, 2010November 30, 2010

Beth Caldwell, MSBeth Caldwell, MSCaldwell Management Associates; Faculty, Office of Caldwell Management Associates; Faculty, Office of

Technical Assistance, National Association of State Mental Technical Assistance, National Association of State Mental Health Program DirectorsHealth Program Directors

22

Brief Historical Overview Brief Historical Overview National S/R Reduction Initiative National S/R Reduction Initiative (2000-2010)(2000-2010)

• Charles Curie “will eliminate R/S” (PA, 1996)

• Hartford Courant Series “Deadly Restraint” (1998)

• GAO Report for Congress (1999)

• NASMHPD MD S/R Reports (1999-01)

• CMS Rule changes (1999, 2000)

• NASMHPD Training Curriculum (created 2002)

33

Brief Historical Overview Brief Historical Overview National S/R Reduction Initiative National S/R Reduction Initiative (2000-2010)(2000-2010)

• NASMHPD OTA Training starts (2003 to present)• New Freedom Commission Report – Transformation

(2003)• Independent projects support core strategies identified

(2003 on)• First CMHS 8 state SIG project (2004)• CMS Final Hospital Rules (2006) • Second CMHS 8 state SIG project (2007)• SAMHSA Recognition Awards (2010)

(NAPHS Success Stories 2003; Colton, 2004; Murphy/Davis, 2005; CWLA; 2003)

44

Brief Historical Overview Brief Historical Overview National S/R Reduction Initiative (2004-2007 National S/R Reduction Initiative (2004-2007))

• CMHS SR SIG Projects – 2004: 8 State Incentive Grants to identify alternatives to

reduce use (HI, IL, KY, LA, MA, MD, MO, WA)– 3 year grant on best practice applications– Lead consultant assigned to each State, utilizing Six

Core Strategies© to conduct 2/3X annual on-site assessments

– Lessons learned: all about executive leadership– Outcomes indicate that the Six Core Strategies© meet

criteria to be considered as Evidence-based.

55

Brief Historical Overview Brief Historical Overview National S/R Reduction Initiatives: 2007-2010National S/R Reduction Initiatives: 2007-2010

• Second CMHS S/R SIG Project– 2007-10: 2nd round of grants, 8 states (CT, IN, NJ, NY,

OK, TX, VA, VT)– Monies for consultation & on-site assessments

significantly reduced – Lessons learned – all about executive Leadership

66

We now We now know know what works to what works to prevent violence and reduce S/Rprevent violence and reduce S/R

• We know that the prevention of conflict and reduction of S/R is possible in all mental health settings

• We know that facilities throughout the U.S. have reduced use considerably without additional resources

• We know that this effort takes tremendous leadership, commitment, motivation, and persistence

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First step in prevention? First step in prevention? Develop a Plan!Develop a Plan!

• TO START: Facility leaders must develop a S/R Prevention/Reduction Action Plan

Action Plan FrameworkPrevention-Based ApproachContinuous Quality Improvement PrinciplesIndividualized for the Facility or AgencyAdopt/adapt Six Core Strategies ©

88

The Six Core StrategiesThe Six Core Strategies© to Prevent © to Prevent Violence and S/RViolence and S/R

1) Leadership Toward Organizational Change

2) Use Data To Inform Practices

3) Develop Your Workforce

4) Implement S/R Prevention Tools

5) Actively recruit and include service users and families in all activities

6) Make Debriefing rigorous

99

Core Strategy #1Core Strategy #1Leadership in Organizational ChangeLeadership in Organizational Change

• The most important component in successful prevention and culture change projects.

• Only Leadership has the authority to make the changes that are necessary for success: – To make violence prevention a high priority– To assure for Reduction Plan Development– To reduce/eliminate organizational barriers– To provide or re-allocate the necessary

resources, and – To hold people accountable for their actions

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Core Strategy #1 Core Strategy #1 Principles of Effective LeadershipPrinciples of Effective Leadership

• Create the Vision

• Live Key Values

• Develop your Human Technology

• Monitor Staff Performance

• Elevate Oversight of Untoward Events• Assure Violence/S/R Prevention Plan

Development (Anthony & Huckshorn, 2008: read their book: Principled Leadership)

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Real Reduction ExperiencesReal Reduction ExperiencesWhat Worked?What Worked?

Examples of Individual Success Stories Examples of Individual Success Stories beginning prior to NETI Training Program on beginning prior to NETI Training Program on

Six Core StrategiesSix Core Strategies

Preventing Violence, Trauma, and the Use of Seclusion and Restraint in Mental Health

Settings

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South Florida State HospitalSouth Florida State HospitalAdult/350 Beds Adult/350 Beds

• LEADERSHIP: – Full support/oversight by CEO/COO/CNO– Strong policy statement/revised S/R policies and

procedures– Kick-off of initiative that included staff, residents and

families, state office, Florida legislators, advocates, & the local community mental health centers

– Led use of data, graphed and posted, for unit comparisons every month/all units

– Project placed on every meeting agenda– Designed ‘town center’ treatment mall

1313

South Florida State Hospital South Florida State Hospital Essential ComponentsEssential Components

• LEADERSHIP:– Debriefing including root cause analysis and daily reports to

Executive Management Group; non-punitive environment. Change in staff roles in crisis response (security, nursing, direct care staff)

– Leadership responding to every incident; on call MG member involved for oversight 24/7

– Leadership hired persons-served/consumer and gave them meaningful roles throughout project (e.g., interview residents and staff post-event; make recommendations; o develop comfort rooms; develop treatment activities)

– Leadership co-led with consumers staff appreciation/recognition

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SECLUSION AND RESTRAINT RESULTS SECLUSION AND RESTRAINT RESULTS January 1999 - March 2004January 1999 - March 2004

TOTAL SECLUSIONS AND RESTRAINTS EVENTS (January 1999 - March 2004

0

5

10

15

20

25

30

35

40

45

99-JAN 99-FEB 99-MAR 99-APR 99-MAY 99-JUN 99-JUL 99-AUG 99-SEP 99-OCT 99-NOV 99-DEC 00-JAN 00-FEB 00-MAR 00-APR 00-MAY 00-JUN 00-JUL 00-AUG 00-SEP 00-OCT 00-NOV 00-DEC 01-Jan 01-Feb 01-Mar 01-Apr 01-May 01-Jun 01-Jul 01-Aug 01-Sep 01-Oct 01-Nov 01-Dec 02-Jan 02-Feb 02-Mar 02-Apr 02-May 02-Jun 02-Jul 02-Aug 02-Sep 02-Oct 02-Nov 02-Dec 03 - Jan. 03 - Feb. 03 - Mar. 03 - Apr. 03 - May 03 - Jun. 03 - Jul. 03 - Aug. 03 - Sep. 03 - Oct. 03 - Nov. 03 - Dec. Jan-04 4-Feb Mar-04

SECLUSION RESTRAINT

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Andrus Children’s Center Andrus Children’s Center (Residential and School)(Residential and School)

Yonkers, New York 1999 - 2008Yonkers, New York 1999 - 2008• LEADERSHIP:

– Total commitment (Note: leadership turnover in school directly correlated to > in restraints at 2 points in time)

– Involved in debriefing after every incident– Decided to truly use data to inform practice– Put a strong focus on Workforce Development: staff

training/staff empowerment– Decided to move to a Trauma model

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Restraint Incidents

42

16

9 9

20

24

2

6

2

66

11

1 2

12

4

268

5

9

27

9 3

5

7

17 15

75

40

0

0

10

10

20

30

40

50

60

70

Time Line

# o

f Res

trai

nts

1717

Worcester State HospitalWorcester State Hospital 156 beds/Civil (NETI training 2003156 beds/Civil (NETI training 2003))

• LEADERSHIP:– Set up taskforce, developed formal plan– Developed new policies – Held kick-off– Increased staff training– Implemented 24-7 response by CEO, COO, CNO– Decided to use data (distributed to staff)– Began to hold regular meetings - all staff & unions;

focused on performance recognition– Developed roles for consumers

18

Seclusion and Restraint Orders

per 1000 Inpatient Days

0

10

20

30

40

50

60

FY '07 Y TD

thru 3/31/07

FY 06 FY 05FY 04 FY 03FY 02 FY 01

19

Seclusion and Restraint Hours

Worcester State Hospital

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

6000

6500

7000

7500

FY 01 FY 02 FY 03 FY 04 FY 05 FY 06 FY 07 thru

3/31/07

20

Seclusion and Restraint Orders by Shift

Worcester State Hospital

Q1 FY 00 - Q3 FY 07

0

50

100

150

200

250

300

350

400

450

500

1stShift

2ndShift

3rdShift

21

Seclusion and Restraint Orders and

Patient Related Employee Injuries*

Worcester State Hospital

Q4 FY '00 - Q3 FY '07

0

200

400

600

800

1000

1200

S/R

Ord

ers

0

5

10

15

20

25

30

35

40

45

50

Pat

ien

t R

elat

ed E

mp

loye

e In

juri

es

# S/ROrders

# PatientRelatedEmployeeInjuries

2222

Elgin Mental Health Services, Chicago Elgin Mental Health Services, Chicago Adult Hospital: Civil & ForensicAdult Hospital: Civil & ForensicNETI Training 2003; SIG 6/05 NETI Training 2003; SIG 6/05

• LEADERSHIP:– Developed a formal plan and rewrote polices– Embraced value of ‘Trauma-informed care’ & engaged in

hard tasks to implement (i.e. revision of unit rules)– Embraced value of ‘consumer-driven care’ (e.g., created

meaningful consumer council; > consumer involvement in multiple hospital activities)

– Held a facility kick-off and followed-up with training for all staff (where staff voice could be heard)

– Shared and posted data

23

24

25

26

27

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SAMSHA FUNDED SIG SAMSHA FUNDED SIG Alternatives to R/SAlternatives to R/S

• 8 States funded 10/2004 thru 9/2007

• Largest Reductions in 2 States: MA & IL

• NETI Training Programs offered 2005

• On-site consultations began 2005

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IL DMH LESSON LEARNED IL DMH LESSON LEARNED

• Leadership responsible for culture change; in some hospitals with weak and/or non-committed leadership, especially when combined with serious, long-term cultures of control, there were serious and ongoing challenges to reduction efforts

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Madden Mental Health Center, IL Madden Mental Health Center, IL

• Madden is an acute care state operated facility with 38 budgeted beds/increased to 150; ALOS: 11 days. In FY08, 4,133 admissions.

• LEADERSHIP:– Executive team, after returning from NETI training,

met with all staff on all units on all shifts to share excitement about reducing R/S

– Used Witnessing after EVERY event– Used data in a deep way (e.g., security guards;

safety plans & psychologists)

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Madden Mental Health CenterRates of Hours, Patients and Episodes of

Restraint*• Anita Hour Rate Combined Hour Rate

Baseline Witnessing initiated Witnessing cont’dR&S 10/01/03- 10/01/04- 10/01/05- 7/01/06- 7/01/07-

9/30/04 9/30/05 10/1/06 6/30/07 6/30/08Episodes*Per 1000 pt days 10 5.66 4.51 3.88 2.79Patients *undup ptsrestrained /pts served) 7% 6.1% 3.95% 2.92% 3.4%Hours *Per 1000 pt hours .82 .43 .23 .16 .11

32

Restraint and Seclusion Patient Rate (Combined)

UCL=11.39

CL=4.81

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Per

cent

of

Pat

ient

s

Data Points

UCL

A

B

Average

B

A

LCL

3333

MA DMH LESSONS LEARNED MA DMH LESSONS LEARNED

• Leadership responsible for culture change

• Two hospitals receiving SIG consultant on-site reviews reduced significantly more than the others – other hospitals needed this type of support;

34

MA DMH: The two state hospitals that received NASMHPD/OTA Site Visits

Interventions per 1000 Pt Days

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Oct-0

4

Jan-

05

Apr-0

5

Jul-0

5

Oct-0

5

Jan-

06

Apr-0

6

Jul-0

6

Oct-0

6

Jan-

07

Apr-0

7

Jul-0

7

Oct-0

7

Jan-

08

Intrv 1000 Pt Days

Taunton State Hospital10 adult units, 1 adolescent unit

(highest value to lowest value)28.63 (February 2005) to

1.75 (February 2008) = 93.5%

Reduction results:

Interventions per 1000 Pt Days

0.00

5.00

10.00

15.00

20.00

25.00

Oct-0

4

Jan-

05

Apr-0

5

Jul-0

5

Oct-0

5

Jan-

06

Apr-0

6

Jul-0

6

Oct-0

6

Jan-

07

Apr-0

7

Jul-0

7

Oct-0

7

Jan-

08

Intrv 1000 Pt Days

Westborough State Hospital5 adult units, 2 adolescent unit

(highest value to lowest value)23.47 (April 2005) to

0.73 (January 2008) = 96.9%

Reduction results:

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Alegent Mental Health Services,Alegent Mental Health Services,Hospital Units in Nebraska & Iowa; Hospital Units in Nebraska & Iowa;

Residential Program in NEResidential Program in NE• NETI Training 2004 for executives – leaders

went back and developed a plan:– All staff trained in TIC throughout 2005 – Phased in implementation of six core strategies

from 2005 to present– On-site consultation visits 2006 (child residential

program eliminated restraints)– Ongoing phone consultation throughout 2007/2008

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Acute Geriatric

7% Acute C/A

Residential

Partial/School

33%Acute Adult

Special Care

60%

Alegent Health Mental Health Services

Omaha NE & Council Bluffs IA

Over 6,300 patients served in the 2008 Fiscal Year

In the first quarter of 2001 (January through March), there were 167 Seclusion/Restraint events. In the last quarter of 2007 (October through December), there were only 42 events

The Alegent Health Mental Health has experienced a 56.23% reduction in the number of Seclusion/Restraint events since presenting Trauma Informed Care to staff throughout the service line in July 2005

SAMHSA’S Alternatives to Seclusion and SAMHSA’S Alternatives to Seclusion and Restraint Recognition ProgramRestraint Recognition Program

• Over 60 applications• Of those the committee ranked in top 22, Beth knew 16 of the

executive leaders (and worked with leaders ranked as the top 6); each leader:– Had deep passion/commitment to a set of core values that

were inconsistent with R/S (e.g., recovery; consumer-driven care)

– Developed a strategic plan that incorporated the Six Core Strategies©, with kick-off and regular updates/ celebrations

– Focused on staff appreciation/empowerment– Used data to inform practice

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Remember what Margaret Mead Remember what Margaret Mead shared:shared:

“Never doubt that a small group of committed citizens can change the world. Indeed, it is the only

thing that ever has.”

Contact InformationContact Information

Beth Caldwell

Caldwell Management Associates

413-644-9319

bethcaldwell@roadrunner.com

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