How to benchmark using your own data
You already should know that Joint Commission on Accreditation of Healthcare Organizations surveyors want to see compliance with restraint and seclusion standards. But to improve quality in this area, you’ll need to do more.
"I think it goes beyond just compliance," says Shari Hughes Scott, MS, LMFT, LPC, RN, psychiatric consult nurse at Children’s Medical Center of Dallas. "Surveyors want to see evidence that we are using appropriate clinical judgment to provide respectful and safe care to patients and families."
That means continually looking at the risk vs. the benefit of interventions on an individual basis, Scott says. "I also think that they want to see concrete evidence that we are actively involving patients and families in the process of reducing aggression and successful coping from the very beginning of treatment."
In addition, it is important for clinicians to partner with the patient to meet therapeutic goals, she adds. "This is opposed to planning care in a way that requires exerting control and power over patients in order for them to make progress with the goals we set for them."
To dramatically improve the way restraint and seclusion is addressed at your facility, consider the following:
• Benchmark using your own data.
It’s very difficult to obtain benchmarking information from other facilities, says Darcy Jaffe, ARNP, director of inpatient psychiatry, psychosocial consultation, and involuntary treatment services at Seattle-based Harborview Medical Center.
"Building a database from which to benchmark with your own facility over time seems to provide the most useful information to gauge how the facility is doing," she says.
Start with these basics, Jaffe advises: Compli-ance with obtaining orders, number of patients in restraints, why the patient is being restrained, and for how long. "Once the database is established, the best performance indicators to use seem to become apparent naturally."
Your monitoring system must be broad, since the use of restraints encompasses the entire clinical staff, she notes. At Harborview Medical Center, these steps are taken:
— Weekly audits of documentation are done to ensure it meets standards and that the restraint use is necessary.
— Daily charge nurse rounds are conducted in which all patients who are in restraints are reported.
— Closed-record reviews are done on a quarterly basis.
— The psychiatric clinical nurse specialist keeps track of all patients who are in behavioral restraints on the medical/surgical floors. On the psychiatric units, the manager reviews all restraint orders and plans for patients in any kind of restraint.
At Children’s Medical Center, an overall baseline assessment was done to assess both behavioral restraints and the use of medical restraint and medical immobilization throughout the facility, Scott says. "Having those baseline numbers, we formed a multidisciplinary task force that continues to meet monthly," she says. "The initial goal was to achieve 100% compliance with regulatory mandates for restraint and seclusion in our institution."
Since that time, the restraint initiative has broadened to include improving the facility’s approach to care through education, policy, and practice, Scott says.
• Make sure your policy addresses Joint Com-mission standards.
To comply with Joint Commission standards for restraint and seclusion, you’ll need clear, comprehensive policies that clinicians are accountable to follow, says Jaffe.
Surveyors want to see documentation that easily shows that the patient was properly assessed regarding the reason for restraints, that all other options were tried first, and that the restraints were discontinued as soon as possible, she says. "They also want to see that the patient/family was included and has a voice in the plan."
Here are ways to comply:
— Develop documentation and order templates that force staff to enter correct information and to view restraints as a priority problem, says Jaffe.
— Consider creating a position that is solely responsible for restraint practices if there are a significant number of patients who need restraints at your facility, she recommends.
— Invest the appropriate resources into staff education. "Don’t stop with a one-time education process," Jaffe says. "There must be thought to include a long-term plan."
— Standardize your documentation and policy and procedure across the institution, advises Scott. "In addition, we have housewide competencies for all direct-care staff regarding the use of restraint and seclusion."
To ensure that each standard or condition of participation was met with each incident of restraint or seclusion, a detailed documentation flowsheet was developed that follows requirements of both the Centers for Medicare & Medicaid Services and the Joint Commission, says Scott. If the clinician follows the written prompts and documents accordingly, it will ensure compliance, she says.
The facility’s policy requires that a performance improvement checklist be completed for each restraint or seclusion that occurs, says Scott.
"Each incident of restraint or seclusion is reviewed by the corresponding manager," she explains. "Trends are noted, which may result in specific improvement plans being put into action."
Have a clinical nurse specialist talk with nurses and physicians when they have a patient in restraints, to help formulate a plan to get the patient out of restraints, recommends Jaffe.
"The more often this happens, the faster the staff get at figuring it out on their own," she says.
• Monitor restraint use.
At Children’s Medical Center, a restraint and seclusion hotline was set up, Scott says.
"All occurrences of restraint or seclusion occurring anywhere in our institution are called in to this data bank with information provided corresponding to regulatory mandates," she explains.
These demographics and variables are placed into a database, which allows trends and patterns to be identified, she says. "This breakdown can provide clues for making important changes, which might reduce the incidence of these procedures."
[For more information on restraint use, contact:
• Darcy Jaffe, ARNP, Director, Inpatient Psychiatry, Psychosocial Consultation, Involuntary Treatment Services, Harborview Medical Center. Telephone: (206) 731-6630. E-mail: [email protected].
• Shari Hughes Scott, MS, LMFT, LPC, RN, Psychiatric Consult Nurse, Children’s Medical Center of Dallas. Telephone: (214) 456-6477. E-mail: [email protected].]
You already should know that Joint Commission on Accreditation of Healthcare Organizations surveyors want to see compliance with restraint and seclusion standards. But to improve quality in this area, youll need to do more.
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