Executive Summary Checklist
Clinicians and Physicians in acute mental health units rely on the environment, medications and care planning to provide treatment to patients and ensure patient safety. Active care planning during acute mental health treatment that is inclusive of the patient and other supports can have a positive effect on reducing harm to patients, staff, and visitors, by increasing resources for amelioration of strong negative emotions. In this project, active and collaborative care planning is operationalized as the combined use of Comfort Plans and Comfort Kits for assessment and intervention, respectively. This will:
- Provide low barrier ways for staff and patients to collaborate on care planning.
- Promote patients to take more of an active role in identification and management of symptoms.
- Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others.
- Be evaluated with metrics such as Client Satisfaction Surveys, patient lengths of stay, patient readmission rates, Code White frequency, and seclusion room use.
The Performance Gap
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). Suicide is not the only metric for patient safety in psychiatry, which has other unique patient safety issues, such as violence and aggression; suicide and self-harm; seclusion and restraint; and absconding and missing patients. 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). As such, there is an urgent need to reduce and mitigate unsafe acts within the mental health care system.
Patients who are in acute psychiatric distress are at risk to harm themselves or others. Collaborative care planning is a tool used to help patients recognize when they are reaching levels of acute psychiatric distress. This self recognition translates into preventing patients from reaching a point of crisis where they are at risk to harm themselves or others. Acute inpatient settings often do a good job of utilizing the environment and medications to promote patient recovery. Patients are admitted to a relatively safe, calm environment removed from the complexities of life that may have triggered the acute psychiatric crisis, and patients receive medication trials under close medical supervision to determine the best pharmacological treatment plan. However, a third arm of treatment, collaborative care planning, is often underutilized (Anthony, P. & Crawford, P., 2000).
Collaborative care planning refers to the combined efforts of staff and patients working together to set and achieve health goals, and involves greater patient involvement in the planning, delivery and evaluation of care. Ideally, it leads to better treatment by focusing on improving and maintaining health rather than just dealing with problems as they arise (Victoria State Government, 2012)). Lack of collaborative care planning often manifests as: patients being unaware of their treatment plan; patients feeling helpless; weak therapeutic relationships between patients and staff. This, in turn, may result in poorer outcomes and increased number of patient safety events. 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. Collaborative care planning can be encouraged through a relatively simple framework utilizing a Two-Step Comfort Toolkit, which will be described below in the “Practice Plan” section. This framework gives tools for staff to work with patients and their supports to build skills for both evaluation and management of emotional distress, which often precede patient safety events.
Leadership Plan
- Provide infrastructure. Use the Two-Step Comfort Toolkit to systematically build patient and support skills development in an effective and efficient manner. 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 is particularly important in acute inpatient psychiatry settings, where psychiatric severity tends to be high, and staff often are time and resource constrained (Porter, 1992).
- Provide scope. Develop a guide for staff and physicians to determine appropriate family and supports to be involved in care planning.
- 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 outcomes. Systematically track and iteratively improve patient engagement by collecting data about outcomes, success rates, adverse events.
Practice Plan
The Two-Step Comfort Toolkit can be completed in as little as two 30-minute sessions. It should ideally be completed as soon as a patient is settled enough to actively and collaboratively engage with the clinician.
Step One – Comfort Planning (Fig.1, Fig.2)
Step Two – Comfort Kits (Fig.3)