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Atascadero (CA) State Hospital, which treats dangerous mentally ill men, and Susquehanna Lutheran Village in Millersburg, PA, which provides long-term nursing care, on the surface may not seem to have much in common with one another or with your facility. But when you find out that both facilities recently won the Ernest A. Codman Award for excellence in the use of outcomes measurement to achieve health care quality improvement, you’ll see two stories worth looking at with lessons to learn for any benchmarking effort.
The Codman Award, given by the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, was created to showcase the effective use of performance measurement. Atascadero State Hospital was recognized for the work of its multidisciplinary mealtime violence quality action team that resulted in a significant reduction in patient violence during meals at the maximum security forensic facility. Susquehanna Lutheran Village was recognized for its efforts to reduce the use of physical restraints that led to becoming a restraint-free facility and training site for restraint-free care for Pennsylvania.
At Atascadero, the quality council knew that violent incidents involving patients were an occupational safety hazard for hospital staff, says Colleen Carney Love, DNSC, RN, director of the hospital’s clinical safety project. A 1996 benchmarking project with five other public sector psychiatric hospitals revealed injury rates were alarmingly high; almost one-fourth of the nursing staff in a one-year period were getting an OSHA-reportable injury.
What the council members didn’t know was when, where, and why the incidents were occurring. So they began to monitor patterns of high-risk situations over the previous five years and found that such incidents peaked during mealtimes. More than half of the incidents occurred while patients were walking or standing in line; one-third happened while they were sitting in the dining room. An average of seven violent attacks per year involved the use of silverware as a weapon.
The quality council identified the stakeholders on this issue, including patients, nutritionists, nurses, and food service workers and supervisors, and put together a committee to recommend solutions. The committee surveyed patients to find out what the mealtime problems were and found that one of the main complaints was that the food service workers were impolite. They also found that patients didn’t like the long wait times in the dining room and that many were anxious about the possibility of silverware being used as a weapon.
The committee made five recommendations:
1. Substitute plastic utensils for silverware.
2. Play music selected by the hospital’s music therapists.
3. Permit patients at the highest privilege levels to leave the dining room after eating.
4. Open the main courtyard and gym during meals.
5. Train food service workers in therapeutic communication.
The results: One year after implementation, aggressive incidents in the dining room were reduced by 40%, assaults using silverware were eliminated, and a total of 70 nursing staff hours a day were saved by eliminating silverware control procedures in the dining rooms.
"Before, we had to count the silverware before the patients left, and if any pieces were missing, we had to do this elaborate shakedown," Love says. "This was a tedious, time-consuming process, and for mentally ill patients that have a low frustration tolerance anyway, it was an institutional provocation."
Other approaches to reducing violence have been to eliminate the top three items used as weapons, work with the patient government, and develop an easy-access card system that allows a staff member to see patterns of violence of a particular patient at a glance. Special incident reports are down 63%, injuries are down 67%, and weapon attacks are down 83%, Love says.
"Our administrators have been visionary in that even though they weren’t required to by external reviewers, they have been very aggressive in looking at trends and patterns of violence in our hospital," Love says. "Violence hasn’t traditionally been looked at as an occupational health hazard in psychiatric settings and in hospitals in general. But in the last five to seven years, external reviewers like OSHA have been paying more attention to violence."
At Susquehanna Lutheran Village, the award-winning quality improvement project got started in a similar way to Atascadero’s. The nursing home received a letter in 1995 from the Pennsylvania Department of Health alerting them that Pennsylvania had the second highest restraint usage percentage in the country. Data from the state showed that the national average for restraint usage was slightly higher than 20%. Further study showed that at Susquehanna, 65% of the patients were being restrained on a daily basis through such methods as bedside rails and waist and chest restraints, says Linda Lesher, LPN, continuous quality improvement coordinator.
Now, the facility is entirely restraint-free and has a staff turnover rate of 19%, compared to the national average of 40%. Complaints regarding care issues have dropped, more patients are being discharged to home, and the use of psychoactive medications has dropped from 36% to 15%.
Federal government guidelines written in the 1987 Omnibus Budget Reconciliation Act urge long-term care facilities to shelve the use of restraints, but no one pushed the issue, Lesher says. She explains that Susquehanna staff considered their restraint usage to be appropriate and necessary. "If someone fell, we were using restraints to keep them from falling again, and we thought that was appropriate usage. As we studied it, we found out that’s really not true. Residents are weakened through restraints, which keep them from getting stronger muscles and moving about. A restraint overall debilitates the resident."
The nursing home formed an alternative restraint team to meet weekly to review residents’ needs and suggest ways to stop using restraints on them. The team reviews falls to determine the reasons, eliminate contributing factors, and suggest preventive measures. The facility also began an initiative called the Eden Alternative, which incorporates plants, animals, and children into the daily lives of residents. "If you take the restraints away, the residents need something to do," Lesher says. "Many residents suffer from [feelings of] helplessness, loneliness, and boredom, and those things need treating just like medical conditions. We provide them something to take care of. Most of them have been taking care of something or somebody their whole lives."
Another change was the introduction of a primary care concept in which nurses, housekeepers, laundry workers, and social services staff all have primary residents for whom they care. That means they get to know the resident well and can catch situations that lead to falls. One resident, for example, would try to stand up from her chair frequently and would fall. The nursing assistant ascertained the woman was modest and was trying to arrange her dress over her knees. The family was asked to bring pants for the woman to wear, and she hasn’t fallen since, Lesher says. "That’s a resident who would have gotten a restraint before."
Residents are encouraged to exercise by lifting weights, walking, or doing sit-ups in bed to build up the muscles weakened by the lack of activity caused by the use of restraints. The fracture rate at the nursing home has dropped from 3.25% per fall before the program to .85% now, she adds.
[For more information, contact:
The Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Web site: www.jcaho.org.
Colleen Carney Love, DNSC, RN, Director of the Clinical Safety Project, Atascadero State Hospital, P.O. Box 7001, Atascadero, CA 93423-7001. Telephone: (805) 468-2690.
Linda Lesher, LPN, Continuous Quality Improvement Coordinator, Susquehanna Lutheran Village, 990 Medical Rd, Millersburg, PA 170061. Telephone: (717) 692-4751, ext. 59.]