Using the corporate Office of Behavioral Health as Seclusion/Restraint Reduction Initiative Project Manager (planning phase):
In late 2006, HHC asked the Commissioner of the New York State Office of Mental Health to request for HHC-wide implementation “Creating Violence Free and Coercion Free Mental Health Treatment Environments for the Reduction of Seclusion and Restraint”a
training from the National Association of State Mental Health Program Directors' Office of Technical Assistance (OTA). This nationally recognized training module was reserved for state-run facilities. HHC was awarded an external two-year grant for staff retraining. This enabled HHC to have the necessary resources to manage and implement the training and other implementation strategies of the initiative.
Corporate culture change training (planning and implementation phases): Three two-day training sessions were held in early March 2007 and July 2007, with a total attendance of nearly 760 leadership and direct care staff. On the basis of the National State Mental Health Program Directors OTA training model, participants were introduced to six core strategies that have been proven to reduce S/R use including concepts of primary and secondary prevention, leadership roles and responsibilities, key characteristics of trauma-informed care systems, using data to inform practice, environmental factors that can be modified to create a safer or calmer environment, rigorous post-event debriefing, and consumer and family roles in the inpatient setting. At the end of the second day, staff gathered by facility to develop a facility-specific work plan to implement the six core change strategies.
Eleven facility-specific consultations (planning and implementation phases): As a next step in assisting the facilities to develop their work plans and to identify opportunities and strategies for improvement, HHC contracted with OTA faculty to provide consultation consistent with the OTA training. The visits occurred between July 9 and September 11, 2007, and focused primarily on the adult inpatient units of each hospital. Several hospitals included their child and/or adolescent units as part of the site-visit consultation. Several of the hospital-visit consultations also addressed issues specific to Emergency Department programs and/or forensic programs. The consultants used a review protocol for the HHC consultation and site reviews that is an adaptation of the formal review instrument developed for a Substance Abuse and Mental Health Services Administration-funded eight-state OTA evaluation project. At each site, the consultants met with the facility's behavioral health leadership team, quality-improvement staff, nursing leadership, and frontline staff to get a thorough picture of the facility's efforts to reduce the use of S/R. The consultants also reviewed S/R documentation in a random sample of facility records. After each site visit, they prepared summary reports of their findings, and their analysis of hospital strengths and priority areas recommended for improvement. Over 100 HHC behavioral health leaders participated in these leadership sessions. Consultants also met with numerous staff and consumers.
Crisis de-escalation training (implementation phase):
Train-the-trainer models for crisis prevention and management were developed and provided in August-September 2007 and in May 2009. Sixteen highly interactive Mandt training4
sessions were provided for groups of 35 behavioral health staff to help them develop crisis de-escalation skills. The Mandt System teaches the use of a graded system of alternatives, which uses the least amount of external management necessary in all situations. HHC also used the Crisis Prevention Institute (CPI) train-the-trainer model of crisis management and de-escalation. CPI trained 69 staff members.
Sensory modulation tools and approaches (implementation phase):
Sensory modulation approaches and tools on an inpatient psychiatric service are an emerging best practice.5
The use of sensory modulation approaches means that the need for more coercive measures such as S/R is reduced. HHC hired sensory modulation experts to train HHC staff at the end of November 2007 and again in May 2009 with a total of 334 staff trained. The corporation also used grant dollars to purchase sensory modulation equipment for each inpatient psychiatric unit operated by the corporation. Each of the 58 units received a variety of sensory tools (including a rocker, weighted blankets, and vests) and a rolling cabinet in which to store them. As part of the training, staff were able to view and rehearse use of equipment. HHC has recently published a guideline on the use of sensory modulation tools and techniques on inpatient psychiatric services that has been distributed along with a staff training module to reinforce effective and safe use of this emerging best practice.7
Data transparency (planning and implementation phases): HHC facilities were asked to submit S/R data to the corporate office before the project was officially announced so that a baseline could be analyzed and shared. Since the kick-off, facilities have been submitting data on S/R restraint use and patient and staff injuries associated with the use of S/R. This data was reviewed monthly by the HHC Council of Directors of Psychiatry of the Departments of Psychiatry at each of the 11 acute care hospitals and lessons learned were discussed. The data is also shared quarterly in a comprehensive data book with corporate and individual facility S/R trend charts. This project was the first time that individual facility data was shared. In addition, in July 2007, HHC included individual facility S/R on its quarterly dashboard/corporate performance report.
Managing agitated patients workgroup (implementation phase): In November 2007, 11 months after the start of the initiative, HHC established a workgroup to focus on how to better manage agitated patients. The workgroup resulted in several initiatives that had an impact on the HHC Seclusion and Restraint Reduction Initiative: 1) various models of psychiatric emergency response teams were explored and shared with HHC facilities; 2) training modules for hospital police were created to clarify their role when asked by the clinical staff to respond to a patient who is agitated or in crisis; and 3) the corporation created a new job title called a Behavioral Health Associate. Behavioral Health Associates receive extensive crisis prevention and de-escalation training and perform some of the duties that had been assumed by hospital police.
Corporate guidelines for developing facility-specific restraint and seclusion policies and procedures (implementation phase): In December 2007, HHC issued corporate guidelines to assist HHC facilities with the revisions that would need to be made to their facility-specific policies and procedures to bring them in line with changes in The Joint Commission and, more importantly, in Centers for Medicaid and Medicare Services regulations. The guideline addresses both behavioral and medical-surgical restraints and went further than federal or state requirements by imposing a two-hour maximum limit on an S/R order for adults, two hours less than what is allowed by Centers for Medicaid and Medicare Services and New York State Office of Mental Health.
A corporate psychiatric emergency services assessment (implementation phase): On January 6, 2008, HHC implemented a psychiatric emergency assessment form developed by the HHC Office of Behavioral Health through a corporatewide workgroup that is used in all the Psychiatric Emergency Services (PES) that includes a trauma assessment, which explores the impact of past trauma on current functioning, patient preferences regarding effective calming measures, triggers for agitation, and preferences regarding S/R use.