Real Reduction Experiences

Holston United Methodist

Home for ChildrenGreeneville, TN

Holston HomeStarted as an orphanage in 1895

Multi-program agencyFoster Care (120 youth)

medically fragile, low intensity, therapeutic

In-Home ServicesAdoptions (49 placements in 2003)

special needs, domestic, internationalChild Day Care (100, infant – 5 yrs. old)

Holston HomeDay Treatment School (75 youth, K-12)Residential Group Care & Treatment (84)

Assessment (8)Boy’s Treatment (40 – Lv. 2 & Lv. 3)Girl’s Group Home (8)Girl’s Developmental Home (8)Boy’s Group Home (8)Preparation for Adult Living (12)[2004 Residential Numbers: 50 - 60]

Staff : 200+ in four sites

Why Change?

It looked bad and felt bad 1998 – 1400+ restraints, 2600+ seclusionsHigh number of disruptions, “bouncebacks,” and runaways Some staff began to raise concerns about the therapeutic quality of our “treatment” approachStaff were not given enough skills to appropriately deal with negative behavior

Culture Analysis –Crisis Creators

High staff turnover

Inexperienced staff

Poor training

Shorter ALOS of youth

Higher numbers of more difficult youth

Older youth

Leadership turnoverpoor leadership in

various positions

Perceived lack of support from administrative staffControl-oriented culture of careFear

Restraint ReductionRestraint Reduction

Year Restraints Youth Injuries Requiring Medical

Attention

Staff Injuries Due to Physical

Management(% of overall)

1998 1447 6 36 (71%)1999 660 2 27 (66%)2000 169 0 4 (27%)2001 93 3 12 (34%)2002 169 0 17 (49%)

2003 116 0 11 (31%)

Restraint Reduction

1447

660

16993

169 1160

200

400

600

800

1000

1200

1400

1600

1998 1999 2000 2001 2002 2003

Restraints

Positive Change and Success:

Seclusion ReductionSeclusion ReductionYear Seclusions

1998 2642

1999 2114

2000 1259

2001 940

2002 607

2003 386

2004 201[1st Q = 166 2nd Q = 35]

Seclusion Reduction

2642

2144

1259

940

607386

0

500

1000

1500

2000

2500

3000

1998 1999 2000 2001 2002 2003

Seclusions

Relationship of Restraint Reduction to Seclusion Reduction

-500

0

500

1000

1500

2000

2500

3000

1998 1999 2000 2001 2002 2003

Restraints

Seclusions

Linear (Restraints)

Linear (Seclusions)

Relationship between restraint reduction and seclusion reduction:

r = .91 (p=.01)

Leadership Towards Organizational Change

Senior leadership decision to reduce restraintsMoney and staff resources put into exploring/implementing changeCWLA consultant brought inResearching what others were doing

Buy-in of middle management and direct care supervisorsMore responsibility on directors and

supervisors to hold staff accountable

Using Data to Inform Practice

CQI Tracking of Restraints and Seclusion

Setting % reduction goals

Collecting data in a more sophisticated manner via Restraint Review Committee

Using Data to Inform Practice: Show them the #’s!

2004 HH Injuries to Staff (Jan. – June)4 during Restraints8 during Physical Guidance**Not all may be related to Seclusion

Seclusions are linked to restraints2003: 80% of restraints due to indication

of seclusion

Stopped the use of seclusion July 1, ‘04

Workforce Development

Increased staff training:From 2-4 days orientation to 2 weeksFrom 1 day of “restraint training” to 4 days

of de-escalation and restraint techniques (2 ½ days of de-escalation techniques)

Supervisory training increasedAdded full-time Staff Development

Coordinator position

Reduction Tools

Recently implemented tools:

Individual Crisis Management Plans

Behavior Support Plans

Consumer Roles in Inpatient Settings

14 youth participated in Treatment Model Task Force focus groups on “building relationships”4 family members participated in Treatment Model Task Force focus groups on “building relationships”Youth input on Individual Crisis Management Plan (ICMP)

Debriefing Techniques

After each restraint, the primary staff involved conducts a Life Space Interview (LSI) with the youth.

LSI documented as a part of Serious Incident Report

Informal debriefing for staff involved conducted by supervisor

Concurrent ChangesChange of treatment culture – 1999

Treatment model task forceMove to a relational model of care:“connecting” vs. “controlling”

Training in Mediation – 2001

Year Grievances Founded2000 311 202001 170 242002 58 82003 23 0

Mistakes & SuccessesMistakes

Went cold turkey

Didn’t give other “tools” early on

Some hired-in directors didn’t buy in

Held on to some staff who didn’t buy in

Successes

Support from leadership

Data and goal-setting

Training on staff resistance

Training, Training, Training

Celebration

What We Have Learned

It gets worse before it gets better

When you take away a tool, you have to put another one in its place

Plan thoroughly and prepare staff

Power struggles must be recognized and redirected

Staff have to be supported and empowered

Involve youth – listen and learn

What We Have Learned

Data collection is key – show them the numbers!

Review process is critically important

Restraint Review Committee:Purpose

Tracking through data gatheringEmphasis on detail of report writing

Identifying trends

Sending a message of importance

Giving feedback to staffLearn from mistakes and successes

Meeting Standards -now mandated by

TN DCS

What We Have Learned

Model for culture change – Edgar Schein

It is a processExpect resistance It takes time to change a culture

5 - 15 years