6 Steps in the Performance Improvement Process (Modified Juran Methodology) Therapeutic Use of Adult ALSA

1. 6 Steps in the Performance Improvement Process(Modified Juran Methodology)Therapeutic Use of Adult ALSA Step 1. Identify a Project • Need to offer a consistent therapeuticapproach for the use of ALSA space on Adult units • With additional adult units offering ALSA space a process to institute and discontinue use of this low stimulation area needs to be developed • Step 2. Mission Statement • We believe there is clinical value in using a low stimulation area to provide a safe and therapeutic milieu in the least restrictive environment. • Select a team • Eileen Glover RN, Jeanne Carroll RN, Sherry Providence RN additional key stakeholders including milieu nurses and MHWs from each unit to be determined Step 6. Replicate Results and Nominate New Projects Continuous Quality Improvement Step 5. Measurement Step 3. Diagnose the Cause • Design effective quality controls • Hold the Gains • Foolproof the remedy • Audit the controls • Monitor on Dashboard • Different units and teams may view how to use this area differently, including design, therapeutic offerings and documentation of such. • ALSA is very staff intensive and should be used only when therapeutically appropriate. • Policies and Guidelines may not be specific enough for consistent use of ALSA. • When an individual is admitted to the ALSA area, there should be a clear documented treatment plan including goals for discharge from that area. ALSA is our most acute area, who should be staffing and how do we determine ratios of staff Treatment team forms not consistent or accessible to all Step 4. Remedy the Cause • Review existing ALSA related policies to ensure they are applicable to all units • Use consistent design and materials when building and repairing area to ensure a safe environment. • Literature review of evidence based practice related low stimulation areas on psychiatric units to occur • ALSA tracking tool has been developed to review LOS, reason for ALSA begin 11/1/11 • Any forms created for Use in treating individuals in the ALSA area should be consistent, available and approved by forms committee • Review monitoring and control options

2. PURPOSE: The Brattleboro Retreat will provide a safe, secure and low stimulation area staffed by trained nursing personnel for a limited number of patients who are verbalizing or demonstrating they are unsafe, and, for those who are unable to tolerate being in the general milieu of the unit. POLICY: To ensure safety for all patients who are highly at risk for self-harm or harm to others, orrequire a low stimulation environment. PROCEDURE: Admission/transfer A physician will order that a patient be admitted directly to or transferred to the ALSA as well as the observation level that is to be maintained. The A&E staff, for direct admissions, or, the unit nursing staff, for transfers, will explain to the patient in terms that are easily understood, the reason(s) for placement in this area. Contraband If a body contraband and skinassessment have not been done prior to the person’s arrival on the unit, one will be done when the patient gets to the ALSA. If the person refuses, he/she will be scanned with a metal detector and then staffed one-to-one until the contraband search is completed. The person’s belongings will also be contrabanded, per hospital policy. One change of clothing and a small amount of toiletry items will be put in a bin labeled with the name and stored in a locked cabinet. Welcome Packet and Orientation Nursing staff will assist the patient in completing the questionnaires in the Welcome Packet, when the patient is able to do so. Staff will orient the patient to the ALSA, answering questions and providing information. Environment Due to the precarious nature of the patients’ ability to self-regulate, the environment in the ALSA will purposely be kept free of clutter and items that can be thrown or used by patients to harm themselves and/or others. In addition to single rooms for patients and a bathroom, there is a seclusion room. The beds in Rooms 207 and 208 are equipped for mechanical restraints, should they be needed. Meals/snacks All patients residing in the ALSA will receive finger foods delivered on disposable plates. Between meal snacks and beverages are scheduled as part of programming. Treatment Planning and Care The initial treatment plan will be done by the A&E nurse at the time of admission. A comprehensive, individualized treatment plan will be developed and written by the patient’s treatment team within 72 hours of admission. The patient will receive a copy of the plan and have opportunity to discuss it with various members of his/her treatment team. The team will write daily goals for the patient to achieve as part of the plan to transition him/her out of the ALSA. Patients will see their psychiatrist daily, Monday through Friday, and the doctor-on-call on weekends and holidays. Each patient will be assigned a check-in person on the nursing staff to meet with on the day and evening shifts. Some patients may be seen individually by certain disciplines (Chemical Dependency and Therapeutic Services) ) to assess programming needs. Programming Daily programming will be developed by the Program Coordinator. It will take into account each patient’s strengths, interests and current level of cognition and functioning. Weekly programming will include the treatment goals of the ALSA, structured to include grounding techniques, improving the ability to focus on tasks, behavior management and medication education.Patient Advocate The patient advocate visits weekly. All patients are encouraged to meet with this person to discuss concerns and matters of interest. Adult Low Stimulation PolicyCurrent

3. Phone Calls Each patient may make two outgoingphone calls on the day shift and two on the evening shift. Nursing staff are available to assist the patient when making the calls. Staff may intervene to end a phone call if the patient becomes abusive, distressed, or overly agitated. Unit capacity and Staffing The ALSA may be as small as a one bed unit with the ability to expand to a five bed area. Baseline staffing is dictated by an individual’s level of observation. Charting Charting in the medical record will be done per hospital policy. Physical Examination/ blood work If a physical examination was unable to be performed in A&E at the time of admission, a Licensed Independent Practitioner (LIP) will come to the unit to perform the patient’s physical within 24 hours of admission. If the patient refuses, this will be documented in the medical record. Blood work will be ordered by the LIP and drawn by the hospital’s phlebotomists. Refusals will be documented in the medical record. Transition to the General Unit Milieu As per discussion and consideration by the Treatment Team, the patient’s psychiatrist will write transition orders for the patient, with support from the nursing staff, to spend specified amounts of time each day in the general milieu. Visitors Visitors will be allowed to visit patients in the ALSA during hospital visiting hours on a case-by-case basis, at the discretion of the charge nurse. It is recommended that visitors call prior to coming to the hospital. Visits will be time limited, one person at a time, unless authorized to have an additional visitor by the charge nurse or treatment team. Visits in ALSA will depend on the safety of visitors and the needs of all patients in the ALSA. When signing in at the switchboard operator's desk, visitors will be asked to leave all belongings in their vehicles before coming to the unit. Questions when reviewing policy Admission and discharge criteria Treatment Planning Staffing needs Adult Low Stimulation PolicyCurrent

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8. Construction/Remodeling Guidelines • ALSA remodeling guidelines • Construction: • MUST MEET ALL LIFE SAFETY CODES and be safe for Behavioral Health Facilities. Use Design Guide for the Built Environment of Behavioral Health Facilities as a resource can be found at www.naphs.org • Clear ALSA room change with V.P. and unit manager. • Area needs bathroom area with shower. • Remove all furniture. Fill holes in floor from anchors w/ epoxy or liquid nail. • Remove all electrical outlets and external wire molding. Fill holes finish to a smooth surface. • Remove all trim on walls, eg. vinyl base trim, chair rail, crown molding. Wooden base trim can stay as long as it is inspected and secure. Fill gap between wall and floor with epoxy caulk or structolite. Fill all holes and finish to a smooth surface. • Cover any alcoves or closet openings with metal studs, ¾” plywood and 5/8” sheetrock. Fill gaps with structolite or epoxy caulk. • Cover any HVAC diffuser with heavy fine screen mesh. Caulk around fixture to prevent looping between fixture and ceiling. • Install bracing and lexan over window to allow window to open four inches. Install wooden lip on lower sash to cover metal lip. • Cover any required protruding electrical boxes, eg. heat temp sensor boxes with wooden surround to eliminate sharp corners. • Tighten light fixture to ceiling. Caulk around fixture to prevent looping between fixture and ceiling. • All fire alarms and sprinklers must be non loopable • Install door with no lever on the inside. As a temporary measure, installing the lever so the lock is on the inside is acceptable. • Install 12x12 viewing window in door. • Install convex safety mirror in corner or on wall so all areas of room can be seen through viewing window in door. • Locate light switch on outside of room. • Safety walk through with Performance Improvement team. • Equiptment/Furniture: • Be mindful the area is used both as an ALSA area, as well as general milieu rooms. • No curtains • As above, use Design guide for Behavioral health for hinges and hard wear as well as furnishings • ** electrical outlets and CPAP • How to work with Flexible areas?? • Communication: • Cordless phone • Hand held door bell to ring in nurses station- Will future EMR dictate any changes?