Transcript PIP Improvement Strategies for Name of Plan

PIP Improvement Strategies
For Alternate Family Care, Inc/
Florida Palms Academy - SIPP
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
DOES THE IMPLEMENTATION OF TARGETED
INTERVENTIONS DECREASE THE RATE OF
RESTRAINT AND SECLUSION USE?
Study Indicator 1
 The rate of restraint use for the measurement year.
 Outcomes
– Baseline results
– 1/1/2009-12/31/2009
– Numerator :81
– Denominator : 4350
– Statistical result: 18.6 Critical events per 1000 bed
days.
Study Indicator 1 cont.
 Remeasurement 1 Results
– 1/1/2010-12/31/2010
– Numerator: 15
– Denominator: 3823
– 3.92 critical events per bed days times 1000
Study Indicator 1-Statistical Results
– 18.6 critical events per 1000 bed days for the baseline
year.
– 3.92 critical events per 1000 bed days remeasurement
year
– Two tailed p value (p<0.0001)- statistically significant
decrease in Restraints.
Study indicator 1- Interpretation
 A Fisher’s exact test demonstrated that the two
tailed P value is less than 0.0001; indicating that
the improvement between the baseline calendar
year and remeasurement 1 was extremely
significant.
Study indicator 1- Interpretation Cont
 In 2010 the remeasurement year the program utilized
slightly less bed days 3823 and only utilized 15 restraints.
 NOTE: one admission accounted for 90% of all restraints
and seclusions utilized during the last 2 months of the
remeasurement year.
Study Indicator 2
 The rate of seclusion use for the measurement year.
 Outcomes
– Baseline results
– 1/1/2009-12/31/2009
– Numerator :75
– Denominator : 3823
– Statistical result: 17.24 Critical events per 1000 bed
days
Study Indicator 2 cont.
 The rate of seclusion use for the remeasurement year.
 Outcomes
– Re-measurement 1 results
– 1/1/2010-12/31/2010
– Numerator :17
– Denominator : 3823
– Statistical result: 4.44 Critical events per 1000 bed
days
Study indicator 2- Interpretation
 A Fisher’s exact test showed that the two tailed P value is
less than 0.0001; indicating that the improvement between
the baseline calendar year and remeasurement 1 was
extremely significant.
On-going successful interventions
Intervention: Additional Involvement from Certified Behavioral Analyst
(CBA)
Barrier: In-effective interventions requiring additional active involvement
from the CBA.
Description/ logistics: Implementation of individual behavioral plan
Staff development (yearly PCM training)
Evaluations/ Effectiveness: This intervention continues to be beneficial
with clients who demonstrate severe aggressive, assaultive and self
injurious behaviors. Since implementing this intervention we have seen a
drastic reduction of the use of restraints and seclusions. This intervention
was implemented in January 2009 and is an ongoing intervention.
On-going successful interventions
Intervention: Therapeutic Crisis Intervention (semiannual refresherscompetence based testing).
Barrier: No specific barrier identified.
Description/ logistics: Semi annual competence based training.
Verbal de-escalation and Physical intervention.
Evaluations/ Effectiveness: This has been significant in reducing
the use of restraints and seclusions as it refocuses the staff on verbal
de-escalation. It also provides many verbal de-escalation techniques
and interventions to use to bring a child back to their baseline
behaviors.
On-going successful interventions
Intervention: Individual Crisis Management plan
Barrier: Unaware of effective interventions to assist a newly admitted
client.
Description/ logistics: Clients are interviewed at admission to identify all
potential triggers, high risk behaviors, and individualized interventions
that are thought to be successful.
Evaluations/ Effectiveness: Since implementation of this intervention we
have seen a reduction in the use of restraints and seclusion during the
first month of admission. Staff are more aware of a new admission’s
triggers, medical history and interventions.
On-going successful interventions
Intervention: Walkie Talkie- Communication.
Barrier: In-effective communication between staff within facility due to
distance.
Description/ logistics: Each staff member is assigned a walkie talkie
while on shift. Codes have been establish to discreetly advise of an
emergency.
Evaluations/ Effectiveness: This intervention has been useful in
preventing several potential crisis scenarios from developing into a
restraint or seclusion; simply by either radioing for assistance, change
of environment or an additional person to assist with verbal deescalation.
Challenges
 Successes
– Rate of Restraints and Seclusions have reduced
in the remeasurement year.
 Future Plan
– Continue to work towards a goal of zero
seclusions and restraints.
ACHIEVING AND
MAINTAINING HEALTHY
WEIGHT IN SIPP CLIENT
POPULATION
Study Indicator 1
 The average change in BMI (body mass index).
 for members admitted with a BMI at or greater than the
85th percentile who were discharged during the
measurement year.
– Admissions in 2010- 24 clients
– 14 were above the 85th percentile (obese or overweight)
– 10 clients had a healthy weight based on BMI.
Improvement Strategy
 Major Barriers
– Motivation to be active
– Medications
– Eating habits while on therapeutic passes
Improvement Strategy cont.
 Interventions
- Structured physical activity/ schedule
- (Wii dance, Wii sports, basketball, flag football,
dance class, exercise class).
- Monitor medication changes and weight changes.
- Educate parents on nutritional food intake. Provide
easy, healthy food ideas while the client is on pass.
Improvement Strategy cont.
Logistics of the intervention: Physical Activity
– Recreational Therapist will develop and post a daily
physical activity schedule.
– Recreational Therapist will monitor clients and staff
during activities and complete a form to document level
of involvement.
– Activities will include: Wii sports, Just dance 3, Wii
active, Football, dance class, flag football, kick ball etc.
Improvement Strategy cont.
Logistics of the intervention: Medication Changes
- Nurse will track medication changes and weight
changes.
- Analysis will be completed between weight change and
medication change to see if there is any correlation.
Improvement Strategy cont.
Logistics of the intervention: Eating habits while on
Therapeutic Pass
- Parents have been educated on nutritional and healthy
living information.
- Nutritional FACT reminders and physical activity options
have been attached to the pass forms.
- Parents complete a pass feedback form regarding the
activities the client engaged in and what foods they ate.
Challenges
 Successes
– Preliminary success in reducing weight in overweight
and obese clients.
– Improved eating habits among clients.
– Staff, clients and parents are more educated on nutrition
and healthy eating habits
Challenges
 Areas for improvement
– Increased involvement in physical activity
 Future plans
– Create opportunities for families to meet with the
nutritionist
– Continue to educate staff on portion sizes and healthy
eating options
PIP Improvement Strategies
for
BayCare Behavioral Health
January 11, 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use for the measurement year.
 Outcomes
– Baseline results: July 2011–September 2011
(36.2 per 1000 bed days)
– Remeasurement 1 results: N/A
– Statistical test results: N/A
– Interpretation to Date: Baseline - Three youth
accounted for 85% of restraint events. Of the
three youth, one youth accounted for 64% of the
restraint events.
Study Indicator 2
 The rate of seclusion use for the measurement year.
 Outcomes
– Baseline results: July 2011–September 2011
(37.3 per 1000 bed days)
– Remeasurement 1 results: N/A
– Statistical test results: N/A
– Interpretation to Date: Baseline - Three youth
accounted for 94% of restraint events. Of the
three youth, one youth accounted for 59% of the
restraint events.
Improvement Strategy
 Restraint and Seclusion Interventions - Training
– Barrier it Addresses: Seclusion and restraint
orientation training was information given to MHT’s vs
1:1 instruction and was not reducing restraint and
seclusion rates.
– Description of the intervention: Facilitate regular,
interactive training for all team members to include
youth’s early warning signs, review of each youth’s
individualized behavior plans and implementation of
Code Grey protocols.
Improvement Strategy (cont)
 Restraint and Seclusion Interventions
– Logistics of the intervention: Behavior Analyst
trained all team members on SIPP Behavior Plan
(completed11/7/11); Management implemented Code
Grey protocols for early intervention and trained all
team members (began 11/19/11.)
– Evaluation of the intervention: Pending
– Effectiveness of the intervention: Pending
Lessons Learned
 Successes: QI meeting feedback and action steps.
 Areas for improvement: Identified need for
designated MHT’s to be trainers for new employees for
consistency; Improved seclusion/restraint data collection
needed for monthly QI meeting.
 Future plans – Discussing seclusion/restraint data at
monthly staff meetings.
TOKEN ECONOMY
SYSTEM PIP
Study Indicator 1
 The rate of MHT appropriate use of the token
economy.
 Outcomes
– Baseline results: July 2011-September 2011 (#
of appropriate use (3)/# of opportunities (83) or
3.6%)
– Remeasurement 1 results: N/A
– Statistical test results: N/A
– Interpretation: Enhanced training is necessary
Improvement Strategy
 Token Economy Intervention #1 – MHT Orientation
– Barrier it Addresses: Orientation training for
MHT’s was written information vs 1:1 instruction
which did not effectively train MHT’s with
expertise/knowledge of program’s Token Economy
System.
– Description of Intervention: 1:1 instruction with
Behavior Analyst.
– Logistics of Intervention: Behavior Analyst
facilitates orientation lasting 20 minutes within the first
30 days of hire when MHT’s are initially shadowing.
Improvement Strategy (cont)
 Token Economy Intervention #1 – MHT Orientation
– Evaluation of Intervention: MHT team members
grasp understanding of system but lacked
implementation.
– Effectiveness of Intervention: Ineffective based on
outcome data.
Improvement Strategy
 Token Economy Intervention #2 – “Behavior Thought of
the Day”
– Barrier it Addresses: Not sufficiently training MHT’s
to implement program’s Token Economy System.
– Description of Intervention: Behavior analyst post
daily examples of youth’s behavior and opportunity for
reward in staff lounge for review by MHT’s.
– Logistics of the intervention: Behavior Analyst used
an actual example of an event and how to respond.
– Evaluation of the intervention: MHT’s giving more
tokens.
– Effectiveness of the intervention: Effective but not
able to maintain due to behavior analyst time restraints.
Improvement Strategy
 Token Economy Intervention #3 – Ongoing Training
– Barrier it Addresses: MHT’s were not absorbing Token
Economy System reviewed during initial orientation.
– Description of Intervention: Implement monthly training for
all team members to include early warning signs, ongoing
knowledge of each youth’s individualized behavior plans and
direct observation and data collection by behavior analyst of
MHT’s implementation of Token Economy System.
– Logistics of Intervention: Behavior Analyst to facilitate a
separate one hour Behavior Plan training for each shift (initiated
11/7/11); Behavior Analyst to attend monthly staff meetings for
each shift to review youth’s plans, retrain, and answer detailed
questions team members have about the token economy program.
Improvement Strategy
 Token Economy Intervention #3 – Ongoing Training
– Evaluation of Intervention: Pending
– Effectiveness of Intervention: Pending
Lessons Learned
 Successes: Team members reported positive feedback on one
hour training in November and continued opportunity for discussion in
monthly staff meetings.
 Areas for improvement: Consistent and ongoing
training for all team members; Behavior analyst notified of all new
team members to schedule 1:1 initial training.
 Future plans: Behavior Analyst attending monthly staff
meetings; exploring having behavior analyst graduate students assist
with data collection of MHT’s.
PIP Improvement Strategies for
Central Florida Behavioral Hospital
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use for the measurement year
- 2011.
– Numerator – The total number of critical events involving the
use of restraints for the measurement year.
– Denominator – The total number of bed days for the
measurement year.
 Outcomes
– Baseline results: 3.9% (41/1031).
– Interpretation: 3% above the benchmark goal of 0%
Study Indicator 2
 The rate of seclusion use for the measurement
year.
– Numerator – The total number of critical events involving the
use of seclusion for the measurement year.
– Denominator – The total number of bed days for the
measurement year.
 Outcomes
– Baseline results: rate of 1.3% (13/1031).
– Interpretation: This is 1% above the benchmark goal of 0%.
Improvement Strategy: Incorporating a Trauma Informed
Care Treatment Philosophy
 Barrier:
– Staff did not understand that the use of restraint or seclusion could be retraumatizing patients
– This lack of knowledge could result in the staff initiating the use of
restraint or seclusion without realizing the collateral damage they may
cause
 Intervention:
– An evidenced based training plan which emphasized use of trauma
informed care philosophy was developed and implemented.
– All staff working the SIPP program (including nurses, mental health
techs, therapists, teachers) participated in a training program which
introduced concepts of trauma informed care
 Evaluation:
– This education was effective however new staff were hired after the initial
training, therefore retraining was conducted.
– The training is now incorporated into the orientation of new staff.
Improvement Strategy: Robust Programming
 Barrier:
– When patients are not involved in productive activities, negative behaviors
such as conflict between peers, property destruction and other aggressive
behaviors occur
– The original schedule was developed prior to the opening of the program,
therefore estimated times needed for some activities such as cleaning room,
homework, etc was over projected resulting in more “down time” than
anticipated.
 Intervention:
– The program schedule was revised to increase:
• the amount of structured programming
• the amount of recreational therapy
• programming hours extended until 8:30pm
 Evaluation:
– This intervention has proven effective.
Improvement Strategy: Use of Calm Rooms
 Barrier:
– Studies show that early intervention results in decrease acting out. One technique
proven is the use of calming rooms. No such rooms were available on the unit
 Intervention:
– 3 rooms were designed with input from the residents for use as calm rooms.
– Rooms included: “piped in calming themed music”; aromatherapy; therapeutic
equipment known for relieving stress
– Criteria was developed for the use of these rooms.
– Staff and patients were educated.
 Evaluation:
–
–
–
–
When used properly this intervention was effective
It was identified that the staff was not following the criteria for use
Staff were re-educated on the use
Criteria for use were posted on the rooms as an ongoing reminder
Improvement Strategy: Use of Line Norms
 Barrier:
– Critical events often occur during transition periods when patients are moving
from 1 activity to another
 Intervention:
– Developed and implemented a process called “line norms”.
• This technique utilized a process by which patients line up based upon
the program level which they are currently in (level 1-4 is based upon the
patient’s behavioral/treatment plan goals being met)
 Evaluation:
– This intervention was very effective, occurrences during transitions
significantly decreased.
Improvement Strategy: Debriefing Process
 Barrier:
– Staff focused on what the patient could have done to prevent the episode
 Intervention:
– Developed and implemented a daily review process of events to include:
• viewing of the video surveillance
• Focusing on what was happening prior to the actual episode
• Defining what the staff could have done differently
 Evaluation:
– We have seen a 20% reduction in episodes since implementing this process
Improvement Strategy: Defining Unit Philosophy
 Barrier:
– Staff members have different philosophical and treatment models
backgrounds
 Intervention:
– Defined unit philosophy with input for Sr. Leadership, Medical Staff, unit
staff
– Education presented at staff meetings, employee newsletter
– Commitment attestation
• Signing of poster
• Included in employee job description
 Evaluation:
– New strategy implemented 12/2011
Lessons Learned
 Successes:
– Emphasis on ongoing staff education
– Defined philosophy
 Areas for improvement:
– Stabilization of staff
– Staff embracing the concepts
 Future plans:
– Implement R/S unit champions
– Develop a process for celebrating improvement data with the residents
MINIMIZING WEIGHT GAIN OF
YOUTH IN A RESIDENTIAL
PSYCHIATRIC SETTING
Study Indicator 1
 Study indicator
– The percentage of patients who have a baseline Body Mass index greater than the
95th percentile BMI that have obtained a BMI of between the 50th and 95th
percentile of the CDC growth chart during their hospital stay
– Numerator:
• Total number of the patients who have a Body Mass index greater than the
95th percentile BMI and have reduced their BMI between the 50th and 95th
percentile per the CDC body mass index weight growth chart during their
hospitalization
– Denominator: Total number of patients in the SIPP-funded program who are over
the 95th percentile body mass index
 Outcomes
– Baseline results: currently collecting baseline data (Sept – Dec 2011)
– Interpretation: preliminary data indicates 33% of patients in the SIPP program
have a BMI of greater than the 95 percentile.
Improvement Strategy: Well Defined Food Distribution
System
 Barrier:
– There is not a well controlled food distribution system for meals or snack.
– Patients allowed to obtain “seconds”
 Intervention:
– Dietary delivering specific snack quantity based upon census
– Dietary staff monitors patients food quantities
– Clinical staff monitors patient to minimize sharing of foods
 Evaluation:
– No issues identified in changes
Improvement Strategy: Nutritional Knowledge
 Barrier:
– Lack of knowledge of nutritional values both staff and patients
– Food is perceived as a motivator/reward for appropriate behavior
 Intervention:
– Staff educated in the concept of healthy life style which includes: physical
fitness, motivation, diet and nutrition, medication management
– Dietitian conducting a weekly educational group on nutrition
 Evaluation:
– Patients are providing good feedback on the ongoing education
Improvement Strategy: Well defined Exercise Program
 Barrier:
– Recreational therapy program well defined, however, no defined exercise
program
 Intervention:
– Development of a exercise program utilizing the President’s Fitness Program
 Evaluation:
– Currently in the developmental stage
Lessons Learned
 Successes
– Ongoing nutritional education
– Adolescent Residents want to control weight
 Areas for improvement
– Portion control
– Developing a specific program that targets the younger population
 Future plans
– Implement an exercise model utilizing the President’s Fitness Program
PIP Improvement Strategies
for Citrus Health Network, Inc.
RITS Program
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use for the measurement year.
 Outcomes for Baseline Results
– Results indicate that 10 restraints per 1000 bed days
(37/3708 times 1000) of the members had a restraint
within the baseline period.
– This rate was 1.0% above the baseline goal of 0.
– The study population included 100% of the
Medicaid clients in the program and did not include
sampling.
Study Indicator 1
 Outcomes for Remeasurement 1 results
– The rate for clients who had restraints in this period
decreased from 10 restraints per 1000 bed days to
9.44 (42/4448) restraints per 1000 bed days.
 Statistical test results
– This was not statistically significant at the 95%
confidence level with a p-value of 1.0. The
remeasurement 1 result was 0.94% above the goal
of 0.
Study Indicator 1
 Interpretation
Based on strategies implemented, the RITS unit was
able to decrease the use of restraints from 10 restraints
per 1000 bed days, to 9.44 restraints per 1000 bed
days. Although these results are not statistically
significant, it does demonstrate a decrease in our need
for restraints. Currently our restraint use was less than
1% above the state goal of 0.
Study Indicator 2
 The rate of seclusion use for the measurement
year.
 Outcomes for Baseline Results:
– Results indicate that 2 seclusions per 1000 bed
days (6/3708 times 1000) of the members had a
seclusion within the baseline period.
– This rate was 0.2% above the baseline goal of 0.
– The study population included 100% of the
Medicaid clients in the program and did not
include sampling.
Study Indicator 2
 Outcomes for Remeasurement 1 Results:
The rate for clients who had seclusions in this period
decreased from 2 seclusion per 1000 bed days to 0.2
seclusions per 1000 bed days (1/4448 times 1000).
 Statistical Test Results:
This was not quite statistically significant at the 95%
confidence level with a p-value of 1.
Study Indicator 2
 Interpretation:
Based on strategies implemented the RITS unit was
able to decrease it’s seclusions from 2 seclusion per
1000 bed days, to 0.2 seclusions per 1000 bed days.
Although these results are not quite statistically
significant, it does demonstrate a decrease in our need
for seclusions to 1 incident of seclusion for the 2010
year. Currently our seclusion use was 0.2% above the
state goal of 0.
Improvement Strategy
 Intervention:
Clinical treatment team including behavioral analyst
developed individualized behavioral plans for
identified clients. Staff was trained in behavioral plan
interventions.
 Barrier it addressed:
Due to acuity in particular clients, overall restraint use
increased during their stay in program. Two clients
during 2010 accounted for 61% of restraints.
Improvement Strategy
 Logistics of the intervention:
The behavior analyst conducted training with the direct
care staff on the implementation of the individualized
behavioral plans that she created. She then supervised
the implementation to ensure adherence to the program.
 Evaluation of the intervention:
The intervention was evaluated by the behavior analyst
in rounds in order to determine if any modifications
were needed.
Improvement Strategy
 Effectiveness of the intervention:
The intervention was successful as the number of
restraints for the 2 clients decreased following the
implementations of the individualized behavioral plan.
Improvement Strategy
 Intervention:
SIPP Clinical Coordinators informed program’s direct
care staff of use of Seeking Safety Treatment Program
as well as other TIC strategies as a way of decreasing
use of seclusions and restraints.
 Barrier to Intervention:
Lack of staff training in formalized TIC treatment
programs.
Improvement Strategy
 Logistics of the intervention:
The clinical coordinator conducted training with the
clinical and direct care staff on the implementation of
Trauma informed care strategies.
 Evaluation of the intervention:
The clinical coordinator then supervised the
implementation of the trauma informed strategies
through supervision and treatment team meetings in
order to ensure adherence to the techniques.
Improvement Strategy
 Effectiveness of the intervention:
The intervention was successful as the number of
restraints for the non high frequency clients also
decreased following the implementations of the
trauma informed care strategies.
Improvement Strategy
 Intervention:
Holiday celebrations were created to develop a more
homelike environment and better relationships with
families.
 Barrier to address:
During community groups, clients were in need for
family contact. Lack of family contract was resulting
in increase in aggression.
Improvement Strategy
 Logistics of the intervention:
The unit clerk planned holiday activities and invitations
were sent out to the families to encourage an increase
in contact between the clients and there families.
 Evaluation of the intervention:
Interventions were processed with the client by the
individual therapist regarding the feeling involved with
the increased family contact.
Improvement Strategy
 Effectiveness of the intervention:
Intervention appeared effective as the rates of restraints
for individual clients decreased.
Improvement Strategy
 Intervention:
Clients participated in more therapeutic passes
including Zoo Miami, Jungle Island, public pools,
parks, museums and libraries.
 Barrier to address:
During community groups, clients indicated lack of
variety in daily activities and stated that extracurricular
activities would decrease frustration and acting out
behaviors.
Improvement Strategy
 Logistics of the intervention: Community
organizations were contacted and outings were planned
for the children in order to decrease frustration and
acting out behaviors on the unit.
 Evaluation of the intervention: The client’s outings
were processed by the individual therapist and their
feelings were reviewed in order to identify whether the
outing were able to decrease feelings of frustration.
Consequences following the passes were also noted to
identify whether there was a decrease in acting out
behaviors following the passes.
Improvement Strategy
 Effectiveness of the intervention:
The interventions appeared to help decrease the
need for restraints as the children who participated
in the passes were less likely to get restraint than
the children who did not participate.
Lessons Learned
 Successes
 As the clients feel more empowered and feel as if they
have some control of their environment; the incidents of
aggression decreased resulting in a reduction of restraints
and seclusions.
 As the clients increased the contact with their families;
they reported feeling better about themselves and
incidents of aggression decreased resulting in a reduction
of restraints and seclusions.
Lessons Learned
 Successes
As clients were given choices on the unit as well as a
variety of different copy strategies to use when angry;
they demonstrated an increase ability to respond to
verbal redirection and demonstrated a decreased
incidents aggression decreased resulting in a reduction of
restraints and seclusions.
Lessons Learned
 Challenges
Although there was improvement noted in clients that
participated in the above mentioned strategies there
continues to be a higher rate of restraints among clients
who are recently admitted. Targeting these clients would
further decrease our need for restraints.
 Future plans
Developing strategies to specifically target our new
admissions.
REDUCING OBESITY
IN THE RITS - SIPP PROGRAM
FOR CITRUS HEALTH
NETWORK, INC.
Study Indicator 1
 The percentage of patients in the measurement
year with a BMI > 30 at the time of discharge.
 Outcomes
– Baseline results are currently being obtained for
the 1/1/2011 to 12/31/2011 year; as the study
indicator was not identified until May of 2011.
– Statistical test will be conducted once the
baseline data is collected.
– Interpretation will be based on statistical results
Improvement Strategy
 Intervention: Menu was reviewed and items
modified as per client request.
 Barrier to address: Client completed client
satisfaction surveys and commented on the need to
make changes to the menu.
 Logistics of the intervention: Clinical and nursing
staff met with the clients following the completion
of the satisfaction surveys in order to identify the
issues with the food.
Improvement Strategy
 Evaluation of the intervention: The intervention
was evaluated by follow-up satisfaction surveys as
well as discussion with the clients during weekly
community group meetings with the Clinical
Coordinator.
 Effectiveness of the intervention: The client’s
reported little improvement as the menu items do
not represent the food choices they would make
independently.
Improvement Strategy
 Intervention: Meeting was held with dietitian to
review and modify menu based on the client’s
feedback.
 Barrier to address: Clients complained of lack of
variety in menu. Clients complained of specific
items that were not considered by them to be kid
friendly.
 Logistics of the intervention: A meeting was
conducted with the dietitian in order to make the
menu more “kid friendly”.
Improvement Strategy
 Evaluation of the intervention: The intervention
was evaluated by discussion with the clients
during weekly community group meetings with
the Clinical Coordinator.
 Effectiveness of the intervention: The client’s
were better able to compromise with staff. They
reported a better understanding of healthier food
choices as staff was more willing to have those
healthier choices appear more “kid friendly”.
Improvement Strategy
 Intervention: Pilates and Yoga exercise groups
were implemented in order to engage clients in
new physical activity.
 Barrier to address: Clients complained of lack of
variety in exercise groups which resulted in
feelings of frustration and increased irritability.
 Logistics of the intervention: A staff was
contracted to provide Martial Arts Groups.
Improvement Strategy
 Evaluation of the intervention: The intervention
was evaluated by discussion with the clients
during weekly community group meetings with
the Clinical Coordinator, a well as continue to
monitor the client’s weight on a weekly basis.
 Effectiveness of the intervention: Clients report
feeling better about themselves and increase
energy following the groups. However, they also
report feeling physically sore following the
groups, and report lack of physical strength and
endurance.
Improvement Strategy
 Intervention: Exercise groups were increased and
scheduled to occur on a daily basis.
 Barrier to address: Clients did not demonstrate
decrease in weight.
 Logistics of the intervention: The schedule was
adjusted to allow for Martial arts group to occur
on a daily basis.
Improvement Strategy
 Evaluation of the intervention: The client’s weight
is monitored on a weekly basis.
 Effectiveness of the intervention: Although the
client’s reports enjoying the Martial Arts Group,
there does not seem to be any improvement in
weight which results in no improvement in BMI.
Lessons Learned
 Successes: When clients feel they have the ability
to provide feedback as to the food options on the
menu they report feeling better able to make
healthy choices regarding the food they eat.
 Areas for improvement: Although Clients
increased their activity level there did not seem to
be any improvement in BMI at Discharge.
Lessons Learned
 Future plans: Continue to work with the nursing
and direct care staff to help the client’s choose
healthy food options as well as maintain
appropriate portion sizes.
Daniel Memorial, Inc.
2010-2011 HSAG
Performance Improvement Plan
SIPP
Study Topic:
 Decreasing Childhood Obesity While in
Residential Treatment
– This topic was identified as an area of great need due to
the number of clients:
• entering treatment that were obese (20 percent over normal
body weight or a BMI over 30).
• continuing to gain weight while in residential treatment.
• that may experience medical concerns such as adolescent
diabetes, hypertension and breathing issues due to obesity
issues.
Study Indicators & Population
 Indicator: The rate of weight lost during the measurement year
as measured by:
Total # of pounds lost during measurement year
Total # of bed days for the measurement year
 Baseline Goal: Decrease weight gain by 10 pounds from
admission weight.
 Population: Medicaid clients ages 5-17, both male and female
enrolled in SIPP greater than 30 days during the specified
measurement period.
Data Sources
Data collection will be continuous; data analysis
will be conducted monthly and will include data
gathered from the following sources:




Inpatient medical record (60-day client health assessment)
Weekly weight chart documentation
Monthly recreation progress notes
Client survey (during and post-discharge)
Barriers & Interventions
Barriers:
 Inconsistent schedule of physical
activity;
 Three female clients admitted into
program weighing 332, 295, 275;
 Minimal alternatives to traditional
snacks;
Interventions:
 Monday – Friday 4:00pm physical
activity;
 Girls cottage began walking in am and
pm after dinner;
 New Food Service Manager provides
alternative, healthier meals

Medication weight gain side effects;


Sedentary male members’ nonparticipation in 4pm activity;
More formalized nutritional plan for
easier monitoring needed;



Non-control of intake on home visits
and at discharge;


Lunchtime recreation time focused on
large muscle exercises;
Boys cottage began walking in am
before school;
A 1,500 calorie diet initiated for all new
clients unless clinically contraindicated;
Family nutrition education during
family therapy sessions and parenting
groups was initiated
Daniel Memorial, Inc.
2010-2011 HSAG
Performance Improvement Plan:
Reducing the Use of Restraint and
Seclusion
Study Topic:
 Reducing the Use of Restraints and
Seclusion
– This topic was chosen for the collaborative PIP in the
state.
• The elimination of the use of restraints in psychiatric settings
has been identified as a national initiative.
Study Indicators & Population
 Indicator 1: The rate of restraint use during the measurement year:
Total # of critical events involving the use of restraints during measurement year
Total # of bed days for the measurement year
 Baseline Goal: Internal goal of reducing restraints by 30 for the
measurement year.
 Indicator 2: The rate of seclusion use during the measurement year:
Total # of critical events involving the use of seclusions during measurement year
Total # of bed days for the measurement year
 Baseline Goal: Internal goal of reducing seclusions by 7 for the
measurement year.
 Population: Medicaid clients ages 5-17, both male and female enrolled in
SIPP funded program within the specified measurement period.
Data Sources
Data collection will be continuous; data
analysis will be conducted quarterly and will
include data gathered from the following
sources:
 Inpatient medical record
 Nursing Emergency Safety Intervention (ESI) log
 Behavior Analyst/Behaviorist critical incident log
Barriers & Interventions
Barriers:
1. No consistent monitoring of ESI
occurrences;
2. Not having a plan in place to address
client distress;
3. Increasing clients’ awareness of being
responsible for their care and how to
use coping skills learned in treatment
and receiving support to do so.
4. All staff not being aware of clients’
stressors and coping skills and using the
information to decrease incidents.
5. No comfortable safe place for voluntary
use.
6. Keeping younger clients <9 safe due to
their increased activity level, i.e.:
climbing, flipping, tossing, etc. which
results in an increase in restraints.
Interventions:
1. The reduction of restraints and
seclusions was added to the SIPP
program’s QI goals.
2. The treatment team now completes
client safety plans upon admission;
3. The treatment team and client create
personal coping skills cards for
members to keep on their person, cards
are reviewed in the morning; clients are
rewarded for carrying the cards
regularly.
4. Both trigger and coping skills for each
client are now posted for staff
awareness.
5. There are now child-friendly, calming
quiet rooms and areas established for
voluntary use.
6. Outside time after meals and more
structured age appropriate play has
increased.
Data/Outcomes
 Baseline Measurement: In the period of January 1
through December 31, 2009, the rate of restraints
was .029; seclusions at .003.
 During the re-measurement period of January 1 –
December 31, 2010, the rate of restraints was
.038; seclusions at .009.
 Goal not met: Restraint and seclusion use
increased due to two outliers in the study that
accounted for 61 restraints and 14 seclusions in a
four month period.
PIP Improvement Strategies for
Reducing Physically Aggressive
Behavior in Members
Devereux
January 2012
Outcomes,
Interventions, and Evaluations
REDUCING PHYSICALLY
AGGRESSIVE BEHAVIOR IN
MEMBERS
Study Indicator 1
 Mean number of instances of Personal Emergency
Interventions (PEI)
 Outcomes (re-measurement 1)
– 25 instances of PEI for 2009 measurement
period
– 10.33 instances of PEI for 2010 measurement
period
– χ2 = 9.05, DF =1 (3.84)
Study Indicator 1
 Interpretation (re-measurement 1):
Significant reduction in physical aggression
from 2009 to 2010
Study Indicator 1
 Outcomes (re-measurement 2)
– 8.66 instances of PEI for 2011 measurement
period
– χ2 = 10.18, DF =1 (3.84) [2011 vs. 2009]
– χ2 = 3.36, DF =1 (3.84) [2011 vs. 2010]
Study Indicator 1
– Interpretation (re-measurement 2):
• 2011 instances of physical aggression
significantly lower than baseline
• No significant reduction in physical
aggression from 2010 to 2011
• Improvements sustained
INTERVENTION STRATEGIES
Improvement Strategy
 Youth Leadership Council implemented
– Barrier addressed:
• less structured time
• fosters person-centered environment
– Weekly
– Frequency tracked by agency leadership
Improvement Strategy
 SAMHSA curricula
– Barrier addressed: need for effective group
curricula
– 12-week program
– Riley & Shopshire, 2002
– Available at:
http://www.kap.samhsa.gov/products/manuals/
pdfs/angrmngmnt_part_wb_08r.pdf
Improvement Strategy
 New Directions
–
–
–
–
Barrier addressed: Need for additional training
Begun in early-December 2011
Emphasis on early intervention
Ongoing until 2012
Improvement Strategy
 Revised Activity Schedule
– Barrier addressed: Need for enriched activity
schedule
– Increase therapeutic/recreational activities
– Driven by member feedback
Improvement Strategy
 Activity Cards
– Barrier addressed: Need for enriched activity
schedule
– Staff provided with a collection of impromptu
activities
• Range from relaxation exercises to children’s games
• Require minimal to no materials
Improvement Strategy
 Teaching to be a Coach
– Barrier addressed: Need for enriched activity
schedule
– Addressed coaching and training
– Completed as of October 2011
Lessons Learned
 Successes
– Increase in client–centered practices
– Sustained level of improvement
– Refine both our research methodology and
clinical practice
Lessons Learned
 Areas for improvement
– Order effects
– Monitoring consistency & fidelity
– Confounding factors
Lessons Learned
 Future plans
– Introduce fewer interventions
– Improve monitoring
– Expand data range
PIP Improvement Strategies
for
Jackson SIPP
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use for the measurement year.
 Outcomes
– Baseline results for 2009 – 19.3
– (86 events divided by 4441 patient days x 1000)
– Remeasurement 1 results for 2010 – 10 (53 events
divided by 4282 patient days x 1000)
– Statistical test results - (Fisher’s exact test)
– p value = 0.0101, statistically significant decrease
Study Indicator 1
 Interpretation –
In the study the internal validity is the strongest
when there is a dependent variable and an
independent variable that is manipulated. In the
Collaborative PIP, the conclusions are based on
correlations and associations which lead to a lesser
degree of internal validity. We can assume that
the interventions affected the rate of seclusion and
restraints positively but our conclusions are
correlations and associations and not cause and
effect.
Study Indicator 2
 The rate of seclusion use for the
measurement year.
 Outcomes
– Baseline results for 2009 – 6.5 (29 events
divided by 4441 patient days x 1000)
– Remeasurement 1 results for 2010 – 1.6 (7
events divided by 4282 patient days x 1000)
– Statistical test results - (Fisher’s exact test)
– p value = 0.0003, extremely statistically
significant decrease
Study Indicator 2
 Interpretation –
The interventions implemented resulted in
an extremely significant decrease in the use
of seclusion.
Improvement Strategy # 1
 Clients develop and post on their door their
personal safety plan
– Barrier it addressed - Lack of staff knowledge
about each client’s triggers
– Description of the intervention – Each patient
develops a personal safety plan that includes
triggers, signs that the patient is getting angry,
and what helps the patient calm down.
Improvement Strategy # 1
– Logistics of the intervention – During the first
two weeks after admission the patient is
assisted by their therapist in developing their
personal safety plan. The plan is then posted on
their door. Each staff is responsible for the
reviewing the plan.
– Evaluation of the intervention – The staff and
the patients find this intervention helpful as it
supplies important information about the
patient that is readily available during a crisis.
Improvement Strategy # 1
 Effectiveness of the intervention –
This improvement strategy has been
effective as there has been a decrease in the
utilization of both seclusion and restraint.
Improvement Strategy # 2
 Revised behavior program – The behavior
program is being reviewed on an ongoing
basis to insure consistent application and to
educate staff on the most effective way to
implement the behavior program for
specific patients
Improvement Strategy # 2
 Barrier Addressed – The potential for punitive and/or inconsistent
consequences
 Description of the intervention – During the weekly Target Behavior
meeting any level drops are discussed. This discussion looks at the
behavior program and the needs of the specific patient.
 Logistics of the intervention – The Target Behavior meeting is
scheduled weekly and reviews the goals for the patients and issues
they have had. Any major consequences and any consequences that
the individual patient gets frequently are reviewed and discussed. The
patient is invited to the meeting to find out how the team can assist the
patient to succeed and prevent further consequences.
 Evaluation of the intervention – The patients and staff are able to
develop strategies that assist the patient to succeed and this has
contributed to the reduction in seclusion and restraint usage.
 Effectiveness of the intervention – The use of seclusion and restraint
has significantly decreased.
Improvement Strategy # 3
 All patients are assessed utilizing “The Trauma
Symptom checklist” and interviewed for trauma
specific issues. The information is incorporated
into the treatment plan and in the development of
targeted interventions. Patient specific
interventions are discussed with the staff in the
weekly target behavior meeting.
 As a part of this improvement strategy:
– the staff received training on trauma informed care
– gender specific trauma groups for the patients were
implemented.
Improvement Strategy # 3





Barriers addressed – Limited staff knowledge about the effects of trauma on
patients and about the trauma sustained by the individual patient and the lack
of a safe setting for the appropriate expression of feelings regarding trauma.
Description of the intervention – The patients are assessed for trauma specific
issues and this is communicated to the staff through the treatment plan and
patient specific interventions. Trauma groups are also provided to assist the
patient in identifying and coping with their own trauma issues in a safe setting.
Logistics of the intervention – On admission each patient is assessed utilizing
“The Trauma Symptom Checklist” and then interviewed by the psychologist
for trauma specific issues. Any identified trauma issues are incorporated into
the treatment plan and discussed with the staff in the weekly target behavior
meeting.
Evaluation of the intervention – The program staff are more aware of the
trauma issues of the individual patients and are more effective in developing
interventions that do not re-traumatize the patients.
Effectiveness of the intervention – The focus on the patients and the
understanding of their experiences has contributed to the significant reduction
in the usage of seclusion and restraint.
Lessons Learned
 Successes – The staff are more engaged and
more creative in their approaches to the
patients with their increased knowledge of
the patients’ past trauma.
 Areas for improvement – More
individuality in the treatment approaches to
the patients
 Future plans – Development of the staff’s
debriefing skills
Patient Satisfaction
Study Indicator 1
 Study Indicator 1 The percentage of patients
responding “Yes” to Questions #14 “Overall, the
food was good” during the measurement year
 Outcomes
– Baseline results - For the baseline period of
2010 only 33% of the patients were satisfied
with the food. This is significantly below the
goal of 75% and below the 70.5% for all SIPP’s
for 2008 (the last year data is available).
– Interpretation – not applicable at this time
Study Indicator 1
– Remeasurement 1 results – Not available
– Statistical test results – Not available
Improvement Strategy #1
 Each patient will keep a food journal for
one week to be evaluated for repetitiveness
of the menu and to generate data to present
to the dietary department. Initial food
journal tested and feedback from patients
and staff incorporated into new food
journal.
Improvement Strategy #1
– List the barrier it addresses –
Lack of data to support patients’ complaints of repetitive menus.
Description of the interventionEach patient was asked to keep a journal of the food served to them
for one week. Then data was to be compiled.
– Logistics of the intervention – Each patient was given a food
journal page each day and were to be collected at the end of the
day.
– Evaluation of the intervention – The patients were not
cooperative with the process. Also, the dietary department
changed to the menus from a four week rotation to a one week
menu that repeats. With this change there was no need for the
patients to complete the journals as we know they are getting
exactly the same food each week.
– Effectiveness of the intervention – The intervention was not
needed as we have the data that the menus are repetitive and this
supports the patients’ complaints.
Improvement Strategy #2
 Patients will meet with the dietary
department after documenting their food for
one week to discuss the data generated and
to develop menus that allow for more
choice. After the changes are implemented
each patient will keep a food journal for one
week to assess the effectiveness of the menu
changes.
Improvement Strategy #2
– List the barrier it addresses –
Repetitive menus
Description of the interventionThe dietician will meet with the patients to discuss their food preferences
and assist with the development of menus that allow for more choice.
– Logistics of the intervention – After meeting with dietary, each patient
was to be given a food journal page each day and the journals were to be
collected at the end of the day to provide dietary data as to the
effectiveness of the changes to the menu.
– Evaluation of the intervention – The patients were not cooperative with
the process. Also, the dietary department changed the menus from a four
week rotation to a one week menu that repeats. With this change there
was no need for the patients to complete the journals as we know they are
getting exactly the same food each week.
– Effectiveness of the intervention – Not able to assess at this time as the
intervention has not been completed. The meeting with the dietary
department is still pending.
Lessons Learned
 Successes – Pending as we are just in the
implementation phase of the interventions
 Areas for improvement – The working
relationship with the dietary department
 Future plans – Development of more
interventions that require participation of
the patients56
PIP Improvement Strategies
for
Lakeview Center, Inc.
The Meridian
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
The goal of the study was to decrease
the use of restraints and seclusion at
the Meridian.
Study Indicator 1
 The rate of restraint use for the
measurement year.
 Outcomes
– Baseline results- Restraints per bed day were 0.0303%
– Remeasurement 1 results- Restraints per bed day were 0.0145%
– Statistical test results- Chi Square with Yates correction equals
25.085 with 1 degree of freedom. The two tailed p value is less than 0.0001. This
result is considered to be extremely significant (p< .05).
– Interpretation- Along with interventions that had already been in place
(CPI, Quality Council Oversight, Personal Safety Plan, and Behavioral Analysis),
training staff in Positive Parenting techniques seems to have resulted in a marked
decrease in the need for restraints.
Study Indicator 2
 The rate of seclusion use for the
measurement year.
 Outcomes
– Baseline results – Seclusion per bed day was 0.0096%
– Remeasurement 1 results – Seclusion per bed day was 0.0062%
– Statistical test results – Chi Square with Yates correction equals 3.511
with 1 degree of freedom. This two tailed p value equals 0.0609. This is considered to be not
quite statistically significant (p < .05).
– Interpretation – While the interventions in place for remeasurement year 1
numerically reduced the number of seclusions and approached significance (p = 0.0609), it
cannot be concluded that the interventions themselves reduced the seclusion rate to a
statistically significant extent. It should be noted that the reduction in restraints and seclusion
exceeded the goal of 10%
Improvement Strategy
 For each intervention
–
–
–
–
–
List the barrier it addresses
Description of the intervention
Logistics of the intervention
Evaluation of the intervention
Effectiveness of the intervention
Lessons Learned
 Successes – The intervention appears to be associated with the
decrease in restraint and seclusion. Areas for improvement include increased
training in implementing CPI, Personal Safety Plans, Quality Council
Oversight and Positive Parenting interventions. The second remeasurement
year will see the trauma informed care intervention implemented which will
hopefully further decrease restraint and seclusion incidents.
 Challenges
 1. Continued training of staff
 2. Continued monitoring of interventions to
assure that implementation of the
intervention are compliant with the training.
NAME OF INTERNAL PIP
Increasing Family Participation
in Treatment
The goal of the study is to increase family participation and
family centered care as an integral part of the comprehensive
treatment provided by the Meridian, and by so doing,
decreasing the rate of recidivism to acute care psychiatric
inpatient treatment.
Study Indicator 1
 Provide study indicator – Percentage of members from
Escambia & Santa Rosa Counties who are admitted to an acute care
inpatient psychiatric (Behavioral Medicine Center) within 60 days of
discharge from the Meridian. The overall objective of the Family
Involvement PIP is to improve the quantitative and qualitative
participation of parents and/or caregivers while their child is in the
treatment at the Meridian. Research suggests that active parental
involvement not only speeds the child’s recovery, but sustains it as
well.
 Outcomes
– Baseline results – Baseline results are being
collected from 1/1/2012 through 12/31/2012.
Improvement Strategy
 For each intervention
–
–
–
–
–
List the barrier it addresses
Description of the intervention
Logistics of the intervention
Evaluation of the intervention
Effectiveness of the intervention
PIP Improvement Strategies for
Manatee Palms Youth Services
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE
RESTRAINT AND SECLUSION
PIP
Study Indicator 1
 The rate of restraint use per bed for the measurement
year.
 Outcomes
– Baseline results yielded a rate of .05
– Remeasurement 1 results yielded a rate of .04
– Statistical test results indicate that the rate of restraint for the
baseline period results were calculated based on 15,590 total
number of bed days for the 2009 measurement year as well
as 738 total incidents of restraint for the baseline
measurement period yielding .05 as our baseline result.
Further, the remeasurement 1 period was calculated based
on 16,379 total number of bed days for the remeasurement
period 1 as well as 669 total incidents of restraint for the
remeasurement 1 period resulting in .04.
– Interpretation: The rate of restraint decreased by 20% for
the remeasurement 1 period.
Study Indicator 2
 The rate of seclusion use per bed for the measurement year.
 Outcomes
– Baseline period results yielded a rate of .01
– Remeasurement 1 period results yielded a rate of .01
– Statistical test results indicate that the rate of seclusion for the
baseline period was calculated based on 15,590 total number of
bed days for the 2009 measurement year as well as 78 total
incidents of seclusion for the baseline measurement period yielding
a rate of .01 as our baseline result.
Further, the remeasurement 1 period was calculated based on
16,379 total number of bed days and 137 total incidents of
seclusion for the remeasurement 1 period resulting in a rate of .01.
– Interpretation: The rate of seclusion remained the same in the
remeasurement 1 period.
Improvement Strategy

Intervention 1: Revised New Hire Orientation Training and Annual Training
on Restraint and Seclusion
–
–
–
–
–
The barrier this intervention addresses is the lack of understanding of staff regarding
definitions of restraint and seclusion and utilization of less restrictive measures prior to
use of restraint and seclusion.
Trainings on the definitions of restraint and seclusion based on the language provided in
the SIPP contract and the federal register occurred. Examples were given of less
restrictive measures to utilize prior to restraint and seclusion.
These trainings were added to the training schedules and an agenda developed and
provided to staff to ensure their understanding. A signed acknowledgement of
understanding by staff was placed in the HR training files.
Evaluation of the intervention: It was determined by the questions being asked by staff
and based on random camera reviews that staff required ongoing refresher training in
addition to the New Hire and Annual trainings, so monthly trainings on using less
restrictive measures were added in small increments to the shift change report as well as
the unit meetings.
Effectiveness of the intervention: This intervention appeared to be effective in educating
staff ongoing. The feedback from staff was especially positive in their understanding of
the definition of restraint and seclusion and in the importance of utilizing less restrictive
measures to restraint and seclusion.
Improvement Strategy
 Intervention 2: The Restraint Reduction PI Team was further
developed by utilizing the “Learning from Each Other – Success
Stories and Ideas for Reducing Restraint/Seclusion in
Behavioral Health” as a guideline/tool.
– The barrier this intervention addressed was the need for a
framework and comprehensive multidisciplinary approach for the
PI Team in the goal of reducing the rate of restraint and seclusion.
– The PI Team on Restraint Reduction utilized the actual tool noted
above as a guideline in it’s endeavor to reduce restraints and
seclusions.
– The multidisiciplinary PI team met at least monthly to go through
every chapter of the tool and identify areas for improvement.
– Evaluation of the intervention: The tool was effective and a lot
of the interventions in our Collaborative project were developed
from ideas utilizing this tool.
– Effectiveness of the intervention: This intervention appeared to be
effective in providing a guide for the multidisciplinary team to
follow in reducing our restraints and seclusions.
Improvement Strategy
 Intervention 3: The Expressive Therapist created Unit Activities
Binders which were individualized to be program specific for each of
the three units (children’s unit consisting of 12 and under males and
females; the female unit consisting of females 13 and over; and the
male unit consisting of males 13 and over).
– The barrier this intervention addressed was the lack of structured activities
after hours and weekends for patients.
– The Expressive Therapist created the binders for each unit and tabbed
them with specific activities individualized for each unit to capture the
interests of each population.
– The staff were trained on utilization of the binders and the binders were
placed on each unit for staff to easily access.
– Evaluation of the intervention: The intervention was effective in the
beginning, however, staff were not properly storing the items needed to
perform the activities and therefore the items tended to disappear.
– Effectiveness of the intervention: This intervention was partially
effective, however, a sign out process for items needed for the activities is
being developed to ensure the items are available when needed and that
the facility is not purchasing the items over and over again.
Improvement Strategy

Intervention 4: USF Learning Collaborative Trauma Study to Promote Best Practice
Standards.
–
–
–
–
–
The barrier this intervention addressed was the lack of knowledge of direct care staff of trauma
informed care and best practice standards.
MPYS participated in and is utilizing the trauma study which was done by the USF Learning
Collaborative to incorporate best practice standards. The plan’s focus was to be implement this more
specifically on the children’s unit (which was also noted to be the unit in which a higher percentage of
restraints occurred overall). The goal was to assist the plan with a revised incentive program based on
safe behavior and creation of new “opportunity” sheets. The program includes “positive praise” for
“on-target behavior.” Further, the therapist on this unit (who participated in the study) works on
instructing the patients on emotional regulation skills in group therapy that are specific to that unit.
She utilizes many of the approaches that were taught through the Learning Collaborative.
The Learning Collaborative continued to meet monthly and in April of 2011 met face-to-face for the
last meeting. The Director of Clinical Services implemented these “new” trauma informed care
practices with staff and programming. Again, the targeted population consisted of the children on the
12 and under unit. The new Director of Clinical Services continued to share ideas and best practices
learned internally with all staff.
Evaluation of the intervention: The intervention was effective.
Effectiveness of the intervention: In 2012, the new Director of Clinical Services will continue with
ideas learned, including implementation of the "Skill of the Week" which will be reinforced in daily
group therapy. This will teach concrete coping skills to the children, and will incorporate MHT staff in
the group to learn the skills and help reinforce them with the children throughout the day.
Improvement Strategy
 Intervention 5: Trauma Informed Behavior Support (TIBS)
Training
– The barrier this intervention addressed was the lack of ongoing and
consistent training in behavior intervention, preventing crisis and deescalation techniques.
– A selected group of core staff participated in the TIBS training to train all
staff in behavior intervention techniques. The Behavior Analyst was one
of these core staff and he incorporates this training into the new hire
orientation process to ensure all staff are knowledgeable and possess the
skills needed to prevent or de-escalate in crisis situations.
– The Behavior Analyst is now scheduling ongoing 'refresher' trainings for
MHT staff to help reinforce the use of the techniques and skills originally
taught.
– Evaluation of the intervention: The intervention continues to be effective.
– Effectiveness of the intervention: This intervention was effective,
however, refresher trainings remain to be a challenge at times due to
staffing schedules and must be broken up into separate trainings to ensure
all staff can attend.
Lessons Learned
 Successes: Most of our interventions were successful. We are
pleased that we did reduce our restraints overall, but are in no
way satisfied with where we currently are. The biggest
successes were the interventions discussed in this presentation.
 Challenges: Challenges were discussed under each intervention
above, however, our greatest challenge - without a doubt - was
losing half of our leadership team in the middle of 2011 and
rebuilding our team while not losing focus on our restraint and
seclusion reduction efforts.
 Future Plans: We are now under the UHS umbrella and have
been given a myriad of resources including corporate support,
on-site visits, and best practice policies and guidelines. Our
Corporate Clinical Training Team provided our staff with a
Verbal De-escalation Training on December 13th and 14th and
will be returning in February at our request to assist us further
with our restraint reduction efforts.
Internal PIP
Manatee Palms Youth Services
January 2012
Reducing Percentage of Overweight/Obese Patients
Study Indicator 1
 The Percentage of Patients in the Measurement
Year with a BMI > 85th Percentile for Age at
Time of Discharge
 Outcomes
– Baseline results are being calculated. The baseline
measurement period is January 1, 2011 –
December 31, 2011.
– Remeasurement 1 results: Remeasurement 1
period will be January 1, 2012-December 31, 2012.
– Statistical test results: Not yet calculated from
baseline measurement period.
– Interpretation: N/A
Improvement Strategy
 Intervention 1: Develop a PI Team on Reducing Percentage of
Overweight/Obese Patients
– The barrier this intervention addresses is the need for a plan which
involves the necessary members to evaluate and develop a data collection
process ongoing to monitor overweight/ obese patients and who can then
look at all cases and develop interventions for reduction of
overweight/obese patients.
– The PI Team on Reducing Percentage of Overweight/Obese Patients
includes the Medical Director, Pharmacist, Director of Nursing, Dietitian,
Director of Performance Improvement, Director of Clinical Services,
Behavior Analyst, and the Expressive Therapist. The team meets monthly
at minimum.
– The PI Team reviews the overweight/obese patients each month and
looks at various factors including their diet, activities, incentives,
medications, etc. The team then determines if there are any changes that
can be made that could assist with the goal of reducing weight.
– Evaluation of the intervention: The PI Team is instrumental in this
project to have a consistent plan for reviewing factors and implementing
plans for improvement.
– Effectiveness of the intervention: The effectiveness of the intervention
will not be completely known until the remeasurement 1 period.
Improvement Strategy
 Intervention 2: Dietitian Review of Current Menu
– The barrier this intervention addresses is the need for healthy
choices as opposed to foods and beverages that are high in
fat and calories.
– The Dietitian reviewed the menu initially and will review
ongoing to ensure that the menu items are healthy and meet
the nutritional requirements and needs of our patients.
– The Dietitian developed a new menu and forwarded for
approval. The Dietitian will continue to review the menu
monthly.
– Evaluation of the intervention: The Dietitian’s input is a
necessity in the intervention of nutritious healthy meal
planning.
– Effectiveness of the intervention: The effectiveness of the
intervention will not be completely known until the
remeasurement 1 period.
Improvement Strategy
 Intervention 3: Pharmacist Review of Patient Medications
– The barrier this intervention addresses is the fact that many
medications used to treat children with depressive disorders can
lead to weight gain.
– The Pharmacist reviews with the PI Team the medications that
overweight patients are currently on and determines if side effects
of these specific medications include weight gain.
– The Medical Director, Pharmacist and Director of Nursing discuss
alternatives to medications that cause or may have caused weight
gain for the patient to determine if there are acceptable alternatives
for the individual patient.
– Evaluation of the intervention: The Pharmacist’s input is a
necessity in the intervention of reviewing medications and
discussing side effects of those medications, as well as determining
alternatives for treatment.
– Effectiveness of the intervention: The effectiveness of the
intervention will not be completely known until the remeasurement
1 period.
Improvement Strategy
 Intervention 4: Behavior Analyst Review of Patient
Incentives
– The barrier this intervention addresses is that incentives
offered may include food items such as fast food, candy, and
snacks that are unhealthy for patients that are
overweight/obese.
– The Behavior Analyst reviews the incentives for each child
and considers alternatives to fast food, candy or snack
incentives for the overweight/obese child.
– Evaluation of the intervention: The Behavior Analyst’s
cooperation and input is a necessity in the intervention for
appropriate incentives for overweight/obese patients.
– Effectiveness of the intervention: The effectiveness of the
intervention will not be completely known until the
remeasurement 1 period.
Improvement Strategy
 Intervention 5: Expressive Therapist Review of Patient Activities
– The barrier this intervention addresses is the fact that patients don’t
always participate in the physical activities offered to promote a healthy
lifestyle.
– The Expressive Therapist develops a schedule of activities for each
individual unit to ensure activities are offered that each population will
participate in. Staff are trained to positively encourage patients
participation in ongoing physical activities provided.
– The Expressive Therapists discusses with the team any resources needed
to provide these physical activities ongoing and to give patients a variety
of choices for these activities to further encourage participation.
– Evaluation of the intervention: The Expressive Therapist’s cooperation in
planning and developing physical activities and encouraging motivation
for the patients is essential.
– Effectiveness of the intervention: The effectiveness of the intervention
will not be completely known until the remeasurement 1 period.
Lessons Learned




Successes: The plan has already observed increased awareness among patients and staff regarding the
Reduction in Percentage of Overweight/Obese Patients project. The majority of staff are supportive and
excited about helping patients in encouraging healthy eating habits and promoting a healthy lifestyle. The
soda machine in the cafeteria was eliminated and we now offer a variety of sugar free drinks in it’s place.
The kitchen staff have stopped using butter in the vegetables. An active medication review and conference
with the physician occurs when weight issues are identified and medication may be a possible attributable
factor. Individual successes have already been noted. For instance, one patient had a loss of 45 pounds and
while he still had a BMI at the 97th percentile he learned to make healthier choices through the interventions
provided. Another patient lost a total of ten pounds despite the fact that parent continued to bring in foods
with high calorie and fat content, though the team continued to educate and provide awareness for parent on
this subject.
Challenges: Patient involvement in physical activities is sometimes a challenge. In 2012 the Expressive
Therapist and Behavior Analyst will take a more active role in providing and encouraging participation in
physical activities and include choices on the schedule. There was a change in the Dietary Manager in the
middle of the year so this created a delay in the menu approval process. Healthy food choices are much
more expensive to obtain and the budge t must be approved to continue to order healthier foods. Cultural
attitudes and beliefs about foods in general is a challenge. For example, parent bringing in non-healthy foods
for patients and teachers providing candy as an incentive in the classrooms. Another challenge is that eating
disorders are often noted in individuals with depressive disorders, which of course is the population that we
deal with. Length of stay can be a challenging factor in this project.
Future Plans: Although we have chosen a difficult topic, it is one we feel is very important . The team is
excited about doing our part in promoting and encouraging healthy lifestyles for our children. We do plan
to increase awareness further this year by implementing a wellness program series for our patients, including
nutrition and education programs. We are also bringing in an outside source, a Director of Nursing from a
local university who has experience in projects such as this. She will be joining our team and will assist us in
our monitoring and developing new interventions.
Again, we are very aware of the national problem of obesity and we are hoping to make a difference in the
lives of our children by providing them with the education and guidance they need to develop healthier
lifestyles.
PIP Improvement Strategies
for
Reduction of Seclusion and
Restraints
January 2012
Outcomes,
Interventions, and Evaluations
River Point Behavioral Health
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Restraint
 Defined:
– involuntary method of physically restricting an
enrollee’s freedom of movement, physical activity, or
normal access to his or her body.
– Also, restraint devices employed for medical purposes
(Geri-chair, posey, etc.) or as personal protective
devices (helmets, bed rails, etc.) should not be reported.
– Types
– Manual Restraint -- individual is restrained by the
physical force of facility staff.
– Chemical Restraint -- enrollee is given a STAT dose of
a neuroleptic medication administered intramuscularly
Restraint
 The rate of restraint use for the
measurement year (outcomes).
– Baseline results
• .014763
• 15 every thousand days
– Remeasurement 1 results
• .009576
• 9 every thousand days
Restraint (cont.)
 The rate of restraint use for the
measurement year (outcomes).
– Statistical test results -- p value was calculated
as .0641
– Interpretation -- Determination was that the
intervention was not quite statistically
significant.
Seclusion
 Defined
– the confinement of a enrollee alone in a room
– is physically prevented from leaving, e.g. manually or
electronically locked doors, doors constructed so that
when closed and unlocked they may not be opened
from the inside (e.g., ―one-way doors‖), and the
presence of staff proximal to the room preventing exit.
– A seclusion event should not be reported if an enrollee
is prevented from leaving a room secondary to being
restrained
Seclusion
 The rate of seclusion use for the
measurement year (outcomes).
– Baseline results –
•0
• Seclusion is not utilized at River Point Behavioral
Health
– Remeasurement 1 results
•0
• Seclusion is not utilized at River Point Behavioral
Health
Improvement Strategy
 Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCs)
– Barriers
•
•
•
•
affect regulation and impulsivity,
self-perception, relationships, somatization,
dissociation, numbing and avoidance,
struggles with their own purpose and meaning in life
as well as worldviews that make it difficult for them
to see a future for themselves.
Improvement Strategy
 Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCs)
– Description of the intervention -- SPARCS is a
16-session group intervention that was
specifically designed to address the needs of
chronically traumatized adolescents
Improvement Strategy
 Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCs)
– Logistics of the intervention
• 16 group intervention sessions addressing
–
–
–
–
–
–
Regulating Emotions & Impulses
Somatization and Physical Health
Attention and Information Processing
Self-perception
Relationships
Sense of Meaning & Purpose in Life
Improvement Strategy
 Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCs)
– Logistics of the intervention – 16 sessions
• 16 one-hour group sessions
• For chronically traumatized adolescents, ages of 1221 who are still living with ongoing stress
• PTSD Diagnosis not required
• 6-10 participants per group, single or mixed gender
• Includes treatment guide with built-in flexibility &
colorful handouts for practice exercises
• Certified Trainer
Improvement Strategy
 Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCs)
– Evaluation of the intervention -- Statistical test
results -- p value was calculated as .0641
– Effectiveness of the intervention -Determination was that the intervention was not
quite statistically significant
Lessons Learned
 Successes -- one graduating class conferred
and discharged
 Areas for improvement – Maintain certified
trainers.
 Future Plans – Continue to measure success.
Maintaining a Healthy Body
Mass Index
Body Mass Index
 Defined -- Body mass index (BMI) is an
approximated measure of body fat using a
formula based on height and weight.
 Outcomes – there are no outcomes at this
time
Improvement Strategy
 Exercise program two times a week.
– Barrier
• Member weight gain in excess of thirty pounds.
• Maintaining healthy body mass index.
– Description of the intervention
• Participants will engage in an exercising program
for at least 30 minutes two times a week.
• BMI will be calculated on admission and at
discharge
Lessons Learned
 Successes -- TBD
 Areas for improvement -- TBD
 Future plans -- TBD
PIP Improvement Strategies
for
SANDYPINES RTC
January 2012
Outcomes,
Interventions, and Evaluations
Tammara Cook, LPN, LHRM
Director of Risk Management
Jennifer Pichardo, MHA, BSN, RN
Director of Nursing
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use per SIPP bed days for the
measurement year.
 Outcomes
– Baseline results = 9.7
– Remeasurement 1 results = 10.2
– Statistical test results = Chi squared with Yates
correction equals 0.130 with 1 degree of freedom
Two tailed p value = 0.7186
– Interpretation = Restraint events for this measurement
year yielded a rate of 10.2 per 1000 bed days which is
higher than the statewide goal of 0. The difference
between the Baseline measurement year and the
Baseline to Re-measurement 1 year was an increase of
0.5 per 1000 bed days. There was no significant
statistical difference between measurement years.
Study Indicator 2
 The rate of seclusion use per SIPP bed days for the
measurement year.
 Outcomes
– Baseline results = 5.6
– Remeasurement 1 results = 5.3
– Statistical test results = Chi squared with Yates
correction equals 0.140 with 1 degree of freedom Twotailed p value equals 0.7083
– Interpretation = Seclusion events for this measurement
year yielded a rate of 5.3 per 1000 bed days which is
higher than the statewide goal of 0. The difference
between the Baseline measurement year and the
Baseline to Re-measurement year was a decrease of 0.3
per 1000 bed days. There was no significant statistical
difference.
Interpretation
 Although there was no significant statistical
change between the measurement years for
Study Indicators 1&2, there were 3 residents
out of the 152 total SIPP residents for that
measurement year, that had a significant impact
on the overall numbers.
 For Re-measurement 1 study year (2010):
– Resident #1 had 22 restraint events and 18 seclusion
events.
– Resident #2 had 13 restraint events and 25 seclusion
events.
– Resident #3 had 19 restraint events and 4 seclusion
events.
Interpretation
 An analysis was completed which excluded these 3
residents. The number of restraint events with this
exclusion totaled 160 and the total number of seclusion
events with this exclusion totaled 65.
 This yielded a new restraint rate of 7.6 per 1000 bed days
and a new seclusion rate of 3.1 per 1000 bed days.
 This would have yielded a decrease of 2.6 per 1000 bed
days for restraint events which is statistically significant.
 This would have yielded a decrease of 2.2 per 1000 bed
days for seclusion events which is also statistically
significant.
Improvement Strategy
 Intervention 1 – Developed a calming room
– List the barrier it addresses – there was no true space
available for residents who needed a place to calm down.
– Description of the intervention – when a resident needed a
place to calm down and de-sensitize and were not to the
point of needing a timeout, they could access the calming
room.
– Logistics of the intervention – 20 minute max time limit,
offered various coping skills, located in a central location to
all 5 units.
– Evaluation of the intervention – originally worked great until
that space was needed for another use due to expanding staff
demands.
– Effectiveness of the intervention – very effective, with the
expansion of hospital next year, there will be a new sensory
room.
Improvement Strategy
 Intervention 2 – Seclusion and Restraint In-service
provided for all employees
– List the barrier it addresses – Staff required more
education regarding prevention of S/R.
– Description of the intervention – In-service addressed
triggers, early warning signs of agitation or distress, deescalation strategies, and de-briefing post intervention.
– Logistics of the intervention – training was available over
six trainings so all staff were able to attend.
– Evaluation of the intervention – staff responded well to
training. This intervention is ongoing as part of annual
trainings and during orientation classes.
– Effectiveness of the intervention – Training was effective
and staff continue to practice various de-escalation
strategies.
Improvement Strategy
 Intervention 3 – De-escalating an Escalated Unit Inservice provided to A UNIT program staff by Tony
Spaniel.
– List the barrier it addresses – A UNIT program staff felt
they needed information and training on how to handle an
escalated unit.
– Description of the intervention – training focused on
discussion and education about possible strategies for deescalating an escalated Adolescent Male Unit.
– Logistics of the intervention – training was held at a time in
which both day and evening shift could attend
– Evaluation of the intervention – training was very
informative for staff
– Effectiveness of the intervention – staff adopted program
ideas specifically for de-escalating an escalated unit.
Improvement Strategy
 Intervention 4 – Crisis Prevention Intervention training
provided to staff with emphasis on vertical rather than prone
restraints.
– List the barrier it addresses – Administration felt that more prone
restraints were being used rather than vertical restraints when
needed.
– Description of the intervention – Training placed an emphasis on
vertical restraints rather than prone, as well as the team control
position.
– Logistics of the intervention – All staff were re-trained by our
four trainers over a one month time frame.
– Evaluation of the intervention – There was an overall decrease in
prone restraints and vertical restraints or team control position
was utilized instead, when necessary.
– Effectiveness of the intervention – The training was effective as
the outcome was one administration and corporate desired.
Improvement Strategy
 Intervention 5 – Hearts and Hope provided a Grief and
Loss In-service emphasizing trauma informed care.
– List the barrier it addresses – Clinical staff verbalized a
need for more trainings. Administration felt all staff could
benefit from training.
– Description of the intervention – The training focused on
trauma informed care and how certain behavior are a
manifestation of grief and loss in children and adolescents.
– Logistics of the intervention – Clinical staff (therapists),
MHTs, and nurses were all welcome.
– Evaluation of the intervention – trauma informed care was
truly introduced to staff.
– Effectiveness of the intervention – Staff were able to
identify behaviors which may have manifested from past
trauma.
Improvement Strategy
 Intervention 6 – All day community training offered to all
employees on Trauma Informed Care.
– List the barrier it addresses – Staff were asking for more training
regarding Trauma informed Care.
– Description of the intervention – Training focused on defining
trauma informed care, understanding how past trauma is
manifested in behavior, and how to address and care for children
and adolescents who have been through trauma.
– Logistics of the intervention – Staff were given the option to
attend training. Staff who wished to attend were provided
coverage on the unit if it was during their scheduled shift.
– Evaluation of the intervention – Excellent, provided staff and
therapists with great information.
– Effectiveness of the intervention – Staff and therapists were able
to utilize techniques learned.
Improvement Strategy
 Intervention 7 – Training provided for all employees on How to
Influence Positive Behavior.
– List the barrier it addresses – Staff required more training on
positive reinforcement and teaching appropriate replacement
behaviors.
– Description of the intervention – Leadership requested the Behavior
Analyst conducting the training to focus on teaching staff how to
provide therapeutic interventions with positive talk and
reinforcement.
– Logistics of the intervention – Training provided over six different
times so that all staff could attend over all three shifts.
– Evaluation of the intervention – Good, staff were able to discuss
specific residents who were having the most difficulty and learn
new techniques.
– Effectiveness of the intervention – Staff continue to utilize positive
reinforcement in the overall unit programming and with individual
residents.
Improvement Strategy
 Intervention 8 – A new unit program was developed
and implemented for all adolescent units.
– List the barrier it addresses – The program that was in place
was ineffective. The point/level program was focused on
behavior only.
– Description of the intervention – Direct care staff and social
services collaborated to implement a new program focusing
on behavior as well as progress towards treatment goals and
objectives.
– Logistics of the intervention – Developed over several
meetings and a trial and error period, revisions made.
– Evaluation of the intervention – Good program. Still needs
minor tweaking.
– Effectiveness of the intervention – Great because there was
buy in from the nursing department and social services
department.
Improvement Strategy
 Intervention 9 – Behavior Analyst provided training for
staff on specific residents (particularly those with multiple
incidents of seclusion/restraint).
– List the barrier it addresses – Staff needed specific trainings in
how to manage negative behavior in a therapeutic manner in
order to help reduce S/R.
– Description of the intervention – Discussed individual
protocols for specific residents and how to manage negative
behaviors to be more therapeutic and reduce S/R incidents.
– Logistics of the intervention – Provided on the units at shift
change for staff working directly with these individuals.
– Evaluation of the intervention – Good, staff were able to
understand rationale for certain behaviors. Therefore
understanding how to manage them.
– Effectiveness of the intervention – Provided minimal decrease
in seclusion and restraint numbers.
Improvement Strategy
 Intervention 10 – All employees attended an inservice on Recovery and Resiliency.
– List the barrier it addresses – Leadership felt that staff could
benefit from this training that was part of a statewide effort.
– Description of the intervention – PowerPoint presentation and
open discussion focusing on living with mental illness and
trauma.
– Logistics of the intervention – Training was provided over six
classes in an effort to cover all shifts.
– Evaluation of the intervention – Good, training was web-based
so there were some technical issues.
– Effectiveness of the intervention – Staff had good feedback
during discussion and were able to take points back to the units
for groups.
Improvement Strategy
 Intervention 11 – All employees attended a mandatory
training on Multicultural Awareness/Working with the
Hispanic Population
– List the barrier it addresses – There were an increasing number
of new admissions of Hispanic residents and staff felt they
needed more training.
– Description of the intervention – Training focused on cultural
issues/problems that these children face, as well as how to
address behaviors associated with.
– Logistics of the intervention – Training was provided in six
different classes to cover all shifts.
– Evaluation of the intervention – Good, staff were amazed at
the types of issues these residents come across.
– Effectiveness of the intervention – Highly effective, we now
have a fully bilingual program that produces great outcomes
with this population.
Improvement Strategy
 Intervention 12 – A two part series training was provided
to staff/clinicians on the Brain and Its Development.
– List the barrier it addresses – Staff were requesting more
training on the disease process for different mental illness
diagnoses.
– Description of the intervention – Dr. Phil Henry came to train
on different parts of the brain, how they develop or why they
don’t and what happens if there is abnormal development.
– Logistics of the intervention – Training was provided in a
lunch and learn forum.
– Evaluation of the intervention – Great speaker, very
informative. Staff were able to ask questions about specific
residents/behaviors.
– Effectiveness of the intervention – Highly effective!
Lessons Learned
 Successes
– Although the data did not reflect improvement
in decreasing seclusion/restraints, there have
been various targeted interventions
implemented over the past 2 years which have
had a positive impact.
– Please note, even though the 3 residents
mentioned in previous slides did account for a
large number of the events, individually each of
them demonstrated progress from admission to
discharge.
Lessons Learned
 Areas for improvement
– Continued staff development and trainings
– Constant reminder of culture of rewarding
positive behaviors and replacing negative
behaviors in a therapeutic manner.
– Communication between nursing and social
services to better treat the “whole” resident.
Lessons Learned
 Future plans
– Full time Behavioral Analyst to be hired in 2011.
– All employees will attend the UHS 8 hour training on
Verbal De-escalation in 2011.
– Adolescent Programs will be tweaked further.
– Children’s Unit Program will be revised completely in
2011/2012.
– Brand new Sensory/Calming room will be built with
the new expansion in 2012.
– Trainings will continue each month for staff, as well as
in the Annual Health Fair.
– We are looking to completely get rid of prone personal
restraints by training all staff in a new crisis prevention
and intervention training in 2012.
STAFF VS. RESIDENT
INITIATED TIMEOUTS
PIP
Study Indicator 1
 The percentage of staff initiated timeouts
for the measurement year.
 Outcomes
– Baseline results – Currently collecting baseline
data through end of 2011.
– Remeasurement 1 results – n/a at this time
– Statistical test results – n/a at this time
– Interpretation – n/a at this time
Improvement Strategy
 For each intervention
–
–
–
–
–
List the barrier it addresses
Description of the intervention
Logistics of the intervention
Evaluation of the intervention
Effectiveness of the intervention
Lessons Learned
 Successes
 Areas for improvement
 Future plans
Collaborative Restraint & Seclusion PIP
2011-2012
Patty Bush, LMHC, BCBA
Vala Wagie, M.S, CPHQ, Executive Fellow in Patient Safety
CY 09-Baseline 2.4 restraints per 1000 bed days
CY 10 – 47 patients experienced critical events which resulted in
532 episodes of restraint The results for remeasurement 1:
100
90
Restraint Use 2010 - Rate per
1000 SIPP funded bed-days
91
80
73
69
70
60
55
50
47
46
45
43
48
48
#patients
# restraints
rate per 1000
40
30
22
20
15
10
0
1
2
3
4
5
6
7
8
9
10
11
12
USE of RESTRAINT OUTCOMES-STUDY INDICATOR 1
Restraint Rate per 1000 SIPP funded Bed Days =
Total #critical events involving the Use of Restraint for measurement year X 1000
The number of SIPP funded Bed Days in the measurement year








2009 Baseline Year
Benchmark ≤22 (PSI)
2.4 per 1000 SIPP funded bed days
2010 Remeasurement 1
Benchmark ≤22 (PSI)
59.6 per 1000 SIPP funded bed days
2011 Remeasurement 2
Benchmark ≤20 (UHS)
50.8 per 1000 SIPP funded bed days
2012 Remeasurement 3 -Collaborative Benchmark
ZERO per 1000 SIPP funded bed days
Definition of a Bed Day A SIPP funded bed-day is a day during
which a SIPP member is assigned to a bed and in which the
patient stays overnight in the hospital’s RTC. Therefore, the
formula for reporting for the SIPP population restraint rates
requires special case adjustment in order to make the measure
valid as prescribed by the collaborative for The Vines data
systems are based on RTC bed days and also includes non-SIPP
funded patients.
The following slide demonstrates the comparison of 2011
restraint rates as reported to UHS (includes non-SIPP funded
patients) and the adjusted restraint rate for SIPP funded
patients only.
120
Restraint Use 2011-RTC BED DAYS
101.43
106.03
100
80
66.13
#patients
58.82
60
48.1
# restraints
43.09
38.93
35.06
40
35.6
rate per 1000
24.48
20
8.53
5.79
0
1
120
2
3
4
5
6
7
8
9
10
11
12
Restraint Use 2011-SIPP FUNDED BED DAYS
104
103.7
100
80
65.8
#patients
60.6
60
47.7
34.3
40
20
# restraints
42.7
40
34.5
13.7
38.7
8.6
0
1
2
3
4
5
6
7
8
9
10
11
12
rate per 1000
New Leadership- A look into the future
 March –New CEO’s Town meetings address 2011 plans “culture change”
for hospital’s restraint free philosophy
 April - Change in Risk Manager

5 staff became UHS Verbal De-escalation Trainers
 May - AHCA representative provided education on seclusion /restraint to
38 direct care staff due to concerns specific to under reporting of physical
holds and seclusions
 June -CEO’s Town meetings address accountability of staff
 for their role in use of verbal de-escalation vs. physical holds
 when youth demonstrate out of control behaviors
 June- Patty Bush, LMHC, Behavioral Analyst. recruited
 May-July– Restraint /Seclusion Reduction PI Plan developed and
approved by MEC/GB
 September/October- Trauma Informed Care and Verbal
De-escalation training for 78 direct care staff
October – Staff trained, patients educated and Reinforcement Rooms
opened
Use of Restraint – Study Indicator #1
Assess for real improvement during 2011
Statistical Test Results Re-measurement 2
 Activity V: Use sound sampling techniques
Data includes the entire eligible population. No sampling
techniques
were utilized, therefore “Not Applicable” as Mu = N
 Chi-square with Yates correction
Chi squared equals 6.173 with 1 degrees of freedom.
The two-tailed P value equals 0.0130 The association between
rows (groups) and columns (outcomes) is considered to be
statistically significant.

Outcome 1 Outcome 2 Total
 Group 1
532
8918
9450
 Group 2
510
10033 10543
 Total
1042
18951

19993
USE of SECLUSION OUTCOMES-STUDY INDICATOR 2
Seclusion Rate per 1000 SIPP funded Bed Days =
Total #critical events involving the Use of Seclusion for measurement year X 1000
The number of SIPP funded Bed Days in the measurement year








2009 Baseline Year
Benchmark ≤3.5 (PSI)
0.45 per 1000 SIPP funded bed days
2010 Remeasurement 1
Benchmark ≤3.5 (PSI)
3.06 per 1000 SIPP funded bed days
2011 Remeasurement 2
Benchmark ≤4.0 (UHS)
0.12 per 1000 SIPP funded bed days
2012 Remeasurement 3 -Collaborative Benchmark
ZERO per 1000 SIPP funded bed days
Use of Seclusion 2011-SIPP FUNDED BED DAYS
12
10.1
10
10
9.6
9.2
8
6.9
#patients
5.7
6
# seclusions
rate per 1000
3.8
4
2
1.1
0
0
0
0
0
1
2
3
4
5
6
7
8
9
10
11
12
Study Indicator 2
Use of Seclusion - Assess for real improvement during 2011
Statistical Test Results Re-measurement 2

Activity V: Use sound sampling techniques
Data includes the entire eligible population. No sampling techniques were utilized,
therefore “Not Applicable” as Mu = N

Chi-square with Yates correction
Chi squared equals 3.591 with 1 degrees of freedom.
The two-tailed P value equals 0.0581 The association between
rows (groups) and columns (outcomes) is considered to be
not quite statistically significant
Outcome 1 Outcome 2 Total
Group 1
532
8918
Group 2
510
10033
Total
1042
18951
9450
10543
Improvement Strategy
Intervention #1 – CEO’s Town Hall meetings
Barrier
 “Culture shift” with focus in verbal
de-escalation was “stalled” - Some
RTC used DJJ style of “hands on”
when a youth lost self control or
who behaviors were out of control.
Evaluation: Review of critical
events via the surveillance camera
monitored staff approach and
competency in use of verbal deescalations, or the lack of
 Intervention – Michel McDonald,
new CEO communicated his vision for
a "culture shift” through Town
meetings . (March, June, July, August)
and during interaction with staff and
patients during morning environmental
rounds
Effectiveness: Outcome of
monitoring evidenced need for
additional skills training for
RTC direct care staff. Restraint
rate failed to demonstrate
decrease and 5 staff were sent
for UHS Training to become
verbal de-escalation trainers.
Improvement Strategy
Intervention #2 - Education
Barrier

 Intervention - T. Anderson, AHCA,
2011 Q1 Successfully transition from
NAPPI to CPI with 202 employees
trained, CPI places an emphasis on
verbal de-escalation, a critical skill to be
utilized by direct care staff in preventing
use of restraint and seclusion. seclusion
and comfort room or personal time out.
Evaluation: Review of the Jan-April
restraint/seclusion data Indicated a
need for additional training on what
constitutes a
Seclusion, restraint (e.g. physical holds,
escort of patient with CPI hold)
provided training to 38 direct care staff
on the State of Florida Adm Code 65
E-9.01 - Seclusion (locked or restrained
from leaving a room) and Time Out
(personal time out and staff directed
time out a/k/a Comfort Room)
Effectiveness: Restraint rate
failed to demonstrate the
anticipated decrease and initially
5 staff were sent for UHS training
to become verbal de-escalation
trainers,
Improvement Strategy
Intervention #3 – Restraint Reduction PL Plan (I of II)
Barrier
 Intervention – Leaders adopted
Resistance for change was
evident with employees who have
current or past employment
in corrections
 New hires were receiving verbal 

de-escalation and trauma
informed care training but some 
long term employees “interfered” 
with new hires effectively use of

this training.

Evaluation: Plan provided Senior
Leaders with structure, and included
recruitment of a behavioral analyst
who would be (1) willing to educate
staff in approaches to avoid physical
holds /seclusions and (2) who
would have “hands on” approach
with staff and (3) who would
develop a program to reinforce
positive behaviors in the patient
population.

UHS Restraint Reduction Plan format
which included 6 nationally
recognized components:
Leadership
Data
Workforce Development
Restraint Prevention Tools
Debriefing
Consumer Roles
Effectiveness: Recruitment
efforts were successful in securing
contracted services of Behavioral
Analyst who met the identified
criteria.
Improvement Strategy
Intervention #4 – Plan to Change Culture (II OF II)
 Barrier: No plan to guide activities

necessary to support a cultural
change”. Restraint/Seclusions
Reduction PI Plan drafted with
focus on staff education to provide
direct care staff with improved skills
for conflict resolution and verbal de-
escalation and team building skills. 
The aim is to provide positive,

engaging, nurturing and

individualized treatment
environments.


Evaluation: Review of the Jan-April
data Indicated a need for additional
training.
Intervention - Restraint/Seclusion
Reduction PI Plan addresses 6 major
areas designed to instill a new
organizational behavior.
Leadership
Data
Workforce Development
Restraint Prevention Tools
Consumer Roles
Debriefing
Effectiveness: Restraint rate
failed to demonstrate decrease
and staff were sent for UHS
Training to become verbal deescalation trainer,
The Vines Behavior System
Patty Bush, LMHC,
BCBA
Purpose of Program
 The Vines Behavioral System (BS) is a
comprehensive behavioral program developed
for The Vines residential program located in
Ocala, Florida. It is also designed to be a stepdown program for residents transitioning out of
the residential program to a less restrictive
residential setting or back to their own homes.
The system teaches and reinforces a wide
range of behaviors including self-care skills,
daily living skills, academics,
recreation/leisure skills, and social skills.
Key Components of Program
 The system is positive in its orientation and
does not incorporate a “Fine or take away”
component because the use of fines often
serves as an antecedent event to cause or
escalate angry or aggressive behavior.
 Reinforcement Times (times when residents
can earn specific reinforcers or engage in
reinforcing activities) follow a normal
reinforcement schedule which does not disrupt
ongoing programming and which can be
generalized to a nonrestrictive setting or to a
resident’s natural home.
Key Elements of a Behavior System







Simple way to track rate of problem behaviors
Simple criteria for earning reinforcement
Principles of Immediacy
Principles of Reinforcement
Frequent Reinforcement Schedule
Teach New Skills
Reinforce Replacement Behaviors (New
Skills)
 CONSISTENCY, CONSISTENCY,
CONSISTENCY
RECORDING METHOD
Frequency/ Rate:
DEFINITION
Measure of the number of times a Bx or event occurs.
EXAMPLE
Number of books read, paper airplanes thrown, meals eaten
PRACTICE
RATE OF BX: Rate = Count/ Time (Used when observation
times for frequency recording vary). Makes it possible to
compare data
20 minutes, 40 frequency, rate equals 2 per minute
PROS/ CONS
(1) Appropriate for Bxs that have clearly definable
beginnings and endings. (2) May be recorded on a checklist,
wrist counter, hand counter, or transfer of objects (e.g.
pennies) from one pocket to another.
APPLICATION
This method is used most often for discrete Bxs. Can record
with some sort of counter device. Also known as event
recording.
Major and Minor Behaviors
 The Frequency Data sheet is divided into
major and minor offenses; major offenses
are more serious behaviors and result in a
greater impact on earned privileges.
 Major Behaviors: Major Verbal, Major
Physical, Major Property
 Minor: Minor Inappropriate Verbal,
Inappropriate Physical, and Defiance
Verbal Aggression
Encouraging others to fight
Physical Aggression
Hitting staff
Property Misuse
MAJOR BEHAVIORS
Major Behaviors
Slamming/throwing objects
Threats to use a weapon
False accusation against staff/peers
Threats to self harm
Threats to harm others
Hitting peers
Hurting self
Sexual contact
Biting others
Breaking objects
Kicking doors/windows
Banging doors/windows
Turning over furniture
Going into unauthorized areas/elopement
Refusing process/therapy group
Minor Behaviors
Defiance
Refusal to carry out a directive
Violation of Hall rules
Refusal to stop when asked
INAPPROPRIATE VERBAL
Refuses school/group
Lying/denying wrong-doing
Gossiping/tattling/partial truths
Manipulating staff/ splitting
Arguing/Backtalk
Cursing / Bad language
Loud Talk/yelling
INAPPROPRIATE
PHYSICAL
Violating personal boundaries
Rude or sexual gestures
Touching others w/o permission
Disruptive behavior during group
Daily Expected Behaviors
 Residents will receive feedback for
initiation and completion of expected
behaviors (self-care skills, daily living
skills, academics, recreation/leisure skills,
and social skills). These expected behaviors
are part of the resident’s daily schedule. An
advantage of this system is that it requires
both the residents and staff to remember
only one set of program contingencies and it
promotes consistency and fairness.
When to Award Completion of Expected
Behaviors
 Whenever possible, a check mark is to be
awarded immediately following each
activity/expected behavior specified on the
Daily Reinforcement Record. Check Marks
are never to be awarded before or during an
activity because this could reinforce partial
performance or lack or performance.
Why not Points??
 Most Level systems use some sort of
Secondary Reinforcer (stars, checks, points,
etc. as a means to track progress towards a
Primary Reinforcer (money, games, edibles,
tangibles)
 Points often lead to power struggles
between staff and patients, create coercive
situations for staff and become a
documentation challenge.
Reinforcement Times
 Reinforcement Times are the times when
residents are then contingently given the
opportunity to engage in reinforcing
activities.
 As many different reinforcers as possible
should be available. Reinforcers must also
be individualized for each resident. The
major emphasis should be placed on activity
reinforcers, especially ones that will be
available to the resident when he returns to
his natural home.
Alternative Education (Teaching Skills)
 Residents who have not earned
Reinforcement Time are to be sent to
“Alternative Education (AE),” which is a
supervised area where special therapeutic
assignments are given. The individual
assignments are designed to improve selfesteem or social skills. When possible, the
assignment should be related to the
unacceptable behavior requiring AE.
Determining Levels
 Based specifically on how patient behaves
 Assign Privileges that allow for more
independence and responsibility as patient
moves up in Levels
 Levels should be time limited and
immediate based on their behaviors
(Immediacy Principle)
Monitoring
 Monitoring outcomes and effectiveness
based on patient’s data
 Monitoring of Daily Schedule
 Monitoring of Reinforcement Times
 Monitoring of Data Collection
AREAS OF IMPROVEMENT Improving
Competency
 Modeling and Role play with staff on the
floor
 Active training verses paper training
 Weekly meetings with direct care staff
 Competency Training Tools
 Monitoring by different levels of staff
(Milieu Coordinators, Therapists, Nurses
and Administrators)
AREAS OF IMPROVEMENT Challenges
 Consistency with implementation of
behavior system
 Completion of data collection sheets
 Positive Interaction between staff and
patients
 Immediacy of consequences both positive
and negative.
SUCCESSES
 Ability to Award Children/Adolescents for Completion of
Expected Behaviors
 Trauma Informed Care and Verbal De-escalation Training
of 78 Direct Care staff (September/October
 Evidence of staff ownership of the positive change in
culture which is reflected in  Reduction in Restraint rate of 104 (July) and 103 (August)
to 38.7 (December)
 Addition of Milieu Coordinators on 1st – 2nd Shift – 7 days
a week – to provide guidance and supervision of
community counselors in collaboration with Nursing staff
FUTURE PLANS
 Swimming Pool approved for use 1/6/2012
Swimming recreation for patients with warm
weather
 Milieu Coordinator with teaching experience,
has completed setting up a curriculum and
classroom for new patients who do not have an IEP
and are unable to go school they have an IEP
 RTC unit scheduled for major refurbishment
 Continue to place great emphasis of the Behavioral /
Reinforcement Room
 Expand the current vocational skills opportunity for
adolescents into a formal program,
PIP Improvement Strategies
for
University Behavioral Center
January 2012
Outcomes,
Interventions, and Evaluations
COLLABORATIVE RESTRAINT
AND SECLUSION PIP
Study Indicator 1
 The rate of restraint use for the
measurement year.
 Outcomes
– BASELINE RESTRAINT RATE: 0.082
– YEAR ONE RESTRAINT RATE: 0.043
– Chi squared equals 251.617 with 1 degree of freedom.
The two-tailed P value is less than 0.0001.
– Data showed significant improvement in the reduction
of restraint utilization. Based on the outcome of 2010
measurements, we have determined that interventions
have UBC on track to meet the goal set for this PIP
Study Indicator 2
 The rate of seclusion use for the
measurement year.
 Outcomes
– BASELINE SECLUSION RATE: 0.042
– YEAR ONE SECLUSION RATE: 0.028
– Chi squared equals 68.126 with 1 degree of freedom.
The two-tailed P value is less than 0.0001
– Data showed significant improvement in the reduction
of seclusion utilization. Based on the outcome of 2010
measurements, we have determined that interventions
have UBC on track to meet the goal set for this PIP
Improvement Strategies
 For each intervention on the next slides the
following format is employed:
–
–
–
–
–
B: The Barrier it addresses
D: The Description of the intervention
L: The Logistics of the intervention
E: The Evaluation of the intervention
F: The eFFectiveness of the intervention
Improvement Strategy
 Intervention: Data Improvement
– B: Not enough effective S&R information for
clinicians
– D: Improved data collection, analysis, and reporting
including weighted BxRATE
– L: Created new databases and reports
– E: Continuing process to meet clinical needs
– F: Rates going down (prior to and during this PIP)
Improvement Strategy
 Intervention: Data Understanding
– B: Limited understanding of data reports
– D: Improved reports and training
– L: Feedback from clinicians and staff incorporated
into new reports and training
– E: Clinicians and staff show better understanding
– F: Improved integration of data reports in
developing interventions and Rates going down
(prior to and during this PIP)
Improvement Strategy
 Intervention: Reduce most restrictive
–
–
–
–
B: Too many restrictive choices for restraint
D: Eliminate all mechanical restraint equipment
L: Took all equipment out of the building
E: Staff used alternative less restrictive
interventions to manual restraint
– F: Manual restraints to zero
Improvement Strategy
 Intervention: Improve Environment
– B: Institutional Setting
– D: Replaced furniture, repainted, redesigned
physical environment
– L: Purchasing and contracting for services
– E: Environment satisfaction scores went up
– F: Staff and patients report less clinical space
reduces tension and Rates going down (prior to
and during this PIP)
Improvement Strategy
 Intervention: Redirect utilization of S&R
– B: Brief seclusion to reduce restraint
– D: Higher risks and longer staff-patient
relationship recovery from restraint
– L: Staff training
– E: Restraints decreased in frequency and duration
– F: Seclusions rose in frequency, however
decreased in duration – injuries decreased and
youth debriefings improved
Improvement Strategy
 Intervention: Staff Education
– B: Staff understanding of trauma and underlying
causes for aggression that leads to S&R
– D: Training in trauma informed care, de-escalation
and early intervention, and introduction of DBT
(Dialectic Behavioral Therapy).
– L: All staff received training
– E: Staff showed greater understanding, patience
– F: Staff appreciated insights, demonstrated better
skills, and Rates going down (prior to and during
this PIP)
Improvement Strategy
 Intervention: Improve Communication
–
–
–
–
B: Communication during pre-crisis and crisis
D: Improve communication in real-time
L: Walkie-Talkies purchased
E: Staff can call for assistance and supervisors
can monitor remote locations better
– F: Staff report feeling less isolated, more
supported, and Rates going down (prior to and
during this PIP)
Improvement Strategy
 Intervention: Response to pre-crisis
– B: Immediate assistance during pre-crisis
– D: Created the B.E.R.T. (Behavioral Early
Response Team)
– L: Redesigned assignment sheets, created process
to assign at least one staff per unit to BERT each
shift, trained staff in early intervention
– E: Changing culture from emergency S&R
response to early therapeutic response.
– F: When implemented properly BERT prevents
S&R. Rates went down after implementation.
Improvement Strategy
 Intervention: Alternative Choices
– B: Limited choices for youth
– D: Comfort Room, Comfort Carts
– L: Created room where youth could choose to go
with coping materials/activity they select as an
alternative to Seclusion Restraint rooms
– E: Positive feedback from staff and youth
– F: Immediate reduction on the pilot unit,
sustained reduction on that unit and reduction on
other units introduced to Comfort Room/Carts
Improvement Strategy
 Intervention: Increase incentives/rewards
– B: Limited recognition of success (Incentives)
– D: Created incentive awards for reducing S&R
– L: Pizza parties, ice cream parties, certificates,
and recognition throughout hospital for the unit
with the most improved S&R rates
– E: Effective use of data
– F: Staff utilize this incentive in groups and when
appropriate, in pre-crisis early intervention
Improvement Strategy
 Intervention: Increase activities/choices
– B: Limited choice of activities for youth
– D: Introduction of after school clubs based on
youth interests and needs
– L: AT Supervisor organized recruitment, space,
activities, and supplies for various clubs
– E: Observable enjoyment and positive
empowerment
– F: Youths participating in clubs has reduced S&R
Rates
Improvement Strategy
 Intervention: Eliminate most restrictive
– B: Prone Immobilization
– D: Reducing/Eliminating the most restrictive and
highest risk physical restraint
– L: Change policy, retrain staff
– E: Increased injuries at first due to vertical holds
breaking down and staff not using next level of
restraint (prone) , injuries decreased as staff
adjusted techniques and use of restraint.
– F: Reduction in prone to only used for emergency
medication administration
Improvement Strategy
 Intervention: School staff education
– B: High incident of S&R during school hours
– D: Retrained school staff
– L: Reviewed data, brainstormed with school staff,
improved communication/cooperation, provided
additional behavioral, early intervention, and deescalation training
– E: Instituted UBC’s behavioral program in school
setting was challenging, however effective
– F: Reduced S&Rs during school hours
Improvement Strategy
 Intervention: Increased Leadership Review
– B: Staff felt disconnected from leaders
– D: Increase follow-up communication
– L: Daily review of every incident and follow-up
(secondary) debriefings with staff and patients
– E: Increased support and understanding of the
S&R experience for all parties and improved
identification of issues, obstacles, and re-training
opportunities
– F: Rates going down
Improvement Strategy
 2010 Intervention: Staff relief
– B: Staff tension, fatigue, possible burn out
– D: Staff lounge, tap-out, monitoring hours
– L: Space for staff to relax away from the unit
provided, reassurance that “tapping-out” when
stressed is acceptable, leadership improved
tracking of individual overtime & double shifts
– E: Cultural changes are slow, but most staff are
responding positively to changes
– F: Rates going down, staff injuries decreased
Improvement Strategy
 2010 Intervention: Increased staff feedback
– B: Continued improving communication/training
– D: More specific discussion of S&R causes/effects
– L: Weekly staff meeting agenda includes S&R
discussion specific to the unit
– E: Staff showed increased buy-in and
– F: Rates going down
Improvement Strategy
 2010 Intervention: Individual Data/Graphs
– B: Lack of enough detail in treatment planning
– D: Increase specificity of data/details of S&R
episodes to Tx Team
– L: The BCABA brings individualized
behavioral data and graphs to each Tx Team
– E: Improved planning and intervention
strategies
– F: Rates going down, improved outcomes in
treatment
Improvement Strategy
 2010 Intervention: Program specific change
– B: One unit accounted for 50-80% of S&R
– D: Changes made to program on specific unit
– L: Clinical and unit staff met to discuss
changes to program structure and milieu
– E: Improved cooperative effort from all
involved
– F: Incidents of S&R decreased on the unit
Improvement Strategy
 2010 Intervention: Zen garden
– B: Lack of alternative treatment/relaxation space
– D: Constructed an enclosed outdoor Zen garden
– L: Zen garden is used for alternative quiet space
for treatment sessions, calming groups
– E: Physicians, therapists, and staff use it regularly
for individual and group sessions
– F: No direct data connection, however staff and
youth report liking the garden
Improvement Strategy
 2010 Intervention: Parenting Groups
– B: Lack of facility-wide parenting groups
– D: Weekly parenting groups initiated
– L: Clinical staff facilitates weekly group providing
education, answers to questions, and a community
aspect to the family challenges
– E: Positive feedback from parents on the program
– F: Parents participating were more involved in
Treatment and youths overall had improved
outcomes
Improvement Strategy
 2010 Intervention: Pet Therapy
– B: Additional alternative treatment approach
– D: Introduced animals to the treatment milieu
– L: Contracted with pet therapy organization,
pets were brought to facility to visit with
patients under clinical supervision,
– E: Hands-on development of nurturing skills
– F: Most patients showed very positive response
and reminders that the pets were coming helped
de-escalate potential S&R events
Improvement Strategy
 2010-11 Intervention: Risk Assessments
– B: Lack of single concise initial risk assessment
– D: Improved Risk Assessment process
– L: Created a one page snapshot completed at
admission of the risks and needs for each pt.
and Safety Plans for aggressive youth
– E: Facilitated improved initial introduction of
pt to the milieu and staff
– F: Reduced first week S&Rs, more immediate
treatment response to changing pt behaviors
Improvement Strategy
 2011 Intervention: Revised Hiring Process
– B: Employee discipline/turnover/terminations
– D: Improved screening and hiring process
– L: HR and RN departments restructured hiring
process emphasizing choosing people with
S&R reduction experience, introduced ACE
(Behavioral) Test to improve screening
– E: Too early to tell as this is a cultural change
– F: We remain dedicated to developing a staff
force effective in continuing S&R reduction
Improvement Strategy
 2011 Intervention: Documentation
– B: Insufficient data detail in behavioral reports
– D: Revised Observation and Behavior Tracking
– L: Changed the Q15 Daily Observation form to
include individualized target behaviors , trained
staff
– E: Clinicians report improved information for
clinical decisions and treatment team planning
– F: Too early to tell, preliminary data is
inconclusive
Improvement Strategy
 2011 Interventions: Improvements on 2010
– B: Complacency
– D: Continuous Process improvements
– L: Reviewed/assessed all previous
interventions and improved wherever possible
– E: Best practices were enhanced
– F: Rates continued decreased first half of 2011
Improvement Strategy
 Interventions Enhanced/Continued in 2011
– B: Individualized treatment planning incorporating
meaningful S&R and targeted behavioral data
– D: Increased training in early intervention, deescalation, and alternative interventions
– L: Increased communication at immediate need
(pre-crisis) and post S&R (treatment planning)
– E: Leadership reviews and involvement in
debriefings, retraining, and staff meetings
– F: Incentives and positive feedback
Lessons Learned
 Successes
– Knowledge, skill, and experience are just parts,
albeit large parts, of reducing S&R
– Mindset, habit, attitude, perspective, and
cultural behavior on all levels throughout the
facility play a large factor in reduction
– Changing a culture is slow and painstaking,
however the rewards of reduced risk, improved
outcome, and a safe and more positive
treatment milieu are worth the efforts
Lessons Learned
 Areas for improvement
– Consistency of Implementation
– Accountability for Implementation
 Future plans
– Continue Intervention Strategies and SIPP PIP
process toward goal of zero S&R
INTERNAL PIP
REDUCTION OF RETURNED
INCIDENT REPORTS
Study Indicator 1
 # of incident reports returned for
clarification during the measurement period
 Outcomes
– Baseline results
– Remeasurement 1, Statistical test results, and
Interpretation of data will be compared to
baseline at the end of year two.
Study Indicator 2
 # of incident reports that are submitted late
 Outcomes
– Baseline results
– Remeasurement 1, Statistical test results, and
Interpretation of data will be compared to
baseline at the end of year two.
Study Indicator 3
 # of reports returned late after being sent
back for follow-up
 Outcomes
– Baseline results
– Remeasurement 1, Statistical test results, and
Interpretation of data will be compared to
baseline at the end of year two.
Improvement Strategies
Barriers That Interventions Address
Staff errors due to insufficient training
Interventions
Annual training in the incident reporting
process is completed for all staff at least
once a year.
Manual compiling and analysis of data
Creation of databases in MS Access
Insufficient reports produced by limitations software with on-going modifications as
of software
software improves or needs arise.
Insufficient resources to meet data entry
needs
Insufficient data to meet regulatory
standards Insufficient data to meet clinical
needs
Re-organized data entry staff
Modified Behavioral Intervention Form to
comply with regulatory statutes for
reporting behavioral interventions.
Insufficient data to meet clinical needs
Revised the databases to incorporate more
Insufficient reports produced by limitations fields and revised the spreadsheets to
of software
produce reports more useful to clinical staff
Improvement Strategies
Barriers That Interventions Address
Errors due to forced changes in forms due
to corporate changes
Improved data reports for clinical needs
Improved data reports for regulatory
agencies
Staff error due to lack of time, rushing, or
too much workload
Improved data reports for clinical needs
Improved data reports for regulatory
agencies
Improved data reports for clinical needs
Improved data reports for regulatory
agencies
Interventions
Modified Incident Form to incorporate
corporate mandated changes and still have
necessary elements for facility process
Revised the databases to incorporate more
fields and revised the spreadsheets to
produce reports more useful to clinical staff
Re-organized data entry staff reducing the
amount of data collected and processed.
Modified Behavioral Intervention Form to
comply with regulatory statutes and
corporate mandates for reporting
behavioral interventions.
Revised the databases to incorporate more
fields and revised the spreadsheets to
produce reports more useful to clinical staff
Improvement Strategies
Barriers That Interventions Address
Improved data reports for clinical needs
Improved data reports for regulatory
agencies
Process errors or delays due to lack of
adequate back up staff or backup process
when data processing staff are off duty
Process errors or delays due to lack of
adequate back up staff or backup process
when data processing staff are off duty
Process errors due to duplication of data
entry in different databases.
All barriers listed below in the barrier
analysis and any barriers further identified
during this PIP
Interventions
Revised the databases to incorporate more
fields and revised the spreadsheets to
produce reports more useful to clinical staff
Re-organized the data entry process to
provide additional back up staff for data
entry
Re-organized the data entry process to
provide additional back up staff for data
entry
Changed the Data Collection Tool (Incident
Report) and database to meet corporate
data standards and simplify data
processing.
Initiated a 3-year PIP to improve the
incident reporting processes pertaining to
data and information flow.
Lessons Learned
 The Interventions will be evaluated for Successes,
Areas for improvement, and determination of
Future plans as this PIP progresses.
 Organizing a report of activities and presenting the
activities may seem cumbersome and feel like
extra work; however it can provide a positive
forum for brainstorming and feedback.
 We are not alone.