creating positive environments of care jayne van bramer, director office of quality management may...
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Creating Positive Environments of Care
Jayne Van Bramer, DirectorOffice of Quality ManagementMay 24, 2011
Creating Positive
Environments of Care
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
Not about reducing restraint and seclusion
About culture change
Changing Culture…
1. Set Direction: Mission, Vision and Strategy
2. Establish the Foundation
3. Build Will
4. Generate Ideas
5. Execute Change
Culture Change through the IHI Framework for Improvement
Our Values Commitment to
Nonviolence and Non-Coercive Care
Commitment to Management of Dysregulation
Commitment to Trauma-Informed Care
Commitment to respectful interactions
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
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?
Restraint and seclusion causes harm both physically and psychologically
In your hospital –
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
“Violence is the Language of the Unheard”
All behavior has meaning
Behavior is a function of past traumas◦ Not noncompliance◦ Not defiance◦ Not manipulation
How do we perceive the behavior of the individuals we serve?
Frustrated In pain Sad Angry Scared
VERY UNLIKELY THE GOAL IS TO HURT SOMEONE
Precipitant of Aggressive Behavior
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)
ConsequencesA dirty word?
Beth Caldwell, Caldwell Management Associates
Paradigm Shift
The shift in thinking is the shift
from prioritizing justice to prioritizing healing.
From Power and Control to Collaboration
"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.
In NYS Jonathan Carey, 13, smothered to death in 2007 by improper restraint. Led to Jonathan's Law.
In NYS15-year-old Darryl Thompson died after being restrained face down by two aides at an OCFS juvenile facility in 2007.
Alexis Javier Cirino-Rodriquez, 20, died as staff were attempting to restrain him after he'd assaulted one of them.
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 NYS, William George Agency, 10/13/10
Safe for you Safe for the people we serve Safe place for families Safe for staff and visitors
Primary PreventionThe Primacy of Safety
Imagine giving tours of your hospital. 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
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 it
Inspire a Shared Vision
Kouzes, J. and Posner, B.The Leadership Challenge, 2008
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
Jim Collins: Good to Great
Leadership 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
Lesson Learned
Practice: Challenge the process Practice: Inspire a shared vision Practice: Enable others to act Practice: Model the way to the desired objectives
Practice: Encourage the heart of everyone involved
Essential Leadership
Kouzes, J. and Posner, B.The Leadership Challenge, 2008
Provide Resources (time and/or money and/or structure)
Acknowledge and Recognize Promote and Protect Flexibility Strategic Use of Job Descriptions and
Performance EvaluationsTrue Recipient and Family Involvement
Leadership Towards Organizational Change
Teaching doesn’t happen in a classroom.
I tell you and you forget.I show you and you remember.I involve you and you understand. - Eric Butterworth
Lesson Learned
Staff Training 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 Rob Terreden, Director
Three Rivers Intensive Residential Treatment Program
Our job as mental health caregivers is
to figure out the triggers and early warning signs for
challenging behavior
Teacher Cheerleader Positive Reinforcer Healer
NOT Rule Enforcers and Jailers
About collaboration and not control
Role of Behavioral Health Staff
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?
Reasonable Risk Taking
Encouraging Flexibility
Promoting the Use of Individual Strategies
How do we support staff in using collaboration and empowering
approaches?Con’t…
Difficult for folks to process during a crisis.
Reception language skills decreased.
What to do in a crisis?
Provide comfort to assist individuals to re-focus
What to do in a crisis?
Don’t Direct BUT ASK
How can I help you?
What do you need?
Are you HALTT?
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
Beth Caldwell, Caldwell Management Associates
The underlying philosophy of
'collaborating' is premised on 'treating
everybody with dignity and respect'.
Rule Busting Committee
Not all change is good, but nothing gets better without it.
• 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?”
Talk to Staff about Change
Rob Terreden, DirectorThree Rivers
Is that it is 24/7 Treatment milieu is a therapeutic agent to
support a Trauma Informed Culture
Advantage of 24/7 Care
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
Practicing compassionate care involves:
Putting the Care in Health Care, TJC
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.
How to put individuals in care and their families at ease?
Putting the Care in Health Care, TJC
Compassionate Care….not
Beth Caldwell, Caldwell Management Associates
Moving From Control to Collaboration
Staff:• Are respectful• Understand 3 basket/plan approach• Extinguish ‘control type statements’ - replace
with collaborative statements• OFFER CHOICES• Identify triggers & respond with
collaborative/gentle teaching approach
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
Numbers Crunching doesn’t tell the story.
"Not everything that can be counted counts, and not everything that counts can be counted."
Albert Einstein
Lesson Learned
What did you find?What did you do about it?Who did you tell?Did you remember the story?
… turning data into information
It takes a village.
Lesson Learned
Communication is key to recovery Among clinicians, shifts, wards, treatment
malls, families, support systems and the individual in care
Not discharge but remember Collaboration, Coordination, and
Communication
Coordination
There is agreement on◦ goals◦ tasks
The relationship is experienced as◦ collaborative empathic◦ respectful trusting◦ understanding hopeful◦ encouraging empowering
Move from Recipient Council to Recipient/Family Involvement in hospital-wide committees
Transparency is your friend
Nothing About Us Without Us
Language/signage is important.
John Kotter of Harvard Business School studied why transformation efforts fail and suggested Eight Steps for “Leading Change”.
Eight Steps for Leading Change
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
Leadership in Action• 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
*
Malcolm GladwellThe Tipping Point, 2000
Seeing the individuals in care differently.
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.
A whole new lens…
Caroline McGrath, Executive DirectorUMass Adolescent Treatment ProgramsClinical Instructor UMass Medical School
Both staff and leadership want tools, something tangible.
Fireball PRN
Lesson Learned
Why Use Prevention Tools?
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
Prevention Tools Include:
Calming PlansSensory ItemsCalming RoomsCalming ItemsYou
Animal Assisted Therapy To decrease depression,
improve mood & affect To reduce anxiety,
isolation, & problem behaviors
To improve self esteem & feelings of self worth
To improve socialization & communication
To provide affection, pleasure, & learn appropriate touch Denise Geissert, M.D.
Child and Adolescent Psychiatric FellowUniversity of Buffalo
Benefits of AAT
To increase the ability to trust others & express feelings
To improve concentration, attention, memory, & recall
To address loss & issues with grieving
To improve problem solving abilities & cooperationDenise Geissert, M.D.
Dogs and Puppies
Not Enough Space? Consider Sensory Carts
Sensory Cart
How we feel is directly impacted byinformation received through the different senses:
1. Sight2. Sound3. Smell4. Touch5. Taste6. Proprioception7. Vestibular input
Sensory Input
Calming Environments
◦plants◦art work, music◦curtains◦music◦comfortable seating◦bedrooms with new
bedspreads ◦place to exercise◦low lighting
(dimmer switches)◦aromas
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Calming Self-soothing Activities:
hot shower/bath wrapping in a heavy quilt decaf tea rocking in a rocking chair beanbag tapping yoga drumming meditation
Comfort Room
It is a prevention tool to reduce the need for seclusion and restraint
It is used voluntarily, though staff may suggest its use and be present if
the person desires it
It is a sanctuary from stress, and/or a place to experience feelings within acceptable boundaries
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Other Environments
Murals
Incorporate the use of sensory items
into both the treatment plan and
calming plan
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 & apathy
Activities serve many purposes:
Rainbow Dance
Instill Joy
Daily group meeting with individuals in care and staff that is empowering. Provides a forum where they can voice their needs and concerns.
Group process around creating a community of safety and building trust
What are Community Meetings and why are they important?
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
Community Meetings Exercise
Are Tools and Activities Enough?
Reduction of R/S is your jobYou are part of the “team”You are a role modelYou are a leaderYou are an agent of changeYou are a primary prevention tool!
Importance of Workforce Development
Culture involves how we treat individuals in care
AND HOW WE TREAT STAFF
Lesson Learned
The Golden Rule
As Management does unto Staff…
So shall Staff do unto Consumers
Beth Caldwell, Caldwell Management Associates
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.
Workforce Caliber
Building A Better Mental Health Workforce Kevin Ann Huckshorn, RN, MSN, ICADC
Hire smart Look for compassion Discuss hot buttons and response Perceptions from individuals in care
Use the probationary period – best they can be
Management by walking around Strength based Develop and Mentor Remember you need your staff more than
they need you
Manage your talent
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
A Leader's Guide to Rewarding and Recognizing Others
Encouraging the Heart Kouzes and Posner, 2003
Debriefing is easier said than done.
Lesson Learned
How Do We Say It?
“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?”
When would you like to have the briefing? 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?
Anyone you do not want there? What is the mechanism for documenting their
perspective?
Effective Debriefing a.k.a. Giving Up CONTROL
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 Seclusion(applied for recognition as an EBP)
"Do not go where the path may lead, go instead where there is no path
and leave a trail."Ralph Waldo Emerson