Outcomes, Interventions, and Evaluations

1. PIP Improvement StrategiesFor Alternate Family Care, Inc/Florida Palms Academy - SIPPJanuary 2012 Outcomes, Interventions, and Evaluations

2. Collaborative Restraint and Seclusion PIPDoes the implementation of targeted interventions decrease the rate of restraint and seclusion use?

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. On-going successful interventions Intervention:Therapeutic Crisis Intervention (semiannual refreshers- competence 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.

13. 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.

14. 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 de-escalation.

15. 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.

16. ACHIEVING AND MAINTAINING HEALTHY WEIGHT IN SIPP CLIENT POPULATION

17. 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.

18. Improvement Strategy • Major Barriers • Motivation to be active • Medications • Eating habits while on therapeutic passes

19. 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.

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. PIP Improvement Strategies forBayCare Behavioral HealthJanuary 11, 2012 Outcomes, Interventions, and Evaluations

26. Collaborative Restraint and Seclusion PIP

27. 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.

28. 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.

29. 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.

30. 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

31. 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.

32. TOKEN ECONOMYSYSTEM PIP

33. 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

34. 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.

35. 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.

36. 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.

37. 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.

38. Improvement Strategy Token Economy Intervention #3 – Ongoing Training Evaluation of Intervention: Pending Effectiveness of Intervention: Pending

39. 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.

40. PIP Improvement Strategies forCentral Florida Behavioral HospitalJanuary 2012 Outcomes, Interventions, and Evaluations

41. Collaborative Restraint and Seclusion PIP

42. 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%

43. 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%.

44. Improvement Strategy: Incorporating a Trauma Informed Care Treatment Philosophy • Barrier: • Staff did not understand that the use of restraint or seclusion could be re-traumatizing 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.

45. 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.

46. 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

47. 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.

48. 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

49. 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

50. 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