As the administrator of the Treatment Center for Children and Adolescents (TCCA), Jay Thompson had

As the administrator of the Treatment Center for Children and Adolescents (TCCA), Jay Thompson had a lot on his mind and on his plate. At just 50 beds, TCCA was the smallest of the publicly funded state psychiatric hospitals, but it more than made up for its size because it was also the busiest state hospital, with an average of 650 admissions per year. This meant a rapid turnover of patients and a heavy caseload for the Center’s limited number of staff. There were other pressures as well, such as the perennial threat of budget cuts, high staff turnover—particularly of psychiatric aides—documentation demands from insurers, and an unacceptable rate of staff injuries. The problem confronting Jay at this moment was related to all of the above issues and more. Beginning with Philippe Pinel’s decision to unchain patients at Bicêtre Hospital in 1792, there has been a long history of attempts to reduce or eliminate the use of seclusion and restraint in the care of the mentally ill. In more recent years, the use of seclusion and restraint (S/R) has been the focus of much scrutiny. In part, this has occurred in response to client injuries and deaths, as well as questions about the therapeutic appropriateness and the emotional and physical impact these interventions have on clients and caregivers. The federal government, through the Medicare and Medicaid programs, and JCAHO responded to these concerns by revising their standards for implementing S/R and setting the goal of reducing their use. Although TCCA had recently passed its JCAHO survey, the surveyor was concerned by the Center’s high use of S/R, recommending that decreasing it be at the forefront of quality improvement activities and making it clear that the next surveyor could expect to see a significant reduction in use. Jay was also getting pressure—no, make that “heat”—from his superiors in the state’s department of mental health. In addition to the distinction of having the highest number of admissions for a state hospital, TCCA also had the problem of having the highest rate of S/R. Jay’s superiors expressed support for him and the organization but made it clear that they expected to see tangible outcomes; in other words, reduce S/R and do it as soon as possible. In addition to external pressure, internal forces were at work. It takes an order from a physician to place an individual into S/R, and the psychiatrists were concerned that an injury occurring from one of these interventions might put their professional licenses at jeopardy. The risk manager and the human resources director were also concerned by the number of staff injuries that were related to these interventions. The Center’s Worker’s Compensation insurance premium was rising, and the injury rate added to the problem of maintaining safe staffing levels. Jay had worked his way up the career ladder in the state mental health system, starting as a psychiatric aide when he was just out of high school. While working, he attended college and earned a bachelor’s degree in social work. He was promoted to a social work position and then continued his studies and attained his master’s degree in social work. This opened doors to management positions, and after more than twenty-five years in the state hospital system, he had worked his way up to his current role as hospital administrator. Nonetheless, his early work experience made him sensitive to the needs of the psychiatric aides, who viewed S/R as a necessary evil: interventions that were needed to keep themselves and the other patients safe. So, although he was supportive of S/R reduction efforts, Jay did not really believe these interventions could be fully eliminated. Jay liked to keep up with the management literature and bought into the concept of a data-driven organization, where data is used for management analysis and decision making. Several years earlier, he had hired Sue Stark as the Center’s Quality Improvement Director and asked her to work with staff to identify clinical indicators that would be used to monitor performance and identify opportunities for improvement. S/R was one of the obvious areas because the data was readily available. Given the JCAHO surveyor’s recommendation, Jay decided that he would make S/R reduction a QI activity and, after some thought, came up with an idea to address the problem. Like Jay, Sue had worked her way up the career ladder, starting as a nurse and then going back to school for her master’s degree in nursing administration. She was intrigued by studies such as the Institute of Medicine’s To Err Is Human, which indicated that greater attention to the way in which clinical procedures were carried out could reduce patient mortality and morbidity. This propelled her into the area of quality improvement, which had been the topic of her thesis. One of the first things that Sue did as the new QI director was to educate the staff on the use of data. She disseminated the seclusion and restraint data to each of the Center’s four treatment units and each month met with the clinical staff to review the data and discuss how the data could be used. Because there was so much data, it was important to be able to make sense of it—for example, to see if and where there were patterns and trends. It soon became evident that more S/R interventions occurred in the late afternoons and evenings, when the kids were out of school. The younger the child, the more likely he or she would be placed in a restraint hold, whereas, the older the child, the more likely he or she would be placed in seclusion. Use of S/R increased when admissions increased. And although a few kids with multiple interventions skewed the data, it was also apparent that use was high throughout the Center, with one in every four children being secluded and/or restrained. The psychiatrists and psychologists were also interested in how the Center compared to other mental health facilities in treating children and adolescents. JCAHO collected such data through its ORYX program, and the National Association of State Mental Health Program Directors also collected the data through its NASMHPD Research Institute. This data indicated that, in contrast to other facilities, the Center used S/R at a higher rate. Sue used the psychological term “cognitive dissonance” to describe the clinical staff’s reaction to this information. When they saw how poorly the Center compared, they came up with a variety of excuses to explain or defend the status quo. For example, the clinical staff indicated that because these databases included both for-profit and not-for-profit hospitals, it was like comparing apples to oranges. However, Sue found that another state hospital, which served the same population, had a similar bed capacity and a similar number of admissions, yet had less than half the number of S/R interventions. Because of this data, it was hard to refute the fact that the Center faced a serious challenge. Such was the situation when Jay called Sue Stark into his office to share his idea for a QI project to reduce seclusion and restraint. “What I want to do,” he explained, “is to create a quality improvement team. They’ll be given the task of identifying things we can do at the Center to reduce seclusion and restraint. We can prioritize the list of actions they come up with and begin working on them one at a time in order to plug away at the problem.” Sue could tell that Jay was excited about the idea, but she had some reservations. She herself was an enthusiastic supporter of QI teams, but she wasn’t so sure this was the best way to approach the problem. Sue knew that organizations that were successful in reducing and even eliminating S/R engaged in multiple activities rather than one at a time. This fostered a process of cultural change. An organization’s culture is its internal identity based on norms, practices, shared values, beliefs, and assumptions. In regard to S/R reduction, successful organizations moved from a culture of external control, in which treatment providers know best, to a culture in which the role of staff is to help empower the patient. Because these changes are often threatening to staff, the change process requires strong leadership from management. And because cultural change is a long-term process, leadership must be unwavering in its commitment. In her review of the literature, Sue also found that leadership’s beliefs and values were the most important factors influencing the organization’s ability to reduce seclusion and restraint. For example, S/R reduction rarely occurred in psychiatric hospitals where the administrator believed that S/R was a legitimate treatment intervention or, at best, a necessary evil. On the other hand, the psychiatric hospitals with the best results had administrators fully committed to the goal and process of S/R reduction. Sue was aware that Jay was still in the first camp, seeing it as a necessary evil, and therefore she was concerned that he was unprepared to provide the level and kind of leadership needed to guide a process of cultural change. Unfortunately, the Center’s past efforts suggested that her worries might be founded. Two years earlier, the Center had rolled out a training program with great fanfare. Every employee had been required to attend a series of training sessions and the initial results had been promising. However, once the project was over, the training was not sustained. Given an annual turnover rate of 25%, none of the staff hired in the following two years—nearly half of the psychiatric aides—had been exposed to the training. And then there was the reward program from earlier in the year. Jay decided that to recognize staff efforts, the treatment unit with the lowest number of seclusions and restraints for the month would earn a pizza dinner for its staff. For a number of reasons, Sue had openly expressed concern about that approach as well. For one, this created a climate in which there were winners and losers, and she had known that staff would quickly get discouraged when they were repeatedly on the losing end. Additionally, this approach did not recognize successful treatment; a newly admitted child may initially display a lot of aggressive behavior requiring a lot of S/R before treatment effectively reduces the aggression. It came as no surprise to Sue that this project lasted only a few months and was quietly phased out. Sue was concerned that Jay’s latest idea might be another short-term, quick fix that would not achieve sustained results. As Jay expanded on his plan, Sue tactfully (she hoped) tried to introduce some suggestions: “It would be helpful if the Center had a clear vision about what it wants to attain in regard to seclusion and restraint reduction and, ideally, a strategic plan to guide these activities.” “Our vision is to get S/R down to the lowest level possible” he responded somewhat defensively, “and as far as a plan, that is what I am hoping we can develop as a result of this activity.” To assure I understand what your expectations are,” Sue continued, “you want the team to use their work experience to identify problem areas and to make recommendations as to what we might do to address these problems. It will be important to clarify whether or not staff are free to explore all the issues, even if it may not initially appear that we can resolve the problem. For example, from my experience, this QI team will probably say that we don’t have enough staff, even though, because our number of positions is fixed, it is a resource issue we have virtually no control over.” Jay concurred and also explained that he wanted Sue to serve as the team’s facilitator, providing guidance for the process, but not participating in the actual content of the discussion. Jay and Sue also talked about the makeup of the team and agreed it would be best to keep it small—no more than six members. They agreed on a psychologist, a nurse, an activity therapist, and three psychiatric aides. Sue also got a commitment from Jay to initiate the process by meeting with the group to directly articulate his expectations. In all, the QI team met a total of eight times over a 2-month period. Sue found the group to be very focused and dedicated to their task. As the group identified issues and concerns, she wrote them on a blackboard. Discussions typically ensued about each issue, and the information she wrote on the board needed to be refined and rewritten. After each meeting, Sue drafted minutes for the group to review along with the list of issues, which grew in length the more times they met. By the sixth meeting, the group felt they had identified all of the relevant concerns and they spent the last two meetings making final revisions (see Exhibit 18-1). The QI team asked to meet with Jay and his executive team in order to present and discuss their recommendations. They wanted to use this meeting to answer questions and discuss how the Center should proceed. Human Resource Management: 1. Occasionally, staff attempt to use accrued leave but cannot because of staffing shortages. Some have gotten to the point that they have lost annual leave and compensatory time. In those cases, provide the employee with money for time that would be lost or extend the time in which they can use their leave. 2. Reevaluate the need for straight 8-hour shifts and the impact this has on change-of-shift meetings and issues related to patient safety. (For example, having enough staff available to monitor children when in their rooms during change of shift.) Otherwise, pay staff overtime for attending change-of-shift meetings. 3. Salaries need to be adjusted to ensure that individuals with seniority are paid more than staff with less experience. Hiring new employees at salaries greater than the pay of more senior staff contributes to low staff morale. 4. Most employees are willing to work when needed, but sometimes this is not always possible. Management has declared that there will be no mandatory overtime. Therefore, management needs to provide alternatives. 5. Tighten up hiring practices and listen to hiring managers’ recommendations regarding the suitability of an applicants. 6. Conduct an employee-satisfaction survey and use the information to improve the quality of work life at the Center. 7. Identify exemplary staff who can function as mentors and provide an increase in pay for those who serve as mentors. 8. Make review of a new employee’s performance an agenda item for shift supervisor meetings. 9. Create a system in which staff who have prevented use of S/R can be identified and provided a monetary bonus. 10. Increase the monetary bonus for not using sick leave. Staffing: 1. To ensure staff and patient safety, when staffing is lower than recommended levels, do not accept admissions and, if need be, buy beds in the community. 2. To ensure patient safety, when staffing is lower than recommended levels (for example when there are employees on light duty), lower the bed capacity. 3. To ensure there is no favoritism in approving leave, appoint one individual to assume responsibility for scheduling direct-care staff. 4. Create a “crisis management intervention team” composed of staff with advanced training and skills who can provide support to unit staff during a crisis intervention. Provide a monetary bonus to those employees. 5. Adhere to scheduling guidelines to ensure that there are adequate numbers of shift supervisors on duty, especially on weekends and holidays. 6. Make the state department of mental health aware that efforts to reduce S/R are in part dependent on staffing levels and use results of staffing study (item 8 below) to support request for more psychiatric aides and nursing positions. 7. Increase the pool of part-time psychiatric aides and ensure that these employees understand they are needed to work on weekends, evenings, and holidays. 8. Complete a staffing study to compare recommended and required staffing levels (standards) to actual staffing levels at the Center. 9. Identify light duty staff who can drive patients to medical appointments, get money from the cashier’s office, etc. 10. Create a list of administrative and administrative support staff available to drive kids and staff to local medical appointments. 11. Allow staff to periodically change shifts for brief periods in order to enhance working with staff on other shifts. This might reduce burnout and the accompanying lost time associated with call-ins. Staff Development: 1. Break orientation into two parts so that new staff has time to spend on the units, working with kids. This will help them relate to the training they receive. 2. Enhance S/R reduction training by increasing the amount of time available for new staff to learn and practice verbal interventions and skills other than holds. 3. Revise orientation so that there is a greater emphasis on the skills new employees need in order to work with patients and to reinforce the type of interactions the Center supports. 4. Realign duties of the shift supervisors so that they serve as mentors to new employees (for their shift but across units) during an employee’s first month at the Center. Additionally, assure that mentoring (from a supervisor or senior staff) is provided during the employee’s first year of employment. 5. Ensure that training opportunities are provided consistently and that a system is established to ensure that staff can attend training. 6. Provide a monetary incentive for staff based on obtaining training to enhance their skills. Programs and Treatment: 1. Provide weekend and holiday activity therapy services. As part of this process, evaluate the amount of time AT staff spend in planning and preparation versus providing direct services. 2. Evaluate the possibility of gender specific units, particularly for the adolescent program. 3. Transporting kids to medical appointments takes staff away from the Center and is extremely difficult to do when staffing levels are low. Given that the Center’s mission is to provide short term, acute stabilization, complete a retrospective review to determine the number of outside medical appointments necessary versus those that are desirable but could be deferred. 4. Identify approaches to ensure that a patient’s treatment plan is implemented consistently across shifts. 5. Evaluate the need for the community integration activities that AT staff carryout. This takes them away from the Center with small numbers of children and appears to be inconsistent with the Center’s short-term, acute model of care. 6. Evaluate the possibility of creating an MR/autistic unit. Environment: 1. Install sound-dampening materials on the units, particularly in the day areas. 2. Change the furnishing in the bedrooms so they are safer. 3. Convert one or more seclusion/time-out rooms into a “sensory room”: a room where kids can go to calm down but which is made into a comfortable, inviting environment, rather than a bare, sterile setting. Communication: 1. More face-to-face communication between management and staff at all levels—particularly during stressful periods. 2. Ensure participation of all disciplines during change-of-shift meetings and during weekly treatment review in order to enhance communication within treatment teams. 3. After the QI workgroup and the executive team meet, share the information with all staff and ask for their input so that the process is inclusive. Leadership: 1. Provide support for monthly treatment team meetings, across shifts, to encourage communication and teamwork. 2. Create a process whereby managers can spend 5-7 days each year working with direct care staff on the units. 3. Reinstate change-of-shift meetings that allow the majority of staff from the two shifts to meet. 4. Provide support for an employee-recognition program. Two weeks after their last meeting, the QI team met with the executive committee. In addition to Jay, this group included Dr. Weston Blake, the medical director, Dr. Charles Simpson, the psychology director, Anna Dupre, the nursing director, Renee Gaston, director of social work, and Al Lindy, the chief administrative officer. The QI group had asked Lesley Duggins, the psychologist on the team, to present their findings. Dr. Duggins began by describing the process and then asked the executive team if they had any questions about the QI team’s findings. And that’s when things began to fall apart. The QI team had expected a lively discussion about the issues they had identified. Instead, they were met with an uncomfortable silence. Finally, Dr. Duggins again asked the executive team if they had any questions and again there was silence, which was broken only when Dr. Blake, the medical director, noted that there was a lot of information to take in. That’s when Sue realized the information was new to the executive team; they had not received advance copies and had not had time to absorb the information! The QI team was clearly disappointed. They had spent a lot of time and energy on this project and expected a lively exchange. “Perhaps,” Sue interjected, “we should give management more time to review and think about these recommendations. Could we set a date for another meeting?” Here again there was disappointment, because the executive team could not meet with the QI team for nearly a month. This connoted to the QI team that the project was of low importance to management. The QI team decided to meet again to process what had happened. Sue was concerned it would become a “gripe session” but understood the group’s ire and frustration because she herself shared these feelings. And although the team did vent their disappointment, they talked about how to improve communication with management, which was one of the issues they had identified in their analysis. Sue left the meeting feeling more positive about the process, but, as she was to find, these feelings were premature. At the next meeting, the executive team did not ask a lot of questions. Instead, they focused on the recommendations they felt were out of the Center’s control, such as not accepting admissions when staffing levels were low. State regulations required the Center to accept all admissions, regardless of the resources that were available, and therefore the organization did not have the legal authority to stop admissions. Consequently, some members of the executive team questioned why these actions were even recommended. Sue had to remind them that the QI team had been charged with exploring all issues and possibilities, regardless of feasibility. However, it was evident, based on their roles and responsibilities, that the executive team members thought that many of the recommendations were not helpful or doable. This placed the QI team on the defensive because they had to justify each of their recommendations. This meeting concluded with Jay stating that the executive team would meet among themselves to further review and discuss the list of recommendations. Two weeks later, Jay called Sue into his office. Jay shared that he was disappointed with the process. Although he felt that there were some usable recommendations, for the most part he did not feel that the QI team did what he had wanted it to do. “This is not the product I thought we would get,” he confided to Sue. “We may be one of those kinds of organizations where QI teams just don’t work.” Sue asked him what would become of the recommendations. Jay handed her a copy of the list, which the executive team had revised, and she noted that more than half of the recommendations were deleted. Jay told her that the executive team would continue to discuss the remaining recommendations to see what could be done. Finally, Sue encouraged Jay to send the QI team a memo or email thanking them for their work, and he promised that he would do so. A month later Jay had still not written the thank-you letter, so Sue stopped by to chat with Jay’s secretary and used the occasion to ask her to remind Jay about it. The letter was sent out a week later. To his credit, Jay did ask the personnel director to look into a number of the human resources issues, such as appointing one of the supervisors to do all of the scheduling, and he asked Al Lindy, the chief administrative officer, to find funds for more part-time staff. Sue recognized that this was reflective of the organization’s management culture: a few baby steps rather than a comprehensive, strategic approach to solving problems. Sue wondered what the next “big idea” to reduce S/R would be. Three months later, Jay announced a total personnel reorganization, with the psychiatrists having direct supervision of the nursing staff. A year later, the details of that plan still had not been worked out. 1. Identify the internal organizational factors that create opportunities and threats to TCCA’s goal of reducing seclusion and restraint (S/R). 2. In health services, managers often have a clinical background. In what ways might that prepare them for a role as an administrator and the assumption of a leadership position within the organization? How might that hamper them in that role? 3. If in Sue Stark’s position, what can be done in response to the executive team’s reaction to the QI team’s recommendations? For example, what could she have done differently to foster a better reception and ultimately use of the recommendations? 4. Based on the Case Study what communication problems might exist in this organization? how can these problems be addressed? 5. Jay’s reservations about eliminating use of seclusion and restraint appear to have influenced his willingness to take bold, decisive actions. Describe a situation in which values, beliefs, and biases can significantly influenced the decision-making process. What can an administrator do to better assess his or her own position and how it might influence his or her management style and ability to provide leadership? 6. Some would argue that cultural change is too nebulous to define, let alone actually influence. And even if you can influence the process, it may not turn out the way you want it to, and it may consume more resources than you have available. Explain why an individual would agree or disagree with this position

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