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Taking violence out of the risk equation

June 21, 2012
by Nick Zubko
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Around 2005, Grafton Integrated Health Network (GIHN), Berryville, Va., began a long-term initiative to improve its operation in terms of outcomes and quality of care, staff satisfaction, as well as the bottom line. The target of the effort, reducing the use of seclusion and restraint practices, was a relative “no brainer” according to CEO Jim Gaynor.

“Grafton has historically served challenging clients who have had a history of aggression (both children and adults), including many children who are non-verbal,” Gaynor explains. “And no one enjoys working in [an environment] where patients are frequently biting you, throwing things at you, or running away.”

What resulted in the intervening seven years was a “major cultural shift.” But according to Gaynor, the key to the initiative’s success was to “anchor” the shift, as well as measure and celebrate success. “If you do that, and are dogged about it, you will get to a tipping point,” he says. “And that’s a really neat thing to experience from a leadership standpoint.”

Starting the initiative

Before launching this initiative, GHIN staff relied upon seclusion and restraint as a “basic behavior modification technique,” while Gaynor says it was “the only tool in our toolbox, and we used the hell out of it.” At one point in 2005 the facility was doing 250 restraints per month. Now, this once-common practice is rarely used at all.

Having made significant progress on the restraint and seclusion front, GHIN staff started looking into how they measured safety. They devised a set of key performance indicators (KPIs) called the “Safety Seven,” which are now used to measure patients every month. The Safety Seven determines whether clients have been:

  1. Left unsupervised.
  2. Involved in an unwarranted physical restraint or seclusion.
  3. Involved in a vehicle accident, caused by a GIHN driver.
  4. Involved in an actual medication error, made by a GIHN employee.
  5. The victim of peer-to-peer aggression.
  6. The victim of a substantiated mistreatment, abuse, or neglect by a GIHN employee.
  7. Demonstrating self-injurious behavior that resulted in injury requiring external medical attention.

“If during that month a client doesn’t meet any those requirements, they are considered to be ‘safe,’” explains Kim Sanders, GIHN’s executive vice president and chief outcomes officer. “In the past, that determination was based on opinion. Now, if a mom or dad comes in and asks about their child’s safety, we have the data to say one way or the other.”

New levels of “debriefing”

Another result of GIHN’s initiative was the evolution of a six-level “debriefing” process that takes place after a restraint happens. While Sanders says the process is “laborious and takes a lot of manpower,” she also says the results are very worthwhile.

First, a manager arrives on site within minutes for an immediate health and safety debriefing with the staff member and the client to gather information and make sure everyone is safe. Within 48 hours, a “learning opportunity” debriefing takes place with the client and the employees on his or her multi-disciplinary team.

In the past, the process stopped with level one--the immediate health and safety debriefing. A manager would talk to the staff, ask what happened, make sure no one got hurt, and it was over. However, by adding level two—the “learning opportunity,”—the entire multi-disciplinary team is forced to look at the incident in a way that drives treatment.

“Really, that’s where the magic happens,” says Sanders. “In essence, we’re reacting to one instance, but we’re also trying to be proactive to eliminate the possibility of the same kind of situation happening again.”

Debriefings are also conducted by administration (level three), and a home treatment team to evaluate trends for individual clients (level four). Findings are then assessed by a “restraint and seclusion review team” to determine safety status on a regional level (five). The same process is performed by an executive review team on a quarterly basis (level six).

At each debriefing, depositions are completed for each restraint or seclusion. Every incident is categorized in one of three ways: warranted, warranted with learning, or unwarranted. Those designations are later used as additional KPIs for the organization.

“This is where it can get tense,” notes Sanders. “If a restraint or seclusion happens, we do consider it a treatment failure,” she explains. “But there is no shame and no blame for our staff.”

In fact, she stresses that the findings don’t necessarily indicate a failure on the part of the staff member involved. For example, the incident could have been the result of incorrect staffing, improper equipment, or additional factors that had to be taken into account.

Effects on worker compensation

Of course, whenever patient violence occurs with any frequency, the safety of the staff is at risk. So, as part of its initiative to reduce restraints and seclusions, GIHN also adjusted its entire workers’ compensation policy and practices.

In addition to creating a risk management department and selecting a new insurance carrier and policy, GIHN also added full-time personnel. They hired an external claims management team, a team of field nurse managers, a new legal team, and a medical provider panel. In addition, personal protective equipment was purchased and a system was developed to appropriately manage the new inventory.

The next step was to create a transitional return-to-work program for workers who had been injured on the job. Under GIHN’s previous program, employees who left work due to injury stayed on leave until they could come back to work at 100% capacity in the role to which they were assigned.