Decreasing Seclusion and Increasing Restraint and Seclusion Documentation Compliance using LEAN. Sheppard Pratt Health System

Transcription

1 Decreasing Seclusion and Increasing Restraint and Seclusion ation Compliance using LEAN Rick Wallace MSN, RN Associate Director of Clinical Services Jacqueline Williams Porter MBA, RN Unit Director Sheppard Pratt Health System Child and Adolescent Neuropsychiatric Unit Children 5 18 years old 80% ASD 40% non/limited verbal 14 bed unit 14 day average stay Wallace, Williams-Porter 1

2 Project Title: 1H Seclusion reduction Date: 10/26/13 Prepared By: Rick Wallace RN Project #: Background: 1H is committed to establishing a safe environment. A problem area for both patient and staff safety is the use of seclusion. By reducing seclusion patients will spend more time engaged with staff in therapeutic activities and staff will enjoy fewer injuries as a result of hands or aggressive pt. behaviors. In the last 12 months 1, hours or $20, was tied up in LDS related work instead of spending therapeutic time with patients. Based on the cost of an LDS and staff call in time and money 1H utilized 1, hours and $20, in staff resources on LDS and LDS related activities. Our goal is to reduce LDS by 40%. This would realize a hourly savings or a $8, savings Current annually. Conditions: Some event Prolonged or Seclusion that causes a severe patient to be aggression upset. unmanageable with lesser measures. Antecedent Goals/Targets: Root Cause Analysis: Behavior Consequence 1H will experience a 40% reduction in LDS resulting in a 40% cost savings of $8, and a time savings of hours a year. Proposed Countermeasures: Effect Confirmation: February March April May June July August September October November LDS/ptday Average LDS/pt day Follow Up Action Plan: Action Owner Due Date Status FORM 01 A3 Template Background Background 1H is committed to establishing a safe environment that makes children s lives better. A problem area for both patients and staff safety is the use of seclusion. By reducing seclusion patients will spend more time engaged with staff in therapeutic activities and staff will enjoy fewer injuries as a result of hands on and aggressive patient behaviors. In the last 12 months 1, hours or $20, was tied up in LDS related work instead of spending therapeutic time with patients. Based on the cost of an LDS and staff call in time and money 1H utilized 1, hours and $20, in staff resources on LDS and LDS related activities. Our goal is to reduce LDS by 40%. This would realize a hourly savings or a $8, savings annually. Wallace, Williams-Porter 2

3 Background 1H is committed to establishing a safe environment that makes children s lives better. A problem area for both patient and staff safety is the use of seclusion. By reducing seclusion patients will spend more time engaged with staff in therapeutic activities and staff will enjoy fewer injuries as a result of hands or aggressive pt. behaviors. In the last 12 months 1, hours or $20, was tied up in seclusion related work instead of spending therapeutic time with patients. Based on the cost of an LDS and staff call in time and money 1H utilized 1, hours and $20, in staff resources on LDS and LDS related activities. Our goal is to reduce LDS by 40%. This would realize a hourly savings or a $8, savings annually. Background 1H is committed to establishing a safe environment that makes children s lives better. A problem area for both patient and staff safety is the use of seclusion. By reducing seclusion patients will spend more time engaged with staff in therapeutic activities and staff will enjoy fewer injuries as a result of hands or aggressive pt. behaviors. In the last 12 months 1, hours or $20, was tied up in LDS related work instead of spending therapeutic time with patients. Based on the cost of an LDS and staff call in time and money 1H utilized 1, hours and $20, in staff resources on LDS and LDS related activities. Our goal is to reduce seclusion by 40%. This would realize a hourly savings or a $8, savings annually. Cost and Time of Seclusion Activity Time Cost Running cost 2 staff to corner a pt and decide, we don t have time for this. 10 /staff $11.50 hr/ or $3.83 for 2 staff x 10 Running time $ MHW and 1 RN to escort pt to QR, lock door and debrief 5 min/staff 3 MHW x 5 min. = $ RN at $26/hr for 5 min = $2.15 $ MHW to sit at the LDS door RN to do LDS paperwork (hands on, get the red out, call MD for order) 1 hour $11.5 $ hour $10.75 $ hours 5 Wallace, Williams-Porter 3

4 Cost and Time of Seclusion Activity Time Cost Running Cost Face to face 10 Call to Dr. Roca RN end of LDS assessment debrief with pt. more paperwork Running Time $4.30 $ hours 15 5 Priceless 2 hours $8.60 $ hours 40 Cost and Time of Seclusion Activity Time Cost Running cost Take pt to terrace, play basket ball and talk. Validate feeling, empathize, leave your own baggage at the door. 20 $3.80 Savings: $82.93 Running time Time savings: 6hours 25 Now, do you have the time??? Wallace, Williams-Porter 4

5 Root Cause Wallace, Williams-Porter 5

6 0.09 Effect Confirmation LDS/ptday 0.04 Average LDS/pt day We ve realized a 33% reduction in LDS for our First PDCA!!! 0 February March April May June July August September October November Psychotic Disorders Unit The Psychotic Disorders Unit at Sheppard Pratt Health System consists of a 22 bed inpatient unit that treats patients with psychotic illnesses, including Schizophrenia, Schizoaffective Disorder, Bipolar Disorders, as well as Neuropsychiatric Disorders. Patients are treated under the expert care of experienced and competent psychiatrists, nursing, and other clinical staff. Project Title: RN ation For Seclusion/Restraint Date: 11/20/13 Prepared By: J. William Porter Project #: Background: Proposed Countermeasures: Project Title: RN ation Effect Confirmation: For Seclusion/Restraint Current Conditions: Goals/Targets: Improve ation Compliance to 100% on TF Root Cause Analysis: Follow Up Action Plan: FORM 01 A3 Template Wallace, Williams-Porter 6

7 Business Statement.Currently, seclusion or restraint documentation compliance is inconsistent. Business Statement The current documentation requirements are complex with potential for multiple errors. Business Statement ation errors can potentially lead to regulatory challenges and can affect our future ability to care for patients. Wallace, Williams-Porter 7

8 Definition of Restraint Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely Type of Restraint Mechanical Restraint is any physical or mechanical device, material, or equipment that restricts the patient s movement against the patient s will. Manual restraint is physically holding a patient that restricts the patient s movement against the patient s will Seclusion Seclusion is the involuntary confinement of a patient in a room alone, for any period of time, from which the patient is physically prevented from leaving. Wallace, Williams-Porter 8

9 Current Condition Inconsistently RRRN forgets to documented call MD; unclear whether to call OD or Attending Initiate Hands On S/R Give IM PRNs Debrief with all responders Hands on Notify MD Patient is a danger to MD not RN not himself call MD or MD or others forgets to put in order RN unclear on how to complete documentation RN forgets to document significant event. MD Order obtained Person doing rounds is not communicating with the person watching the patient Every15 minute check One Hour initial assessment Inconsistently documented Face to Face assessment every four hours Significant event Call for someone to do face to face. Unclear whether to complete or Rationale for discontinue order. Missed often. continued S/R not Patient not always 24 hour leeway always clear debriefed. is too much time RN assessment every Complete S/R 1 hour to justify MTP completed order. continued S/R or within 24 hours. discontinue Debrief patient. 25 S/R Compliance Pie Chart [Audit of 72 charts over a 3 month period] A total of 525 Data Points PRE INTERVENTION Frequency in Compliance Frequency not in compliance Pre Intervention audit results Adequate reason 64/ % Order written 70/ % Face to Face 70/ % Nursing Assessment 69/ % Q15min checks 10/ % Hourly assessment 7/ % Order completed 71/ % MTP/TPR 14/ % Hands On 62/ % All components correct 9/ % Wallace, Williams-Porter 9

10 S/R ation Non Compliance Pareto by Reason 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Frequency Non compliance Cummulative Frequency % Root Cause Analysis No designated person Why aren t MTP/TPRs done after S/R episodes No designated person No format on how to do it. Never been discussed Never thought to create one Not on orientation sheet Staff is not trained No training during orientation on unit Sheets outdated No communication between nursing and clinical education Ideal Condition Initiate Hands On S/R Give IM PRNs Debrief with all responders Hands on Patient is a danger to himself or others Order One Hour initial Notify MD100% Accuracy obtained Significant event assessment Call for someone to do face to face. Every15 minute check Face to Face assessment every four hours RN assessment every 1 hour to justify continued S/R or discontinue Complete S/R order. Debrief patient. 30 Wallace, Williams-Porter 10

11 Metrics Name Date Physician s order present in chart Initial RN assessment within 1 hour Adequate reason documented for S/R Q 15 minute checks completed Hourly assessment present Face to face by clinician completed within 1 hour RN assessment present Seclusion and restraint mark complete Master treatment plan update within 24 hours Significant event done 32 Wallace, Williams-Porter 11

12 Wallace, Williams-Porter 12

13 Post Intervention Audit Results Adequate Reason 35/35 100% Obtain Order 35/35 100% Hands On 35/35 100% Initial RN Assessment 35/35 100% Hourly RN Assessment 11/11 100% Significant Event 35/35 100% S/R Order Completed 35/ % Face to Face 34/35 97% MTP/TPR 34/35 97% Q 15 Minute Checks 12/15 80 % All Components Complete 28/35 80 % S/R Compliance Pie Chart [Audit of 35 charts over a 2month period] A total of 350 Data Points POST INTERVENTION Incorrect Correct One Staff member contributed to this variance Wallace, Williams-Porter 13

14 GOAL 100% Accuracy Wallace, Williams-Porter 14