Taking violence out of the risk equation

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

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

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

Starting the initiative

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

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

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

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

New levels of “debriefing”

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

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

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

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

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

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

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

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

Effects on worker compensation

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

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

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

But, depending on their job, a sprained ankle or wrist could mean they were out for weeks. As part of the new policy, GIHN instituted a transitional return-to-work program, which covers different levels of injury and associated jobs. Injuries are now evaluated on a case-by-case basis and employees who are unable to perform their normal jobs at 100% are temporarily placed in other jobs, enabling them to continue to be productive.

So while an employee may not immediately return to a position in the group home, for example, he or she might work in the office until they are fully recovered. “It truly does get people healthier quicker, and back into their normal routine a whole lot faster than sitting at home,” Sanders notes.

In terms of savings, when GIHN was doing restraints as “business as usual,” Gaynor says the organization’s high risk index was reflected in its insurance rates. Based on what was quoted as $2.5 million in 2004/2005, the number soon fell to $1.6 million (Figure 1). Now it’s below $1 million and “still sinking.”

Looking at the results

When GIHN began the initiative, Gaynor’s mandate was two-fold: “We needed to get out of the restraint business and we needed to do it in a way that prevented staff from being injured any further. While the first year was “a little iffy,” he says a “tipping point” soon occurred.

“Successes start to happen, they go viral, and people want to be on that side of the equation,” explains Gaynor, who credits the program’s success with its focus on “the art of asking better questions. If you approach it that way, it will be embraced as a value-added learning opportunity across the board.”

The results have been what he calls a “massive reduction” in the number of staff who are involved in client-induced injuries. When other organizations learn of the initiative’s results, he says that they have a number of common questions.

“For example, people often ask about the duration of restraint and seclusions (when they do happen), and whether seclusions are being substituted for restraints—thus taking a benefit by using what some would see as a more coercive technique. In fact, the duration of the average restraint has also significantly decreased. “When we do use them,” Gaynor explained, “they are much shorter.”

Other significant improvements between FY 2005 and FY 2011 include:

• Client induced injuries dropped 65% (Figure 2)

• Staff injuries from restraints dropped 93% (Figure 3)

• Lost time expenses fell by over $410,000 (Figure 4)

And while those numbers tell part of the story, GIHN has also conducted numerous independent staff satisfaction surveys to ascertain how employees feel about the changes that have taken place.

“Those ratios have increased pretty proportionately with a lot of these trends,” notes Gaynor. “Morale has gone up, and all that has significantly resulted in a decrease in sustainable staff turnover margin.”