creating positive environments of care jayne van bramer former director, office of quality...
TRANSCRIPT
Creating Positive Environments of Care
Jayne Van BramerFormer Director, Office of Quality Management
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Note: This presentation was originally made on May 24, 2011. It has been modified and updated for accessibility.
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The New York State Office of Mental Health wants to acknowledge the contributions of the National Association of State Mental Health Program Directors (NASMHPD) and its Office of Technical Assistance (formerly NTAC) for many of the concepts and some of the presentation slides that you will hear and see during this conference.
Office of Technical AssistanceNational Association of State Mental Health Program Directors
66 Canal Center Plaza, Suite 302Alexandria, VA 22314 (703) 739-9333
http://www.nasmhpd.org
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I am here to talk about a subject that is near and dear to my heart. Not simply restraint reduction, but the creation of positive environments of care and the culture change that is necessary to achieve that.
This work is not for faint of heart. Changing your organizational culture is the toughest task you will ever take on.
Your organizational culture was formed over years of interaction between the participants in the organization. Changing the accepted organizational culture can feel like rolling rocks uphill.
It’s not about reducing restraint and seclusion…
It’s about culture change
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Organizational cultures form for a reason. Perhaps the current organizational culture matches the style and comfort zone of the company founder. Culture frequently echoes the prevailing management style. Since managers tend to hire people just like themselves, the established organizational culture is reinforced by new hires.
Experts estimate that it takes 3 to 5 years to really change a culture. So let’s begin! What I want to share with you is a compilation of what I have learned from national experts, heard from hospitals in other states, and my private lessons learned.
Culture Change
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People learn to perform certain behaviors through either the rewards or negative consequences that follow their behavior. When a behavior is rewarded, it is repeated and the association eventually becomes part of the culture.
For us, much of our hospital culture is learned through interaction.
Culture is difficult to change because it requires people to change their behaviors. It is often difficult for people to unlearn their old way of doing things, and to start performing the new behaviors consistently. Persistence, discipline, employee involvement, kindness and understanding, organization development work, and training can assist you to change a culture.
It starts with the leadership. Leaders must first “talk the talk” (espouse the new values), and then “walk the walk” (model behaviors dictated by the new culture).
Culture = Behavior, and it is Learned.
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1. Set Direction: Mission, Vision and Strategy
2. Establish the Foundation
3. Build Will
4. Generate Ideas
5. Execute Change
Culture Change through the Institute for Healthcare Improvement Framework
http://www.ihi.org/Pages/default.aspx
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It is really also the framework for my talk today and what I hope to share with you - ideas for setting the direction, establishing a foundation for change, motivating employees, providing ideas, and making it happen.
The IHI Framework
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Commitment to Nonviolence and Non-Coercive Care
Commitment to Management of Dysregulation
Commitment to Trauma-Informed Care Commitment to respectful interactions
So how do we talk the talk? We do that by setting the direction which is our mission, vision, and values - who we are.
Our Values
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With a clear picture of where the organization is currently, the organization can plan where it wants to be next.
Mission, vision, and values provide a framework for the assessment and evaluation of the current organizational culture
Your organization needs to develop a picture of its desired future. What does the organization want to create for the future? Mission, vision, and values should be examined for both the strategic and the value based components of the organization. Your management team needs to answer questions such as:
– What are the five most important values you would like to see represented in your organizational culture?
– Are these values compatible with your current organizational culture? Do they exist now? If not, why not?
– If they are so important, why are you not attaining these values?– Do your mission statements foster a recovery orientation? Are they strength-based?
Hopeful?– And don’t forget the towards-what-end piece. You will provide safe, effective, high quality
care in order for…
We Plan our Desired Organizational Culture…
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People do recover and regain meaningful life roles.
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I remember a psychiatric hospital in which I spent 16 months as a patient.
It was considered to be one of the most reputable private psychiatric hospitals in the
country. It had the resources to purchase the best supplies for their occupational
and rehabilitative therapies. The wards had wall to wall carpet. The antique furniture
was professionally upholstered, and there was an Olympic size swimming
pool and outdoor tennis courts. Undoubtedly, the professionals at this private
hospital were administering the most updated technology available back then.
But what I remember most about this hospital was that many of the professionals
were insensitive, authoritarian, and often times they appeared to be more
concerned with their reputation as researchers than as compassionate helpers.
Upon reflection, it is no wonder that I ended up leaving that hospital
in worse condition than when I was admitted.
RESPECT: A Catalyst for Recovery
by Joel C. Slack
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My parents finally had me transferred to a state psychiatric hospital. There was definitely no swimming pool, no tennis courts and the furniture was in disrepair. The wards had never been refurbished and to this day my stomach turns when I remember some of the meals they served us. The most updated therapies were never administered because there were no funds to purchase the accompanying training.
But what I remember most about this state hospital was that the professionals were conscious about their reputation as being kind and thoughtful helpers. With no resources, respect was all they had to offer the patients. And they offered their respect generously. Consequently, I began to feel better and stronger about myself and then began to participate and respond to whatever (poorly funded) services were available. I began to recover.
In light of all that is offered in mental health systems around the world, respect continues to stand tall among the catalysts for recovery.
Joel Slack
RESPECT: A Catalyst for Recovery
by Joel C. Slack
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Redesign processes Employ best practices Use information support tools and data Coordination Nothing about us without us Manage your talent Accountability
Strategies to Operationalize Our Commitments
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Make the Status Quo Uncomfortable• Recognition of pervasiveness of trauma• Recognition of the harm of restraint and seclusion
Make the Future Attractive• Envision the best• Nurture the vision
Where to Begin?
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We start by helping staff understand the pervasiveness of trauma. Research has shown that the rate of reported abuse in childhood and/or adulthood among women living with mental illness is alarmingly high: 80% of psychiatric inpatients have been physically or sexually abused. Studies find rates of 60-90%, the higher levels being found in populations like we treat.
We teach a universal precautions approach, since so many individuals in care have traumatic backgrounds - and often, so do the caregivers.
Rajan, D. (2004). Violence Against Women with Disabilities.
National Clearinghouse on Family Violence (NCFV). [Online]. Cited September 20:
http://www.phacaspc.gc.ca/ncfvcnivf/familyviolence/pdfs/2005femdisabl_e.pd
It’s About Trauma
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Restraint and seclusion causes harm both physically and psychologically. Teach your staff about the dangers, so they begin to question.
In your program…
…Do minor rule violations lead to control struggles where privileges are withheld or threats are made?
…Must privileges (rights) be “earned”?
…Do points equate with access to activities and programming?
…Are compliance and containment mistaken for actual learning of new skills and real improvement?
Make the Status Quo Uncomfortable
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Inadvertently, we as leaders have reinforced to staff that their job was to keep things quiet. That their job was control. I shudder when I think back on how I made rounds in the evening at Manhattan or Bronx, because you know what I said? “Everything quiet?”
Behavior is a function of past traumas. Behavior is not noncompliance, not defiance, not manipulation. Noncompliance is somebody doing something that you don’t want them to do. I am the queen of noncompliance.
Behavior is a function of past traumas. Talk to staff about how restraint and seclusion cause harm, and the focus is on violence prevention and keeping everyone safe.
It’s About Leadership
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Behavior is a function of past traumas.◦Not noncompliance…◦Not defiance…◦Not manipulation.
All behavior has meaning
How do we perceive the behavior of the individuals we serve?
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“A riot is the language of the unheard”Martin Luther King, Jr.
We need to understand this, and teach a replacement behavior.
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Frustration
Pain
Sadness
Anger
Feeling scared
Precipitants of Aggressive Behavior
The core reason is often trauma.
It’s very unlikelythat the goal is
to hurt someone!
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Train staff in use of collaboration rather than consequences.
If consequences must be used, make sure they are effective (e.g. planned ahead, clear, consistent, brief, pleasant voice, follow through, teach to alternative)
Beth Caldwell,
Caldwell Management Associates
Consequences: A dirty word?
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The single biggest shift in attitude we have to help staff through is from the belief that consequences are the most potent agents of change, to the belief that education and emotional supports are the most effective ways to help people change their behavior.
So what we need to do is train staff in collaboration and the use of positive behavioral interventions.
We need to continually revise (every 3 months) or rid your program of Level Systems, and replace them with individual goals and/or everyday collaboration and choices.
Consequences: A dirty word?
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The shift in thinking is the shift from prioritizing justice to prioritizing healing.
Paradigm Shift
When you think of behaviors as responses that are the best they can offer, rather than intentional misbehavior, it changes the paradigm.
You don’t punish your piano student for making mistakes.
You say…“You’re not ready for a performance yet, let’s keep practicing. Don’t give up. I’ll teach you. You can learn this.”
Not, for example… “I can’t let this guy get away with hitting a wrong note. They need to be punished or they’ll never learn.”
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"Kids do well if they can. If they can't then it’s our job to find out why and teach them the skills they need so they can do well.”
Ross Greene, Ph.D.
And the same applies for adults.
From Power and Control to Collaboration
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I want to talk for a minute about the dangers of restraint in NYS.
Why are these power struggles wrong?
They lead to hands-on interventions.
Power struggles can and do lead to death.
A Matter of Life and Death
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Jonathan Carey, 13, smothered to death in 2007 by improper restraint under OMRDD’s care. This event led to Jonathan's Law.
In New York State
15-year-old Darryl Thompson died after being restrained face-down by two aides at an OCFS juvenile facility in 2007. It didn’t get as much press as Jonathan Carey…perhaps because he was a poor African American child?
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In NYS, William George Agency, Alexis Javier Cirino-Rodriquez, 20, died on 10/13/10 as staff were attempting to restrain him after he'd assaulted one of them.
The forensic pathologist “determined the cause of death to be from probable mechanical asphyxiation, from chest and neck compression during a struggle, with the manner of death being accidental.”
In New York State
Not in our system, you think? Well, thankfully, deaths are few and far between, but in 2010 we did have a restraint death in a CPEP, of an individual who had definite trauma issues that were not really attended to.
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– Safe for you– Safe for the people we serve– Safe place for families– Safe for staff and visitors
Primary Prevention:The Primacy of Safety
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First do no harm. It is the Hippocratic Oath, but also the core of what we do.
Without a safe environment, no one can recover, heal, or develop resiliency.
Staff can’t perform competently. Leaders can’t lead effectively.
Safety is the foundation for all our work.
When we talk to staff about safety, we need to communicate the fact that coercion-free environments are also safer for staff.
Data has shown that such environments have fewer assaults on staff and fewer allegations of abuse.
First do no harm.
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Imagine giving tours of your program.
What do you want people to see?
How would you want the environment to be different?
How do you want people to feel?
Help staff see the vision The future determines the present
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Imagine your hospital in five years.
What does it look like? How does it feel?
What are the policies?
What is the admission process?
Open? No door? Spa-like? Sanctuary? Peaceful, warm, friendly?
A program that caresA program that’s safeA program that communicatesA program that understandsA program that healsNow what does that look like.
Help staff envision a better future
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Inspire a Shared Vision
Three essentials – Listen deeply to others– Discover and appeal to a common purpose– Give life to a vision by communicating expressively, so that
people can see themselves in itKouzes, J. and Posner, B.
The Leadership Challenge, 2008
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It is those values and that vision and mission that becomes your roadmap and can be operationalized into a strategic plan
Give staff something to rally around
Help staff get in touch with why they went into this field.Sit and talk to them. So how did you end up working in mental health? Why here and not an IBM or McDonald’s?
We want to save the world, right? Help them reconnect to those feelings of wanting to help people.
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Jim Collins profiled why some companies make the leap and others fail. He also published a Good to Great Social Services monograph. In it he talks about how you apply the concepts to the social sectors. In terms of getting the right people on the bus, he sees an advantage to the social sectors because we can tap into their idealistic passions - these are people who seek nobility of service and meaning beyond the mighty dollar.
Good to Great by Jim Collins
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I think some of our leaders try to lead through the use of power. State employees, unions, permanency (how good is that, right?) underscore the need for us to lead through leadership. We don’t have that much traditional power.
But we do have the power of inclusion. The power of language. The power of shared interests. And the power of coalition.
When a new CEO was hired for the Girl Scouts of America, she was asked by a NY Times reporter how it felt to be on top of such a large empire. She paused and explained she was not on top of anything, yet she had the ability to lead hundreds of disparate councils, each with their own governing board and almost a million volunteers into a new era - where tough teen issues like teen pregnancy and use of alcohol were confronted and addressed through educational materials and badges could be garnered for such topics as math and technology.
To get things done within a diffuse power structure you need to rely on persuasion and the powers just mentioned - inclusion, and shared interests, and language and coalition.
Leadership and power
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Lesson LearnedLeadership comes in all shapes and sizes;
Leadership is in your heart.
Inspire Shared Vision
“If you want to build a ship, don’t drum up the men to gather up the wood, divide the work and give orders. Instead, teach them to yearn for the vast and endless sea.” Antoine de Saint-Exupéry
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While I still believe that is the ideal scenario, we have seen success when a unit manager (super TA) has taken this on as a passion.
True Leaders can be informal too, and inspiration can come from many sources.
Who reading this is a leader? Raise your hand... Every hand should be up. You are not a leader because of your title or your salary.You’re a leader because you can talk the language of a visionary and an idealist.You are a leader because you can forge a path no one has taken previously.
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Starting to see a theme here on how to effect change? Practice: Challenge the process
Commitments: (1) Search for opportunities and (2) Experiment and take risks Practice: Inspire a shared vision
Commitments: (3) Envision the future and (4) Enlist others Practice: Enable others to act
Commitments: (5) Foster collaboration and (6) Strengthen others Practice: Model the way to the desired objectives
Commitments: (7) Set the example and (8) Plan small wins Practice: Encourage the heart of everyone involved
Commitments: (9) Recognize individual contribution and (10) Celebrate accomplishments
Essential Leadership
Kouzes, J. and Posner, B.The Leadership Challenge, 2008
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– Provide Resources. It doesn’t have to be money. It could be time to work on this committee assignment or designation as lead of working group.
– Acknowledge early adopters. – Recognize those staff with a passion for this and empower them!– Promote and Protect Flexibility and individualized approaches.– Strategic Use of Job Descriptions and Performance Evaluations.
Don’t use the civil service job descriptions, make your own and set expectations of hope, collaboration and strength-based, trauma-informed interactions.
– True Recipient and Family Involvement
Leadership Towards Organizational Change
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I tell you and you forget.I show you and you remember.I involve you and you understand. - Eric Butterworth
We have had a lot of success where we used on-ward trainer-mentors who became part of the fabric of the organization and provided modeling and mentoring to staff on an ongoing basis.
To have someone reframe in the moment and be willing to roll their sleeves up and identify and get involved in a difficult situation was very important.
Teaching doesn’t happen in a classroom.
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Edgar Dale’s Cone of Learning shows how well people remember what they’ve learned, after two weeks, depending on how they learned it.
“Verbal receiving” (passive learning) results in no more than 30% retention.
“Visual receiving” (passive learning) results in no more than 50% retention.
But active learning - by participation, talking, simulating, or doing the real thing - results in up to 90 retention!
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Moment-to-moment assessment of level of stability/dysregulation Matching an intervention to that level Building Partnering Relationships Pre-teaching Motivation without threats Early Intervention Ways to build up mood and resilience/increase joy Creating situations that are as safe as possible Being persistent without escalating a situation Individualizing your response Emphasizing intrinsic rewards of positive behavior Facilitating soothing and self-soothing Power of refocusing attention
Staff Training
Rob Terreden, Director Three Rivers Intensive Residential Treatment Program
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We train staff in – CPR– Infection Control– Filling in an incident report– Writing notes
All important stuff.
But Rob Terreden’s items are the essence of the job that help a person’s recovery. These are what builds resiliency.
They are skills that Maximize Staff Influence and Minimize the Use of Coercive Techniques.
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Our job as mental health caregivers is to figure out the triggers and early warning signs for challenging behavior
…and teach replacement behaviors.
So much for leaders. What about staff?
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Teacher Cheerleader Positive Reinforcer Healer
…Not Rule Enforcers and Jailers.It’s about collaboration and not control.
The Role of Behavioral Health Staff
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And the job is to take opportunities to build positive experiences and teaching outside the context of a failure.
This means offering support when a person is only slightly agitated - which also means becoming skilled at assessing an individual’s level of dyscontrol or agitation.
The people we serve learn more from success than failures.
The Role of Behavioral Health Staff
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Modeling and Mentoring Training Paying Attention Strength Based Supervision Capture Success; Record and Celebrate
How do we support staff in using collaboration and empowering approaches?
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That approach is not good enough. To be a great leader you must be willing to get your hands dirty and show your people how it's done when the circumstances warrant it. What it doesn’t mean is swooping in when an individual is totally out of control to try and save the day. Because you know what will happen. Punched in the nose!
Model the behavior you wish to see in staff.
Training around collaborative, practice reframing directives with staff, empowering, strength-based, trauma-informed interactions. Train in conflict avoidance. Do we do this? Do we assess these competencies? How hopeful and positive are we?
Strength-based supervision - Public praise, Private feedback. Great Mr. Jones. Say something positive.
Catch them doing something good. Every time you make rounds. Keep a notebook to remember.
"Do as I say, not as I do."
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USF taught teachers how to implement best practices.
They measured uptake:
Classroom and role-playing only: only 5% implementation
Classroom, role-playing, coaching and supervision:95% implementation!
Supervision can be in groups, but staff need some individual time. Shape behavior by praising the competencies we want to see.
University of Southern Florida
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Reasonable Risk-Taking
Encouraging Flexibility
Promoting the Use of Individual Strategies
…Scary, right?
How do we support staff in using collaboration and empowering approaches?
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I need you to support your staff in taking risks.
I’m offering Individualized Care.
It’s Risk Management gone amok.
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It’s difficult for folks to process during a crisis.
Reception language skills are decreased.
Broca’s area of the brain is actually deactivated. That area is responsible for speech, so it’s difficult to talk. The amygdala’s flight or fight response is activated.
Think these sensory things will work? Oh wait I have some peppermint gum. I try to hand that to you…
We need to provide comfort to assist individuals to re-focus.
What to do in a crisis?
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Imagine that you’ve worked a very long day… Your Director wanted several things finished by COB. One of those days with no time to sit. We’ve all had them. Pull into your driveway and see a car. Through the sheer drapes you can see your husband kissing another woman. You are so angry that you can’t even lock the car - you go flying through the front door. Your sister-in-law is there and she hands you a stress ball and tells you to calm down.
How are you feeling?
Exercise
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• How can I help you?• What do you need?• Are you HALTT?
Don’t direct, but Ask…
Don’t tell people to calm down. Ask: Are you Hungry? Angry? Lonely? Thirsty? Tired?
You are angry and right then you want your anger validated…and that woman out of your house.
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Individual’s level
Look, Listen and Observe
Not yelling direction from across the room
Do realize the person is not processing,and make adjustments as needed
Give space
Use a supportive stance
Soft voice
Use Visual Support
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Body language is so important. How do we talk to the individual in care? Stand over them?
Take a safe and supportive stance. Talk to individuals on their level, not standing while they sit.
Think about when you took your child to daycare or preschool for the first time. What did the teacher do?
That famous UCLA study:Communication is 93% nonverbal.
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Our wards are often too loud. Don’t yell down the hall. No screaming “Telephone!” at lunch time.
Read incident reports. Staff seem to approach almost every issue like it is the line in the sand issue because we have indirectly reinforced that their job is control.
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The underlying philosophy of 'collaborating' is premised on
'treating everybody with dignity and respect'.
Beth Caldwell, Caldwell Management Associates
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Collaboration is about treating everyone with dignity and respect.
One respects the person in care/co-worker/boss enough to approach him/her in every interaction using a kind and sensitive voice tone.
Anyone remember Dr. John Oldham? He was a Medical Director for OMH. Monthly meetings get heated. The louder we got, softer he got. Very effective.
Collaboration is…
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Respect is like Air
Take it away and that is all people can think about
Michael Woods, M.D.
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This can be a really fun exercise.
Have each shift write the rules down - each shift. Include both written and unwritten.
Think they are the same across shifts? They differ even by different staff on the same shift!
Go through each, and determine what rules are for recipient recovery, versus staff convenience.
What is empowering versus easier for staff?
What rules are absolutely necessary?
Do we need rules about when to get up? When to shower? When to do laundry?
Rule-Busting Committee
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“But if I let John sleep in on Saturday, everyone will want to, and the day shift will be annoyed at the evening shift.”
Talk through/walk through the scenarios.
But…but…
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Let’s not be so arrogant or rigid so as to believe that we can’t grow and learn.
“Are you saying we’re no good?” “I’m saying we’re great and can do better.” Even “best practices” are only best until we imagine something better.
In the face of dangerous behaviors, let’s not speculate about whether this new approach can work. Let’s ask, “Is there anything we haven’t tried yet to support getting the best from this youth?”
Not all change is good, but nothing gets better without it.
Rob Terreden, DirectorThree Rivers
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We are creatures of habit, and talking to staff about change is an important part of the process.
But nothing gets better without change. We can all grow and learn. We can all do better. We can all try something new.
All change is scary.
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…Is that it is 24/7.
The treatment milieu is a therapeutic agent to support a Trauma-Informed Culture
The Advantage of 24/7 Care
We have a lot of opportunity to have an impact. With almost 30 years in mental health, I have been around long enough to see the term “therapeutic milieu” became almost a dirty word where the flavor of the day became structured programs and activities.
The pendulum is swinging back. The brain can be changed. That is what treatment is about. That’s why it’s hard. It takes consistency, and working with individuals over and over and over again.
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Asking questions and listening attentively to the answers
Interpreting facial expressions and body language while maintaining an awareness of one’s own
Judging the best way to explain a diagnosis, treatment, and self-care to individuals and family members based on considerations such as language, culture, and education
Putting the Care in Health Care, TJC
Practicing compassionate care involves:
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Make eye contact. Smile. Sit rather than stand. Listen without interrupting. Convey attentiveness by leaning forward. Keep arms uncrossed. Respect silence. Use touch appropriately. Ask questions. Discuss expectations and past experiences fully.
Putting the Care in Health Care, TJC
How to put individuals in care and their families at ease
Ask yourself:On a daily basis, do we assess aides and nurses for these skills?
Teach!Monitor!Reinforce!
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Staff:• Are respectful• Understand 3 basket/plan approach (see next slide!)• Extinguish ‘control type statements’ - replace with collaborative statements• Offer choices• Identify triggers & respond with collaborative/gentle teaching approach
Beth Caldwell Caldwell Management Associates
Moving From Control to Collaboration
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The 3 basket approach to conflict involves deciding whether you can - Let it go Compromise, collaborate Hold firm
Most of us have raised our kids this way. Remember the terrible twos? Adolescent daughters? Teenage boys?
If you were like me you quickly learned to pick your battles. We have to decide what we can ignore or let go, what we can negotiate, and what is written in stone.
Car seat - MustNo drugs - MustCurfew - NegotiableWon’t eat dinner? Let it go
The 3 Basket Approach
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The Ultimate Clinical EBP – Congruence (genuineness, honesty with
the individual in care)– Empathy (the ability to feel what the person in care feels)– Respect (acceptance, unconditional positive regard)
Employ Best Practices
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ACT, DBT, CBT, Supported Employment, Wellness, Co-occurring Treatment, Family Psychoeducation, Trauma Focused CBT, Multisystem Therapy…These are all great.
But most powerful EBP? You don’t need to be a trained clinician to provide it.
Consumers who were asked what made the difference in their recovery said it was care, compassion, and hope.
Sometimes from one person.
The Super EBP is within all of us. We don’t need a Ph.D., we don’t need to be clinical. We want to decrease that 15-year gap between what research tells us works and what we actually do.
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Numbers Crunching doesn’t tell the whole story.
“Not everything that can be counted counts, and not everything that counts can be counted.” Albert Einstein
Lesson Learned
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Another lesson I learned through our grant:We submitted a ton of data and monitor patterns and trends monthly. What we didn’t capture was the human side of what we are doing:
The story of the nurse who helped the child create a fort with her blanket and a chair and then crawled into the fort to administer meds…
The adolescent who approached the nurses station with wrists turned outward asking for some of the cream that helps her sleep…
The aide who walks around the ward with a bedtime basket with various pillow sprays the children can pick from…
The child who felt better about their admission after the hospital allowed Mom to bring her pet rat into the hospital during the Mom’s visit…
I could go on and on.We have decided as part of our final year activities that we are going to try to capture these moments.
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What did you find?What did you do about it?Who did you tell?Did you remember the story?
Turning Data into Information
“Could This Happen in Your Program?” http://www.justicecenter.ny.gov/sites/default/files/archivereports/Publications/00037.pdf
Why is it so effective? It puts a face on it, makes issues come alive.
Emphasis is on measurement, because that which can’t be measured can’t be improved. But we still need to remember the story. It is the story which inspires.
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It takes a village.
Lesson Learned
Partially because this work is so hard, the effort needs to be all-inclusive.
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Communication is key to recovery: Among clinicians, shifts, wards, treatment malls, families, support systems and the individual in care
Collaboration, Coordination, and Communication
The three C’s are mandatory for a successful transformation.
TJC has concluded that upwards of 80% of adverse events have communication problems as root causes.
SBAR Hand Off. It’s an opportunity to ask questions, to have a conversation, not a piece of paper:http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
Coordination
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There is agreement on– goals– tasks
The relationship is experienced as– collaborative empathic– respectful trusting– understanding hopeful– encouraging empowering
“Nothing About Us Without Us”
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Move from “Recipient Council” to recipient and family involvement in hospital-wide committees!
We need true involvement, not just an annual survey. Not just an advisory committee, but recipients and families participating in key hospital committees and task forces. It is having them to be a regular part of the review process (or sign-off) for new policies.
We want the most honest feedback. Solicit it post-discharge. Ask recipients to manage the survey process.
Transparency Is Your Friend
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We don’t always see the message we deliver.
Language/signage is important.
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Go with a family member or someone receiving outpatient services.
See it with fresh eyes.
Is your signage warm and welcoming?
On a kids’ unit in a state PC, I saw a sign that said:“10 feet from the Nursing Station or lose 100 points.”
We see so many “Do Not (…)” signs and rules…“Police Leave Your Guns…”
Go though your facility with fresh eyes.
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When we are talking, do we have the language down? Is it strength-based, trauma-informed, person-centered?
Do we follow through on policies and practices?
Our language
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Establishing a Sense of Urgency Forming a Powerful Guiding Coalition Creating a Vision Communicating the Vision Empowering Others to Act on the Vision Planning for and Creating Short-term wins Consolidating Improvements and Producing Still More Change Institutionalizing New Approaches
Eight Steps for Leading ChangeJohn Kotter of Harvard Business School studied why transformation efforts fail, and suggested Eight Steps for “Leading Change”.
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Working the tipping point– Create an “epidemic” around the main thing– Talk it, write it, sell it
…Identify champions– Make your ideas contagious
…Memorable, motivating, practical and personal– Use early adopters to spread the word – Communicate, train, mentor and reinforce
Leadership in ActionMalcolm Gladwell’s The Tipping Point, 2000
When you are working on culture change, keep in mind that you don’t have to convince everyone!
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Seeing the individuals in care differently.
Knowing that people do well if they can.
Training to help appreciate that if individuals have challenging behaviors, they are not doing it on purpose.
Appreciate their “maladaptive behaviors” are their best attempts at coping with their difficulties in self-regulation and life’s daily challenges.
Caroline McGrath, Executive Director
UMass Adolescent Treatment Programs
Clinical Instructor UMass Medical School
A whole new lens…
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Adopt the concept of “universal precautions.”
Appreciate the prevalence and pervasiveness of trauma and our responsibility to make sure our practices and policies are trauma-sensitive.
Seeing behaviors through a trauma-informed lens deepened our empathy for the adversity they faced, and helped us to understand that their “trauma logic” was not so crazy.
Where we want to go
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Both staff and leadership want tools, something tangible.
We have received repeated requests for tools from our grant sites - both leadership and staff wanted us to give them the tools to be successful - tools apart from the Six Core Strategies. The fact is, the most important tool is inside them - it’s that strength-based, non-coercive interaction. It’s compassion, it’s empathy, but sites wanted something “tangible”. The grant allowed us to provide stuff on many levels.
We have come to truly appreciate the power of sensory modulation.
Try a Fireball PRN!
Lesson Learned
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Prevent injury and trauma to staff and individuals in care
Help de-escalate
Meet individual’s identified sensory needs
Help maintain a safe therapeutic environment
Why Use Prevention Tools?
We expand our tool box of interventions and strengthen the therapeutic alliance
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Calming Plans…Sensory Items…Calming Rooms…Calming Items…You!
Prevention Tools Include:
Get a PRN to go for a swing, or to pet a dog if there is one.Doctors in hospitals in other states write orders like this. Next time you call a doctor, ask them to write a PRN order for basketball.
These are our tools to prevent R/S.Increased options in crisis and daily activities, for youth and staffDecreased agitationClear, measurable way to decrease levels of distressImproved quality of care and therapeutic experienceImproved work environment
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To decrease depression, improve mood and affect To reduce anxiety, isolation, and problem behaviors To improve self esteem and feelings of self-worth To improve socialization and communication To provide affection, pleasure, and learn
appropriate touch
Denise Geissert, M.D.
Child and Adolescent Psychiatric Fellow, University of Buffalo
I am not a pet person, but I have become a believer in the unconditional love of an animal.Animals have been used for companionship for centuries. Evidence of a symbiotic relationship between humans and animals dates back to earliest forms of civilization.A positive bond between humans and animals has always existed.
Animal Assisted Therapy
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To increase the ability to trust others and express feelings
To improve concentration, attention, memory, and recall
To address loss and issues with grieving
To improve problem-solving abilities and cooperation
Denise Geissert, M.D.
Benefits Animal Assisted
Therapy
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This is Tommy, the psychiatric service dog at Western New York Children’s Psychiatric Center
Tommy
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Grant sites have gone from no animals, to having therapy dogs come in once a week, to having a therapy dog belong to the agency.
Parents now routinely bring family pets in when they visit.
We ask them to do this in parent handbooks.
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Kids playing with fuzzy puppies. Doesn’t that feel good?
Thanks to Robert Reusch at WNYPC for sending me this link.
Please maximize this tool… It’s very, very effective. You could get an affectionate ward cat!
Dogs and Puppies
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Brylin’s cart is used frequently.
Warhead candies are available.
They’ve seen a decrease in:◦ Restraint use◦ Property damage◦ Self-destructive behavior◦ Physical assaults/injury
Not Enough Space?
Consider Sensory Carts
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The House of the Good Shepherd was our first PARS grant site to recycle an old medication cart.
Sensory Cart
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How we feel is directly impacted by information received through the different senses:
1. Sight2. Sound3. Smell4. Touch5. Taste6. Proprioception7. Vestibular input
Sensory Input
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Sensory experience is something all human beings share. How we feel is directly tied to the sensory information we
process through the 5 senses.We all have ‘sensory diets’ – primarily, we are either looking for
stimulation or looking to avoid stimulation. These sensory needs change over time; they are not static. If you become ill or have a migraine headache, your sensory
needs change.
Sensory Experience
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Western NY Children’s Psychiatric Center
There are some very simple enhancements that create positive sensory experiences and promote better feeling states.
Calming Environmentsplantsartworkmusiccurtainsmusiccomfortable seatingbedrooms with new bedspreads place to exerciselow lighting (dimmer switches)aromas
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hot shower/bath
wrapping in a heavy quilt
decaf tea
rocking in a rocking chair
beanbag tapping
yoga
drumming
meditation
Calming, Self-Soothing ActivitiesCalming activities are particularly helpful for people with tension and anxiety who have difficulty unwinding and feeling physically relaxed. These strategies can be practiced. People who feel physically better will begin to feel better emotionally. The mind and body are connected.These are activities that can be used by the person in the home and community.
Tai Chi was most effective for one person, and the hospital worked hard to link her up with this resource upon discharge.
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A prevention tool to reduce the use of seclusion and restraint
Comfort Room:
Comfort rooms are places of sanctuary, right on the units.
Persons served are an integral part of developing your comfort room.
Teen Lounge at Brylin
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Use of a Comfort Room is voluntary - though staff may suggest its use and be present if the person desires it.
Comfort Room
The House of the Good Shepherd
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It is a sanctuary from stress, and/or a place to experience feelings within acceptable boundaries.
Brylin’s Comfort Room: Snoezelen tubes on left
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To meet the calming needs expressed by youth, these spaces were developed at Western NY Children’s Psychiatric Center.
The space outdoors was turned into a quiet garden where children can be alone with nature, with a staff member, or with family.
Because so many children have “energy to burn”, the youth saw exercise as a way to self-regulate. This is particularly important for children who need motion to calm.
Other Environments
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The House of the Good Shepherd
Murals
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Practice calming plans. Self-control is of paramount importance.
The most important skill we can teach our children is self-control.
It’s also important for individuals in care.
Write orders to implement calming plans.
Incorporate the use of sensory items into both the treatment plan and calming plan
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Increase resilience to stress by creating a reservoir of pleasure
Show we care
Foster bonding with staff through having fun together
Offer joint pressure, and heavy work to calm nervous system
Foster feeling that life is worth living; counter feelings of hopelessness and apathy
Activities and programming is not just busy work to pass the time.Poets and philosophers have proposed that joy and sorrow are actually just different ends of one emotion or continuum.When you increase joy and have fun, some of that other stuff does go away. Even symptomatology.
Activities serve many purposes:
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Let’s take a look at a new evidence-based intervention for addressing trauma.
The program is called Rainbow Dance, out of Massachusetts. It’s primarily used with children who have experienced natural disasters, but it’s also used effectively with our population.
When I look at it, I see joy.
http://www.bostoncf.org/
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Have fun on your wards. Be silly. – Dance– Sing– Tell Jokes– Giggle
Read “Teaching Your Children Joy” by Linda and Richard Eyre
Create the joy of spontaneity. Have an upside down meal!
Create a “Favorite things” wall.
The joy of the earth: the smell of lilacs, treasures in a vegetable garden.
(you can even plant in bags these days - check out Gardener’s Supply Company)
The joy of creativity and imagination (art)
The joy of sharing and service (find something wonderful to share - a flower, something nice you heard on the news, a joke)
Do secret good deeds.
Instill Joy!
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They are daily group meetings with individuals in care and staff. The meetings are empowering. They provide a forum to voice needs and concerns.
It’s a group process to create a community of safety and build trust.
What are Community Meetings and why are they important?
Community Meetings are the best way to ensure that individuals in our facilities are understood and respected.
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What are you feeling?
What is your goal for today?
Who can you ask for help if you need it?
Sandra Bloom, M.D.
Creator of the Sanctuary Program
http://www.sanctuaryweb.com/
Community Meetings Exercise
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Tell them…
Reduction of R/S is your job
You are part of the “team”
You are a role model
You are a leader
You are an agent of change
You are a primary prevention tool!
Importance of Workforce Development
Our best asset…Our workforce.
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Culture involves how we treat individuals in care…
…and how we treat staff
Lesson Learned
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As Management does unto Staff…
So shall Staff do unto Consumers
The Golden Rule
Beth Caldwell, Caldwell Management Associates
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An informed and skilled workforce is critical to make a transformed system of mental health care a reality.
A recovery-oriented system of care must, first and foremost, be informed by the prevalence of trauma among the people it serves.
It is imperative to have a workforce completely indoctrinated in the value and power of full inclusion of service recipients in interdisciplinary teams.
Building A Better Mental Health Workforce Kevin Ann Huckshorn, RN, MSN, ICADC
Workforce Caliber
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Kevin Ann Huckshorn is the national leader at the forefront of these efforts.
A skilled workforce is key to system transformation. A skilled workforce understands trauma and person-centered care.
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Hire smart• Look for compassion• Discuss hot buttons and response• Perceptions from individuals in care
Use the probationary period when they are the best they can be
Practice management by walking around
Make supervision and guidance strength-based
Develop and mentor staff
Remember: You need your staff more than they need you
So make the best of this resource. Manage your talent.
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It is okay to say to someone in an interview: You know, I am not sure this job is for you.
Not everyone is cut out for this work.
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1. Set clear standards
2. Expect the best
3. Pay attention
4. Personalize recognition
5. Tell the story
6. Celebrate together
7. Set the example
Encouraging the Heart
Kouzes and Posner, 2003
A Leader's Guide to Rewarding and Recognizing Others
Can you think of a time a boss recognized you or praised you? So what was special about that?
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1. Set clear standards. The first prerequisite for encouraging the heart is to set clear standards (goals and values or principles). To be successful in encouraging the heart, it's absolutely critical that everyone cherish a common set of standards.
2. Expect the best. Only high expectations have a positive impact on actions and on feelings about oneself. Thus, passionately believing in people and expecting the best of them is another prerequisite to encouraging the heart.
3. Pay attention. One way of showing you care is to pay attention to people, to what they're doing, and to how they're feeling. If you are clear about the standards of behavior you're looking for, and you believe and expect that people will perform like winners, then you're going to notice lots of examples of people doing things right, and doing the right things. Every time you make rounds.
Encouraging the Heart
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Debriefing is easier said than done.
Almost everyone is having a hard time meeting the requirements of OMH policy and regulation. People ask about post-event debriefing, who needs to be there, what they need to ask.
There’s been too much focus on the process and not the outcome. Get feedback from the person.
Lesson Learned
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“Is there anything that you would do differently?”“What could we have done to make the restraint (or seclusion) less hurtful?” “What upset you most?”“What did we do that was helpful?”“What can we do better next time?”
It’s critical that we use the right language to debrief an incident. There are many things to take into consideration.
Can you think of a few things to consider? (Age, developmental age, state of mind, physical location, language or cultural barriers, etc.)
It is important that questions are asked in non-threatening, non-judgmental manner.
How Do We Say It?
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“When would you like to have the debriefing?” “Where would you like to meet to talk about how we can
better help you get through times like yesterday?” “Are there any special staff you would like to be present? Are
there family members you would like us to get on the phone or invite to the meeting?”
“Is there anyone you don’t want there?”
What is your mechanism for documenting their perspective?
Effective Debriefing a.k.a. Giving Up Control
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Leadership towards organizational change
Use of data to inform care
Workforce development
Restraint and Seclusion Prevention Tools
Use of Consumer Roles
Rigorous Debriefing
NASMHPD/NTAC Six Core Strategies ©to Reduce the Use of Restraint and SeclusionHas been recognized as an EBP!
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• Leadership builds consensus about values, vision, and mission and brings together a guiding coalition to make a strategic plan.
• Leadership provides pre-and post-witnessing on the use of restraint and seclusion, 24/7.
• Leadership appreciates the facets involved in changing a culture to improve the care and treatment environment. These facets include the norm, language, and customs. “It’s the way things get done around here.”
• Data is elevated and reviewed daily, hung in all areas for stakeholder review as well.
A quick plug for the Six Core Strategies©
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“Do not go where the path may lead, go instead where there is no path
and leave a trail.”
Ralph Waldo Emerson