Evaluation of the Safety-Care TM Behavioral Crisis Prevention & Management Training by QBS, Inc. University of Utah

1. Evaluation of the Safety-CareTM Behavioral Crisis Prevention & Management Training by QBS, Inc.University of Utah Presented by Will Backner and Stacey Graziano February 2010 Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders US Office of Education 84.325K H325K080308

2. Safety-Care Behavioral Safety Training is a competency-based crisis prevention training program developed for staff who work with individuals with the potential for aggressive behavior.

3. Philosophy of Program Safety-Care procedures are based on research from applied behavior analysis (ABA). Utilizes concepts of behavior support including reinforcement and functional assessment. Focuses on identification and reinforcement of alternative behaviors. Safety-Care is taught using behavioral instruction methods.

4. Certification Requirements • The core Safety-Care course is two days in length (12–16 hours of training time) and basic trainer training is three days. • Certification lasts for one year for both Trainer and Specialist certification. Specialist recertification takes one day and Trainer recertification is one day if conducted at the customer’s site.

5. Certification Fees • Safety-Care Specialist Training (1½ day training by certified QBS Master Trainer) • At customer's site—up to 10 participants $3,600 • At customer's site—up to 16 participants $5,760 • Attend open session at QBS $360 per person • Safety-Care Trainer Training (3 day training by certified QBS Master Trainer) • At customer's site—up to 10 participants $7,000 • At customer's site—up to 16 participants $11,200 • Attend open session at QBS $700 per person

6. Certification Fees Advanced Module Training by Certified QBS Master Trainer • Half day—up to 10 participants $1,150 • Full day—up to 10 participants $2,300 • Curriculum customization Free • Curriculum development $100 per hour • Certification/Annual Recertification • Attend 2 day recertification during open session at QBS $200 per person • 1 day recertification at customer’s site—up to 10 participants, 5 minimum $200 per person • Specialist certificate cost (initial training or recertification) $4 per person • Transfer Safety-Care Trainer certificate to a new organization $200 

7. Training Outline • Introduction: general introduction to the course, causes and conditions associated with challenging behavior, the reinforcement model of behavior, and the inadvertent reinforcement of challenging behavior. • Incident Prevention: provides methods for reducing the likelihood of behavioral crises and improving staff safety. Includes creating a safe and positive living environment, dressing for safety, and safe interaction with potentially aggressive individuals. Staff will also learn, practice, and demonstrate competency in reinforcement and basic preventative safety. • Incident Minimization: methods for identifying crises and stopping or reducing their intensity. Includes detecting antecedents (triggers and signals), predicting behavior, and getting assistance. Trainees will also learn and practice approaches to intervention with agitated individuals, de-escalation, and reinforcement of non-crisis behaviors.

8. Training Outline • Incident Management: how to safely cope with a serious behavioral incident. Includes physical safety skills, releases, management of weapons, leadership during behavioral crises, procedures for safe holding, alternatives to holding, emergency release, planned rapid release, and emergency release. Organizations can choose not to use certain physical interventions if they believe they are not appropriate to their setting and mission. • Post-Incident Procedures: recovery procedures following crises, debriefing of staff, debriefing the individual. • Role-Plays: following the presentation of the Safety-Care curriculum, role-plays of increasing intensity are presented. Role-plays are tailored to the kinds of problems that trainees encounter in their work settings. Role-plays are designed to teach staff how to use the skills they’ve learned, and which approach to take.

9. Competencies • Safety-Care has several goals: • Prevent behavioral crises. • Reverse the escalation & intensity of crisis behaviors. • Teach & strengthen behaviors that reduce crisis behaviors. • Safely manage crises without injury or trauma. • Terminate crises quickly. • Reduce the likelihood of future behavioral crises.

10. Legal Liability Safety-Care is consistent and compatible with regulatory and accreditation standards, including JCAHO (Joint Commission on Accreditation of Hospital Organizations), CARF (Committee on Accreditation of Rehabilitation Facilities), COA (Council on Accreditation), and CMS (Centers for Medicare and Medicaid Services) and other relevant state regulations. It has been officially certified by the State of Maine’s Department of Health and Human Services, Division of Licensing and Regulatory Services and by the Department of Mental Retardation in Massachusetts. Safety-Care is also used in a number of other states where regulatory agencies do not specifically certify individual safety courses. QBS should be contacted regarding specific Safety-Care regulatory standards.

11. Website

12. Types of Interventions Restraints and Procedures

13. Incident Prevention • Create a Safe Environment • Minimize disorganization, clutter, and excessive stimulation • Dress for safety (No loose clothing) • Modify environment (Remove dangerous objects) • Safety Habits • Know where you are • Manage your own behavior and emotional reactions • What you say and how you say it • Facial expressions • Physical behavior • Differential Reinforcement • Describes continuous, random, and scheduled DR • Describes how to praise effectively • Elbow Check • Stand to the side of the client (facing the same direction) • Place nearest palm of hand on his or her arm right above the elbow with you fingers facing forward • If the client struggles, keep your arm rigid to prevent the client from striking you • Back off if there is significant resistance

14. Incident Minimization • Identify environmental antecedents • Eliminate them or help the client cope with them • Identify behavioral antecedents • Allows you to intervene early before the client’s behavior escalates • The Safety Stance • Place yourself in the client’s vision and stand to the side at a 45 degreeangle • Stand an arms length away plus a foot • Stand in a thinking stance with the closer arm near the face • Stand with feet shoulder width apart, front foot pointed toward the client and rear foot pointed toward the side. • Safety sitting • How to sit and work with clients safely • Calling for assistance • How to call for help in dealing with a client appropriately

15. Leadership • How to determine who is in charge during an emergency and what the leader should do. • De-Escalation • How to calm down an agitated person safely. • Uses a step down model. • Avoid power struggles • The help strategy • Helps the person understand that there are more appropriate ways to get the same information. Based on assumption of a communication problem. • The prompt strategy • Prompt the client what to do rather than the disruptive behavior. • Prompt to do an incompatible behavior or high probability behavior. • The wait strategy • Give the client time to calm down. • Management of weapons • Can be any object that could cause harm. • Remove potential weapons before a crisis escalates. • No method to remove weapons from client. • Call for assistance, protect clients and yourself, and contain the client

16. Physical Safety • The protective stance • Uses arms to protect from potential hits by client • The safety shuffle • Shuffling back to maintain a safe distance without backing into a corner. • Moving and Deflecting • Describes how to use arms to deflect hits and move away from clients. • Shoulder Check • A method to protect yourself from an aggressive client by moving behind them and placing your hands on their arm and back so they cannot turn to hit or grab you. • Supportive Guide • A guiding procedure that uses a client’s own momentum to quickly change the direction of movement without pulling pushing or grabbing.

17. Wrist Release/Grab Release • Technique for releasing a grab on your body or wrist without hurting the client. • Choke Release • Describes how to remove client’s hands from your neck if they are attempting to choke you from the front or the rear. • Head lock release • Procedure for keeping your airway open and releasing a head lock. • Hair Pull Release • Describes how to stabilize your neck and release client’s grasp of your hair. • Bites • Describes way to avoid bites and release bites.

18. Physical Management and Restraint • Emergency physical management • Describes risk of physical interventions, when they should be used, and what to do. • 1-Person Stability Hold • Procedure for holding a client in place so that they cannot hurt themselves or others • Also includes a method for dealing with the client sitting down during the hold • 2-Person Stability Hold and Escort • Method for two people to hold a client in place or • Includes provision to escort them if they do not resist with them facing forward or an escort where they are facing backwards if they do resist. • Chair Stability Hold • Uses three staff members to hold a client in a chair with arms. • Releasing from physical intervention • Includes signs of when to release a hold such as changes in the color of the client’s face and labored breathing.

19. Post-Incident Procedures • Recovery • How to set the environment until the client returns to normal • Debriefing • Reviewing the incident with the client including their triggers and what the client thought happened during the event. • Reviewing the incident with staff to identify context of the event, environmental antecedents, behavioral antecedents, and interventions used to manage the client’s behavior. Also, review interventions to make changes so they are more effective.

20. Media and Research • No media (DVDs, ect.). Only training manuals. • Research • Google Scholar was used to search for any research on the Safety-Care program. None was found. • Books and journal articles that cover the use of Behavioral Momentum and Restraint are listed as references for the program, but none of them specifically examine the Safety-Care system.