Significant Achievement Awards

The Clinical Safety Project at Atascadero State Hospital takes an innovative approach to prevention of violence in psychiatric settings by framing the problem of violence as an occupational health hazard. The program uses findings derived from careful analysis of violent incidents to develop interventions for prevention that are tested in an ongoing process of improvement of care. Over the program's 11-year history, its original blend of clinical initiatives and risk management strategies has contributed to a marked reduction in the frequency of violent incidents, staff injuries from violence, and the use of seclusion and restraint at the hospital.

Atascadero State Hospital, a 1,000-bed maximum-security forensic psychiatric facility for men, is operated by the California State Department of Mental Health. The hospital has 1,600 employees. Located in the Central Coast region of California, midway between Los Angeles and San Francisco, the hospital serves the entire state of California. Its mission includes public protection and evaluation and treatment of involuntarily committed patients who are deemed dangerous to the community.

Patients treated at Atascadero State Hospital include mentally disordered offenders, mentally ill inmates referred from prisons, men found not guilty by reason of insanity, and offenders who have been found incompetent to stand trial. The patients have been committed by the California courts or the Department of Corrections or, for parolees, the Board of Prison Terms. The majority of the patients committed by the penal system have a diagnosis of schizophrenia, and most have committed violent criminal offenses such as murder, assault, armed robbery, and rape. In 1997 the hospital began housing, evaluating, and treating offenders committed under California's violent sexual predator law, and it is adding a 250-bed facility to treat this new category of patients who are committed by the mental health system. The average length of stay ranges from 63 days for offenders who have been found incompetent to stand trial to 734 for the violent sexual predator population.

The Clinical Safety Project was organized in 1988 by Harold Carmel, M.D., and Melvin E. Hunter, J.D., M.P.A. Currently fully funded by Atascadero State Hospital, the project has in the past received financial support through grants from the Health and Safety Commission of the California Department of Industrial Relations and supplemental funding from the Health and Safety Office of the California Department of Mental Health.

Challenging the prevailing notion that violence is an expected part of the job in psychiatric settings, the project is an expression of the hospital's goal of fostering a norm of nonviolence. Keeping this goal in the forefront has allowed the hospital to overcome the typical social and psychological barriers to violence prevention such as institutional denial, reliance on situational crisis management to deal with violence, and the tendency to blame the victim.

Over the past ten years, the proportion of violent offenders in the hospital population has increased to more than 90 percent. However, the efforts of the Clinical Safety Project have contributed to significantly reducing staff injuries by 67 percent, from 161 per year in 1987 to 53 per year in 1998.

The direction of the project's ongoing violence prevention activities has been shaped by analysis of data gathered from a hospitalwide survey of staff members' experiences, beliefs, and opinions about violence by patients. Additional data come from the project's ongoing assault investigation program, which is adapted from traditional strategies used in accident investigation in the occupational health field and from root-cause analysis.

Patients are involved in violence prevention activities through the violence abatement committee of the hospital's patient government program and through the patient-staff health, safety, and violence prevention committee. These committees involve patients in several ongoing initiatives and provide regular access to patients' perspectives on what provokes violence and how to solve problems of violence.

Ongoing review of weapon use patterns has resulted in the modification or elimination of high-risk items that had frequently been used as weapons. The frequency of weapon attacks has been reduced by 66 percent from a high of 72 in 1991 to 29 in 1998. The three items most frequently involved in violent incidents—pens and pencils, silverware, and toothbrushes—have been eliminated from use as weapons.

A current initiative is to reduce the use of chairs as weapons. A committee was formed to analyze data on attacks using chairs, and light-weight chairs have been removed from areas used by patients. A system of monitoring furniture purchases has been established, and a cost-benefit analysis is under way to examine the usefulness of replacing the chairs in the patients' dining rooms with fixed stools.

Violence at mealtimes, a high-frequency occurrence, was targeted and reduced through staff-patient collaboration and the application of continuous quality improvement techniques. As a result of strategic changes in mealtime policy and procedures, violent events in the patient dining rooms have been reduced by 60 percent, and 70 nursing staff hours per day have been conserved and reallocated.

The project developed the prevention-at-a-glance violence profile, a document that provides staff with easy access to information on the patient's assault pattern, weapon use history, victim pattern, antecedents to assault, and history of effective and noneffective interventions. Critical-incident debriefing is available on request for staff involved in a violent incident.

In 1993 the hospital initiated augmented behavioral treatment programming for habitually violent patients. Staff used creative adaptations of operant and classical conditioning techniques to successfully eliminate violence among 25 habitually violent patients, and the patients were discharged to less restrictive settings. Besides improving the patients' quality of life, the behavioral treatment techniques empowered staff by instilling hope and dispelling the notion that some patients are basically treatment refractory. The expansion of augmented behavioral treatment planning to psychology services throughout the hospital is currently being investigated.

Other current projects include a pilot study to determine the effectiveness of protective gear in reducing injuries to staff members who are involved in containing violent patients. In addition, a study of trends and patterns of staff-patient boundary violations and their relationship to security risks and efforts to enhance the working alliance between clinical staff and hospital peace officers are under way.

With the assistance of the Clinical Safety Project, hospital staff recently designed a training program to teach staff members verbal and physical self-defense techniques. The program's effects on participants' injuries, time lost, self-efficacy, and retention of skills over time were tested in a rigorous intragroup control design involving 366 staff members. The evaluation showed statistically significant results on several measures of self-efficacy as well as promising results suggesting reduced injuries and time lost and increased retention of trainees.

The Clinical Safety Project is staffed by two registered nurses and a psychologist. Together they gather data on violence and injuries in the hospital, work with staff and patients on various violence prevention initiatives, and serve as internal consultants to hospital management. Colleen Carney Love, R.N., D.N.Sc., director of the project, oversees its day-to-day operation, coordinates the hospital's critical-incident debriefing program, and is active on several hospital committees. Kurt Haag, R.N., the violence prevention coordinator, conducts assault investigations of all events that result in staff or patient injury, sexual assault, or weapon use. He also coordinates the patient-staff health, safety, and violence prevention committee and serves as a member of various hospital committees and quality assurance teams. Psychologist Mark Becker, Ph.D., is allocated time to consult regularly with the project staff and provides training for and monitoring of the hospital's behavioral treatment programs. Melvin Hunter, J.D., now at the California Department of Mental Health headquarters, continues to consult regularly on current project initiatives.

Staff members' publications and presentations have brought both the problem of violence in psychiatric settings and the project's reproducible model for violence prevention to national attention. Staff regularly consult with psychiatric settings both nationally and internationally, and the project's standardized method for measuring staff injuries from inpatient violence has been adopted by numerous psychiatric hospitals.

The National Institute for Occupational Safety and Health cited the work of the Clinical Safety Project in its 1996 monograph on violence in the workplace. California's Occupation Safety and Health Administration referenced the project in its 1993 guidelines for security and safety of health care and community service workers. Maintaining Your Quality Edge, the quality improvement journal issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), featured the Clinical Safety Project as a model violence prevention program. In 1998 the project received the JCAHO's Ernest E. Codman Award for excellence in the use of performance measures to reduce inpatient violence and improve patient care.

The Comprehensive Pediatric Care Unit treats children and adolescents with severe and complicated medical and psychiatric illnesses. The ten-bed unit is located in the Lucile Salter Packard Children's Hospital at Stanford University in Palo Alto, California. Conceived 18 years ago as a psychosomatic service by child psychiatrists Hans Steiner and Charles Walton and adolescent medicine specialist Iris Litt, the unit continues to maintain this focus, and it has become the core of a continuum of care that includes partial hospitalization as well as intensive and standard outpatient services.

The unit is affiliated with the department of psychiatry and behavioral sciences and the department of pediatrics at Stanford University Medical School. Children and adolescents with problems amenable to treatment on the unit have diagnoses of anorexia nervosa, bulimia nervosa, somatoform disorders, and psychological factors affecting physical condition.

James Lock, Ph.D., M.D., a child psychiatrist who is the unit's medical director, and his colleagues have developed a medical rehabilitation model for helping children and adolescents recover from severe and disabling somatoform disorders and eating disorders that put them at risk for medical compromise, injury, and death. The unit is visited regularly by physicians and health programmers from other states and from countries around the world who wish to learn about an effective approach for treating young patients with such unremitting disorders.

Under the medical rehabilitation model, patients with somatoform disorders are gradually able to "give up" their symptoms in the context of what the patient experiences as a series of medical interventions. Patients are encouraged to explore the conscious elements of their experience of pain or disability in supportive therapy. As treatment progresses, they explore suppressed family-related anger and conflict that underlie the somatoform condition. Individual therapeutic activities are enhanced by participation in an active adolescent milieu that helps patients exercise more independent and autonomous functioning.

As patients progress in individual therapy, family therapy is undertaken with the goal of identifying and modifying impediments to the expression of anger and conflict that encourage the adolescent's passive dependence and somatic responses. In most cases, the family is unaware of the impediments, which include problems in the parental dyad, psychological and sometimes physical enmeshment, fear of sexual development, and fear of abandonment. These issues are addressed as family members observe improvement of the adolescent's symptoms, which serves to confront their denial and collusion with somatization.

The goal of this combination of therapies is to allow the adolescent to abandon the somatic presentation, but to do so in a way that lets the individual keep the presentation until it can realistically be given up. Because the medical rehabilitation model encourages small but consistent stepwise improvements, it is more difficult to regress once progress has been realized. The patient's changing clinical presentation is juxtaposed with the family's conceptualization of the illness and unconscious support of it, allowing for gradual acceptance of change.

The unit has recently reviewed outcomes from the somatization rehabilitation protocol in a report on a retrospective series of cases that examined changes in medical disability, medication, medical appliances used, psychiatric diagnoses, and family structures. After the underlying psychiatric illness was identified and treatment was initiated, patients experienced more than a 50 percent increase on the Global Assessment of Functioning scale, with a remarkable decrease in medical disability and use of inappropriate medications and appliances. Significant changes in patients' family structures were also noted.

The Comprehensive Pediatric Care Unit has developed strategies for meeting challenges presented by the changing health care environment. Many insurers have carved out mental health portions of benefits, and providers must deal with complicated reimbursement systems for patients with combined medical and psychiatric problems, particularly eating disorders. Physicians and nurses on the unit have created a model critical pathway for the treatment of adolescents with anorexia nervosa. The three-stage treatment pathway defines the optimal sequencing and timing of interventions by various professionals on the unit. Key elements include medical, psychiatric, nursing, nutritional, and educational needs of patients and their families, which are assessed as patients progress along the treatment path.

Clear criteria for movement from one treatment stage to the next are included. The pathway helps clinicians and managed care reviewers measure patients' progress. In addition, because the pathway integrates both medical and psychiatric aspects of treatment, payers use this tool to negotiate which areas of care they will cover. A case manager, who is a key member of the unit's treatment team, follows patients from referral through discharge and follow-up, which permits continual evaluation of the match between patient resources, clinical needs, and treatment resources and facilitates communication with payers.

In recent years the Comprehensive Pediatric Care Unit has developed an open milieu that is available to the rest of the hospital through the psychiatric consultation-liaison team. Clinicians may increase the intensity of psychiatric interventions for any child or adolescent with medical and psychiatric problems through use of the unit's skilled psychiatric nurses, group therapists and group program, and the behavioral milieu. The unit has seen its liaison function to the hospital grow, which has increased awareness and appreciation of child psychiatric services and has resulted in better service integration and improved care for children and adolescents with a variety of conditions. About one-third of patients on the unit have primary medical disorders that formerly would have been treated on general pediatric units.

The unit has established joint training of child psychiatric and pediatric residents through milieu-based learning, case-based learning, cross-disciplinary teaching teams, modeling by attending physicians, didactic presentations, and shared research. When pediatric residents rotate through the unit, they join psychiatric residents and faculty in evaluation and treatment sessions. Their participation gives them the opportunity to see firsthand how the mind and body interact with developmental needs in eating disorders and somatoform disorders. Child psychiatry residents participate in medical rounds and develop appreciation for the difficulties and needs of their pediatric colleagues in the mental health area. Rather than emphasizing board qualification as a goal of training, the unit focuses on collaboration between the two professions. The residents gain valuable experience in comanaging patients with complicated conditions.

The Comprehensive Pediatric Care Unit uses a variety of measures of program effectiveness to ensure the quality of services and improve outcomes. Outcomes measured from the eating disorders protocol include length of stay, cost, and clinical data such as rates of weight gain and medical stability, use of specific procedures, and occurrence of untoward events. Data indicate that in recent years patients with eating disorders are being admitted to the unit later in the course of their illness; they are more medically unstable and require more acute medical interventions.

The programmatic aspects of the unit's services are entirely funded by the Lucile Salter Packard Children's Hospital, which provides for nursing services and case management as well as medical direction and support. The Packard Foundation, Stanford University School of Medicine, and a variety of grants support academic activities not related to service provision. In addition to the medical director and case manager, the unit's staff consists of a program coordinator; a nursing director; one charge nurse and one or two floor nurses per shift; a milieu counselor for the day and evening shifts; three full-time teachers for primary, middle, and high school, who are supplied by the local school district; an art therapist trainee, who is a practicum student; a recreation therapist; and an intake coordinator.

Primary care physicians are playing an increasingly prominent role in delivering mental health care, but may be hampered in providing specialized treatment because of difficulty obtaining psychiatric consultation and access to mental health care for their patients. The Hamilton-Wentworth Health Service Organization Mental Health Program was set up in June 1994 to address these problems by bringing mental health counselors and psychiatric consultants into the offices of family physicians. This innovative model of collaboration has created a new kind of partnership between mental health and primary care providers, enabling patients to move readily from one provider to another according to need.

The program has successfully integrated mental health counselors and psychiatrists within the offices of 87 family physicians in 36 primary care practices, or health service organizations, serving 170,000 people in Hamilton-Wentworth, a community of 460,000 people in southern Ontario. The collaborative arrangement has improved communication between primary care and mental health care providers and enhanced primary care physicians' skills and comfort in handling their patients' mental health problems. The program has attracted the attention of community and health planners in Canada, the U.S., and other countries and has provided leadership in national initiatives to improve linkages between mental health and primary care services.

St. Joseph's Hospital, sponsor of the Hamilton-Wentworth Health Service Organization Mental Health Program, is a 550-bed general hospital with a comprehensive psychiatric program that includes a 33-bed inpatient service, two large outpatient clinics, specialty clinics, rehabilitation programs, and a regional emergency psychiatric service and outreach team. The program's total budget of about $2.2 million (Canadian) comes from the Alternative Payment Programs Branch of the Ontario Ministry of Health.

Each practice participating in the program is assigned up to two full-time-equivalent (FTE) counselor positions, depending on the size of the practice. The counselors are supported by a psychiatrist consultant who visits the practice once every few weeks. The program currently includes 24 FTE positions for counselors and employs 41 counselors, many of whom work part time. The work of the program's 2.3 FTE psychiatrist positions is shared by 14 individual psychiatrists.

The majority of the counselors are registered nurses or social workers with many years of experience in general counseling or outpatient psychiatry services. The counselors will see any patient or discuss any patient's case with the family physician if the physician feels that additional mental health expertise is required. The emphasis is on short-term intervention by the counselor, although some patients may receive longer-term services if necessary. Patients are seen by a counselor within two weeks of referral by the physician, but urgent cases can be seen immediately. The counselor advises the family physician about specific mental health interventions or community resources and assists in making referrals to those services.

The psychiatrist consultant will see any patient at the request of the family physician or the counselor and will provide limited follow-up care. Because the psychiatrist is on site at the physician's office, discussions with the physician about a patient's medication, medicolegal issues, or potential referrals may take place in brief "corridor contacts." The psychiatrist may discuss a case with the family physician before the physician sees a patient or may go over a management plan with the physician before the patient leaves. During the psychiatrist's next visit to the office, the patient's progress can be reassessed, and any problems that have arisen can be reviewed. The psychiatrist is also available by phone to discuss emergencies with the counselor or family physician. Informal case-based teaching or short structured educational presentations by the psychiatrist give the family physician an opportunity to learn about topics chosen for their relevance to the physician's practice.

The program's central management team includes Nick Kates, M.B.B.S., F.R.C.P.C., the part-time program director, and Anne-Marie Crustolo, R.N., M.S., the full-time program coordinator. A part-time evaluation coordinator, a database manager, a research assistant, and four support staff make up the rest of the team. The team is responsible for organizing the allocation and flow of program funds, recruiting counselors and psychiatrists, and evaluating program activities. The central team also provides additional resources to the practices participating in the program, including visits by geriatric and child psychiatrists, educational materials for providers and patients, educational and support groups for patients, educational workshops for primary care physicians on topics of their choosing, and a reference service.

The program monitors the quality of services and promotes continuing quality improvement through an evaluation procedure that includes analysis of activity reports of counselors and psychiatrists and satisfaction questionnaires completed by providers and patients, as well as visits to each health service organization. A database used for evaluation of the program's effectiveness includes demographic, treatment, and outcome data for every patient referred by the family physician to a counselor, psychiatrist, or outside agency for mental health care. The primary care physicians who are the clients of the program participate in every aspect of ongoing program development.

In 1997 the program received 4,007 referrals. Each FTE counselor receives about 170 new referrals a year, and an FTE psychiatrist sees 530 cases a year in consultation. Both of these figures are approximately three times the number of cases seen annually by counselors and psychiatrists in general outpatient clinics in the same region. A wide variety of clinical problems are referred to the counselors, and 95 percent of patients seen by the psychiatrists have at least one DSM-IV diagnosis. Since the program began, participating family physicians have referred more than nine times as many patients per year for mental health care as they did before the program started.

The Hamilton-Wentworth Health Service Organization Mental Health Program plays a key role in detecting common mental health problems at an early stage. Because patients appear to prefer to receive mental health services in their family physician's office rather than a mental health clinic, the program has allowed assessment of a large number of individuals with psychiatric disorders who might not otherwise receive care. It has created greater awareness of the role of the family physician as a provider of mental health care and the need for collaboration between primary care and mental health care providers, and it has spurred greater involvement of primary care physicians in local mental health care planning.

The program has become a valued training site, in particular by providing psychiatric residents with the opportunity to work collaboratively with primary care physicians. In conjunction with the departments of psychiatry and family medicine at McMaster University in Hamilton, the program has sponsored several research projects on ways of integrating mental health and primary care services.

Within Canada a number of communities are developing and evaluating similar programs, and representatives of two large U.S. health maintenance organizations have looked at implementing the program model. Representatives from the Ministries of Health of Holland and Israel have also visited the program to learn from its approach, and research collaborations have been established with programs in Melbourne and Newcastle, Australia.

At a national level, staff of the Hamilton-Wentworth program were instrumental in persuading the Canadian Psychiatric Association and College of Family Physicians of Canada to initiate a program to strengthen collaboration between psychiatrists and family physicians. At both the provincial and the national levels, program staff have participated in planning for primary care reform, in which the integration of specialized mental health services within primary care is envisioned as playing an important part.