Quality Improvement Initiatives

I. Medication Reconciliation

Summary: In 2005, The Retreat along with all Joint Commission accredited Hospitals (JCAHO) sought to develop a medication reconciliation process as part of JCAHO’s 2005 Patient Safety Goals. The intent of this safety goal is to help avoid medication errors including wrong dose, omissions, medication duplication and drug interactions.

Under this goal, hospitals are expected to ensure the accurate medication history of the patient when they arrive including Over-the-Counter and herbal medications. Upon discharge a complete list is communicated to the patient and the next provider of service when a patient is referred or transferred to another setting.

Interventions: A task force was formed that included Pharmacy, Medical and Nursing staff. The teamwork among this interdisciplinary group allowed for a successful implementation of the medication reconciliation process. The task force was responsible for the medication form design, policy changes and staff education. They conducted a Failure Mode Effects Analysis to review areas in the new process that needed improvement. Recommendations were made and implemented.

Results: The Pharmacy has conducted weekly audits since the inception of the new medication reconciliation process. To date the audits show that 95% of patient medications are reconciled from admission to discharge. This means that at discharge, patients leave with a medication list that shows what medications they were on at admission, what medications were either administered or discontinued during their stay and what medications they are taking at discharge.

II. Adolescent Residential Elopements

Summary: The term “elopement” in behavioral health care settings refers to a patient who leaves the facility without following policies and procedures – essentially “running away.” Unlike more restrictive inpatient units, residential treatment facilities in the state of Vermont are prohibited from locking the unit doors. Furthermore, Vermont state regulations prohibit staff from physically restraining patients when they are eloping.

Recent research suggests that premature treatment termination is linked to elopements. It is disruptive to treatment and the milieu. Since 2003 there has been a steady increase in the elopement rate of adolescent residential patients at the Retreat.

Among various institutions there are different criteria for what constitutes an elopement. Many consider an elopement to be only when a patient leaves the grounds. We consider a patient having eloped the moment they leave the unit.

Intervention: During 2004 and 2005 a number of interventions were implemented.

A Therapeutic Intervention Survey was developed and implemented. This survey is completed by patients at admissions. It lists a variety of coping skills that patient identify as helpful to them during periods of escalation.
Elopements were identified as a self destructive behavior to target in the treatment plan, using interventions such as rating urges, skill development and coaching, and contingency management strategies to decrease the behaviors.
The Adolescent team collaborated with the local Police Department creating a communication link between the department and our internal security staff.
The procedure during an elopement was clarified and Trauma-Informed principles such as individualized patient interventions have been introduced to all staff. (See Quality Initiative III on Seclusion and Restraint Reduction).

Results: The average elopement rate for 2004 was 15.8 per thousand patient days. In 2005 it was 10.4 which represents a 34.2% reduction in elopements of residential adolescent patients.

III. Seclusion and Restraint Reduction

Summary: One of the greatest failures in the history of psychiatry has been the unnecessary use of coercive techniques in the treatment of patients. Anna Marsh founded the Retreat based on the philosophy of humane treatment, and principles of respect for each individual.

While the Retreat has embraced these principals for 170 years, we are now adopting the most progressive step forward in our history by applying what is called a trauma-informed recovery and resiliency model of treatment. Rather than taking a paternalistic approach to the people we serve in directing their treatment, we are seeking to partner with them in their recovery process, and engage them more fully in directing that process. This involves recognition of the role that a history of trauma plays in the lives of many of the people we serve, and doing everything possible to help them heal from and not to re-enact that experience. One outcome of the use of this approach is a dramatic reduction in the frequency of the incidence of seclusion or restraint. By utilizing earlier intervention and a variety of non-traditional de-escalation techniques that are developed with the individual being served, we are better able to prevent reaching that crisis point. While this is new for the Retreat, and for private psychiatric hospitals, it is by no means a new or unproven approach.

Intervention: To assist us in implementing this change we have undertaken a phased approach based on a national model developed by the National Technical Assistance Center and the National Association of State Mental Health Program Directors. Further we have sought consultation from national leaders in Treatment Recovery including Dr. Daniel Fisher, Director of the National Empowerment Center, who served as a member of the President’s New Freedom Commission on Mental Health.

An interdisciplinary Task Force for this Trauma Informed Recovery and Resiliency Model initiative (TIRRM) was formed in early 2005. A representative from Vermont Protection and Advocacy also participates on this Task Force. The TIRRM initiative is driven by Six Core Strategies from the training program. These strategies which include staff education and consumer involvement have guided the initiative.

To date we have implemented weekly seclusion and restraint “rounds” on each unit to analyze each instance of physical intervention. This time is also used to review treatment successes or “near misses.” Late in 2005, the Executive Staff began facilitating monthly roundtable discussions open to all staff. Additional continuing education classes that are TIRRM specific have been offered with over 120 staff attending.

A full day planning retreat was held in late 2005 to look at prioritizing next steps of the initiative. Of particular challenge has been developing consistent TIRRM principles while recognizing the various needs of each unit’s population. What is appropriate and indicated for children may not necessarily be appropriate for adolescents or adults.

Finally, such a culture change takes times and it is expected that full implementation including consumer involvement and all staff training will take an additional 1-2 more years. Early data, however, show some significant change in the Retreat’s rate of both seclusion and restraint.

Results: All but one of the 6 departments showed a reduction in both seclusion and restraint. Some of the most significant gains have been in the Child and Adolescent Inpatient Units at the hospital. The Child (patients under the age of 12) rate of seclusion was reduced by 69% from 2004 to 2005 and restraint by 18.4%. The Adolescent (patients who are 12 or over) inpatient rates of seclusion and restraint were reduced by 44.2% and 22.2% respectively for the same time period. The Adult Inpatient Co-Occurring Unit showed a 118.9% increase in their restraint rate and a 19.8% decrease in seclusion. The Adult Psychiatric Unit showed a 25.6% decrease in restraint and 17.2% decrease in seclusion. The Adolescent Residential programs showed a 58.4% reduction in restraint. Abigail Rockwell Adolescent Residential Program showed a 7.5% decrease in restraint.

For more information on quality improvement initiatives at Retreat Healthcare please contact:

Jennifer Rush, Manager of Performance Improvement
Retreat Healthcare
Anna Marsh Lane
Brattleboro, VT 05301
Phone: 802-258-4337
Email: or Jrush@retreathealthcare.org
Fax: 802-258-3756