Executive Summary Checklist
Clinicians and Physicians in acute mental health units rely on the environment, medications and care planning to provide treatment to patients. Care planning during acute Mental Health treatment that is inclusive of the patient and other supports is vital to patient safety. Poor care planning leads to poor outcomes. When care planning is absent or incomplete, serious patient harm and/or harm to others may occur.
To empower staff to promote and increase client collaboration, there is a need for:
Provision of accurate information. Staff education will be provided about the therapeutic effects and impact of client involvement in care planning.
‘User-friendly’ documentation. Promotion of a “Comfort Plan” tool to enable staff to easily collaborate with patients and document the care plan.
Mechanisms for gaining service user feedback. Use of a Client and Family Satisfaction Survey to assess use and value of the Comfort Plan, as well as objective measures such as seclusion room use, code white frequency, and length of stay.
The Performance Gap
Improved clinical outcomes are known to result from collaborative care planning (Craven et al, 2006). We aim to increase patient safety by promoting collaborative care planning between staff and patients in acute inpatient psychiatric settings.
Patient safety incidents in a mental health context include: violence and aggression; suicide and self-harm; seclusion and restraint; and absconding and missing patients (cite). Patient safety events in psychiatry are a serious concern. One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging (Mills et al, 2013). Seclusion rates in an acute inpatient psychiatry unit can reach as high as 31%, with the most common indicator of seclusion was risk to others (74%) followed by risk to self (61%) and risk of absconding (55%) (Tunde-Ayinmode et al., 2004). Up to 47% of mental health care providers have experienced violence at work (Nolan, 1999).
Collaborative care planning includes patient involvement in the planning, delivery and evaluation of care. Collaborative care planning appears to have particularly strong effects in patients with more severe disorders, and even low levels of collaboration can have positive outcomes (Craven et al., 2006). This bodes well for acute inpatient psychiatry settings, where psychiatric severity tends to be high, and staff often are time and resource constrained (Porter, 1992).
By bringing in simple, structured ways for staff to collaborate with patients, we aim to improve clinical outcomes and decrease patient safety incidents. Specifically, we propose to foster patient safety by promoting the use of a Comfort Plan (Appendix A), which is a tool for patients to work with staff on developing a proactive plan for times of acute psychiatric crisis.
Leadership Plan
- Provide infrastructure.
- Develop a motivational interview protocol to guide staff and physicians in determining appropriate family and supports to be involved in care planning
- Develop comfort planning practices for staff to engage with patients prior to care planning.
- Develop or adopt a comfort planning model that includes X, Y, Z and specific elements of importance to your community
- Provide capacity. Protect time to engage in patient comfort planning.
- Provide capability. Educate staff on how to leverage comfort planning, how to engage patients to identify their triggers, and when to seek additional resources
- Provide motivation. Highlight the importance of patient involvement in patient outcomes, empower staff to take action to proactively assess and include patients in their treatment.
- Provide a systematic way to track and iteratively improve patient engagement. Collect data about outcomes, success rates.
Practice Plan
Practice comfort planning with patients as a way to engage them in their care planning.
- Practice motivational interview protocol to accurately discern and map out with patients their distress signs when in acute psychiatric crisis (e.g. upon admission).
- Formalize the process of initiating, documenting, and following up with patient’s around their comfort plan
- Formalize the process of disseminating information about a patient’s comfort plan among unit staff, clinicians and support staff.
Technology Plan
The technologies used should be focused on providing the best patient care and be easy to implement for acute care hospitals. Technologies are not a replacement for the clinical treatment received in hospital but instead supplement the treatment and increase favorable patient treatment outcomes.
Patient & Family Engagement
The inclusion of a patient’s family and/or support persons (friends, religious leaders, private mental health clinician etc.) in a patient’s care planning while in hospital is vital to providing complete care for the patient.
We have identified the involvement of family and other supports as a key factor in promoting optimal patient outcomes, and propose to:
- Create a conceptual model of family and support engagement in acute psychiatric settings
- Create tools to help clinicians better assess and map out a patient’s family and support system e.g. genograms
- Provide identified family and supports with psychoeducation about ways to best support a patient during an acute psychiatric crisis
- Develop metrics for quantifying the impact of family and support on patient outcomes, to contribute to the existing body of research.
Metrics
Topic
For organizations using a Safety Event Classification system, the following metric specifications apply. If not, consider adapting this model as a template. Serious Safety Event (SSE) Rate Rate of Serious Safety Events per 10,000 adjusted patient days (Throop & Stockmeier). A SSE results in harm that ranges from moderate to severe patient harm or death.
Outcome Measure Formula
Numerator: Number of patients with a Serious Safety EventDenominator: Total number of adjusted patient days* Rate is typically displayed as Events/10000 Adjusted Patient Days
Metric Recommendations
Direct Impact: All Patients
Lives Spared Harm: Lives = (SSE Rate baseline - SSE Rate measurement) X Adjusted Patient Days baseline
Notes: Adjusted patient days uses inpatient revenue and total patient days to calculate a “patient day” for inpatient and outpatient settings that accounts for outpatient workload.
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