reinventing quality 2010
TRANSCRIPT
Reinventing Quality 2010
Used for the wrong reasons◦ Failure of other treatment methods◦ Staff convenience◦ Power struggles
Not evidence-based practice
Unwanted outcomes: Injuries including: Coma Broken bones Bruises Cuts requiring stitches Facial damage
Interference with relationship with caregiver
THERE IS A BETTER WAY!!!
Deaths due to: Asphyxiation Strangulation Cardiac arrest Blunt trauma
Critical information for organizational leaders and most especially staff…◦ Part of our inherited culture is the use of restraint as a “therapeutic technique” and a safety measure ◦ We now know that restraint can be prevented◦ Prevention in key
Restraint elimination involves significant culture change
Start with knowing and identify factors that contribute to an environment in which restraints are likely to be used
TO START: Develop a Restraint Reduction Action PlanAction Plan FrameworkPrevention-Based ApproachContinuous Quality Improvement PrinciplesIndividualized for the Facility or AgencyAdopt/Adapt Six Core Strategies ©Baseline Data Collection
Public Health Prevention Approach Self-Determination Principles Individual and Staff Experiences Trauma Informed Care Leadership Principles CQI (Continuous Quality Improvement)
Primary Prevention (Universal Precautions)◦ Prevent conflict from occurring by anticipating
risk factors
Secondary Prevention (Selective Interventions)◦ Minimize and resolve conflicts when they occur
Tertiary Prevention (Indicated Interventions)◦ Debriefing/CQI: Post restraint interventions to
mitigate effects, analyze event, take corrective action and avoid reoccurrence
1998: Hartford Courant Series January 1, 2001 – DDA ban on prone physical restraints 2001: Institute of Medicine Report “Crossing the Quality
Chasm 2003: Maryland Developmental Disabilities Administration
(DDA) ban on supine physical restraints 2005: National Association of State Mental Health Program
Directors NASMHPD Medical Directors’ (NASMHPD) Training Curriculum – Six Core Strategies
2007: DDA Adaptations to Six Core Strategies 2008: DDA announces restraint elimination initiative –
establishes Trauma Informed Care Restraint Elimination Task Force
2010: Eliminating Restraints in Maryland – Task Force Report to DDA
Restraint can be a source of trauma experience
Restraint may have happened during the trauma event, especially during sexual assault
May trigger re-experiencing the trauma event
What is trauma? Definition (NASMHPD, 2004):◦ The personal experience of interpersonal violence including
sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism, and disasters.
Trauma also includes verbal and emotional abuse. Until recently, trauma exposure was thought to be unilaterally
rare (combat violence, disaster trauma)(Kessler et al., 1995)
56% of an adult sample (general population) reported at least one trauma event
(Ibid)
Effects are neurological, biological, psychological and social in nature:◦ Changes in brain neurobiology◦ Social, emotional & cognitive impairment◦ Adoption of health risk behaviors as coping mechanisms
(eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence)◦ Severe and persistent behavioral health, health and social
problems, early death(Felitti et al, 1998; Herman, 1992)
Five million crimes are committed against individuals with disabilities each year in the U.S. (Petersillia, 1998)
More than 90% of people with developmental disabilities will experience sexual abuse in their lifetime. (ARC, 1995)
Individuals with developmental disabilities are 4-10 times more likely to be victims of crime than people without a developmental disability (Wilson and Brewer, 1992)◦ Assault – 2.9 times higher◦ Sexual assault – 10.7 times higher◦ Robbery – 12.7 times higher
NASMHPD, 2005
142 deaths in the US from 1988 – 1998 due to S/R, reported by the Hartford Courant (Weiss, et. al, 1998)
111 fatalities over 10 years in New York facilities due to restraints (Sundram, 1994as cited by Zimbroff, 2003)
The Institute of Medicine (IOM) estimates 44,000 – 98,000 medical error-related deaths occur each year. JCAHO receives only 400 medical-error death reports per year – less than 1% of the IOM estimate.
JCAHO implemented a Restraint Death Sentinel Event database in 1996. In 2005, the first 10 year report, 138 restraint deaths were reported.
Applying the IOM estimate to JCAHO data, there could be as many as 1,380 restraint related deaths per year in the US.Retrieved from: http://www.jointcommission.org/NR/rdonlyres/167DD821-A395-48FD-87F9-6AB12BCACB0F/0/Medical_Liability.pdf
For every 100 mental health aides,26 injuries were reported as a result of a restraint in a three-state survey done in 1996
The injury rate in health care is higher than what was is reported for workers in:◦ Lumber◦ Construction◦ Mining industries
(Weiss et al., 1998; US Dept. of Labor, 2005)
Ray, Myers, and Rappaport (1996) reviewed 1,040 surveys received from individuals following their New York State hospitalization
Of the 560 who had been restrained or secluded:
◦ 73% stated that at the time they were not dangerous to themselves or others
◦ 75% of these individuals were told their behavior was inappropriate (not dangerous)
17
Holzworth & Wills (1999) conducted research on nurses’ decisions based on clinical cues of patient agitation, self-harm, inclinations to assault others, and destruction of property Nurses agreed only 22% of the time When data were analyzed for agreement due to chance
alone, agreement was reduced to 8%
Nurses with the least clinical experience (less than 3 years) made the most restrictive recommendations
Luiselli, Bastien, and Putnam (1998) conducted a behavioral analysis to explore contextual variables related to the use of mechanical restraints
Results: The most frequent antecedent to the use of mechanical restraints was a staff-initiated encounter
Research indicates that cultural and social bias may exist.
Those more likely to be restrained:
◦ Younger and on more medications(LeGris, Walters, & Browne, 1999)
◦ Younger, male gender, and Black or Hispanic descent (Donovan et al., 2003; Brooks et al., 1994)
Cochrane Review (2000)
◦ 2,155 articles, no controlled studies
◦ Restraint use efficacy and therapeutic value not established
◦ Serious adverse effects were cited
(Sailas & Fenton, 2000)
Aversive and isolating interventions tend to be associated with a significant increase in negative behaviors and significant decrease in positive behaviors
Individuals who lack the capacity to understand contingency-based interventions may actually have counterproductive outcomes
(Papolos & Papolos, 1999)
Numerous unfounded beliefs exist
Harm caused in restraints is well documented
Benefits of restraint use are not substantiated
Biases exist in the system
Not evidence-based practice
Significant culture change is required
Announced by Michael Chapman, DDA Executive Director, in Spring 2008
Goal is elimination: “We know we will struggle to realize this with some people. We must continuously strive for elimination, rigorously debrief every restraint event and ensure that we are doing all we can to prevent future incidents.”
Established a joint Task Force with MACS in August 2008 – 18 members from government, provider and advocacy groups
Final report disseminated to DDA and MACS in July 2010 DDA management team is currently reviewing specific
recommendations
Advocacy – 6 members
Behavioral Health – 12 members
Data – 9 members
Human Resources – 6 members
Implementation Strategies – 7 members
Leadership – 6 members
Quality – 9 members
Training – 12 members
October 2008 - Town Hall meeting – What are the opportunities and challenges?
June 2009 - Forums in the four regions of Maryland
March - June 2009 - Six meetings with Behavioral Principles and Strategies (MD behavior supports and crisis prevention/intervention training) trainers statewide
2 conference presentations◦ MACS Direct Support◦ Arc MD Convention
July 2009 - Behavioral Health Town Hall meeting
November 2009 - Town Hall meeting to review draft Task Force recommendations
General definition: Any physical, mechanical, or chemical technique or device
used to prevent or to intervene during an event for the purpose of restricting an individual's access to his or her body or to the environment. It is recognized that some devices or techniques can be used as restraints for some people and as support for others. This definition does not include techniques or devices used for physical or medical support.
The specific technique or device does not dictate whether or not it is a restraint. The intent of the use of the technique or device is the determining factor.
Leadership toward organizational change Use of data to inform practice Workforce development Use of restraint prevention tools Self-advocate roles Debriefing activities
National Association of State Mental Health Program Directors, National Technical Assistance Center, 2005
Organizational Change DDA Providers
Trauma Informed Care Positive Behavior Supports Staff Support Advocacy and Community Support Funding Measuring Success and Project Testing
What is RCA?◦ Systematic process for incident investigation Determines fundamental system deficiencies Questions are asked until no more questions exist or
can no longer be answered Identification of Root Causes and Latent Conditions
Root Cause A cause that if corrected would prevent recurrence of this and
similar incidents Address underlying system issues, rather than single problems or
faults Can include system deficiencies, management failures,
inadequate competencies, performance errors, omissions, non-adherence to procedures and inadequate organizational communication
Latent Conditions Less apparent failures of the organization or design that
contributed to the occurrence of errors or allowed them to harm people
Identifying latent conditions attempts to answer the following question: What exists in the organization that allowed the root cause to exist?
Intended to have generic implications for the system as a whole
DDA Pilot Project◦ 6 Providers◦ Examining feasibility and value of use of RCA in
community settings as a CQI tool
MD Patient Safety Center◦ Resource for training on safety and CQI/Root
Cause Analysis◦ Free resource to all DDA licensed providers http://www.marylandpatientsafety.org
Diane DresslerStatewide Training
Coordinator & Housing Specialist
MD Developmental Disabilities Administration
Arnie DordickExecutive DirectorLangton Green, Inc.