Introduction and Alignment

This workshop focuses on clinical practice issues involving consumer/client safety that have the potential to negatively impact client and organizational outcomes. Understanding the interaction of biopsychosocial aspects that the client brings into the therapeutic relationship and staff and organizational influences can provide insights to guide effective care planning and advocacy activities. 

Upon completion of this assignment, you should be able to:

  • Compare and contrast characteristics of the client, healthcare provider, and healthcare organization that contribute to positive and negative client safety outcomes.
  • Discuss strategies to minimize healthcare-associated risk or harm to the client (consumer) that incorporates client preferences and strengths, and healthcare provider factors.
  • Formulate a plan to maintain a practice environment that emphasizes client safety in diverse mental healthcare settings.



  1. Prepare a 1-2 page paper that reflects the readings for this week.
  2. The paper should include the following:
    1. Characteristics of the provider and organization that lead to both positive and negative patient safety outcomes.
    2. Develop a plan/discuss strategies that will allow for positive interactions with patients and provides patient safety in diverse mental health care settings.
  3. When you’ve completed your paper save a copy for yourself and submit a copy to your instructor using the Dropbox by the end of the workshop.

Select here to access the Dropbox.

Assessment Criteria



Question answered comprehensively

  • Characteristics  – both positive and negative addressed (20 pts)
  • Plan/strategies discussed for safe patient care (20 pts) 


Paper APA formatted, references and citations in correct APA format


Writing style/punctuation/grammar, minimum length of 3 pages


Total Points


The New York State Office of Mental Health Positive
Alternatives to Restraint and Seclusion (PARS) Project
Jennifer P. Wisdom, Ph.D., M.P.H., David Wenger, M.A., L.M.S.W., David Robertson, R.N., Jayne Van Bramer, M.A.,
Lloyd I. Sederer, M.D.

Objective: The Positive Alternatives to Restraint and Seclusion
(PARS) project of the New York State Office of Mental Health
(OMH) was designed to build capacity to use alternatives to
restraint and seclusion within state-operated and licensed in-
patient and residential treatment programs serving children
with severe emotional disturbances. Its long-term goal was to
eliminate the use of these restrictive interventions throughout
the state’s mental health system of care by creating coercion-
and violence-free treatment environments governed by a phi-
losophy of recovery, resiliency, and wellness.

Methods: The central feature of the PARS project was training
in, implementation of, and engagement with the Six Core
Strategies to Reduce the Use of Seclusion and Restraint,
a comprehensive approach developed by the National Asso-
ciation of State Mental Health Program Directors. This report
provides an overview of the project, results from January 2007
through December 2011, and lessons learned by OMH.

Results: The three participating mental health treatment
facilities demonstrated significant decreases in restraint
and seclusion episodes per 1,000 client-days. Each identi-
fied specific activities that contributed to success, including
ways to facilitate open, respectful two-way communication
between management and staff and between staff and
youths and greater involvement of youths in program de-
cision making.

Conclusions: All three facilities continued to implement
key components of the PARS initiative after termination
of grant-funded activities, and OMH initiated multiple ac-
tivities to disseminate lessons learned during the project to
all inpatient and residential treatment programs throughout
the state mental health system.

Psychiatric Services 2015; 66:851–856; doi: 10.1176/

For over 20 years, mental health providers have questioned
the efficacy of restraint and seclusion as treatment inter-
ventions for maintaining safety in inpatient and residential
psychiatric programs (1–3). The Joint Commission has en-
couraged the reduction of the use of restraint and seclusion
(4). Consumer advocacy groups (1,5,6), public reports (7,8),
and the National Association of State Mental Health Pro-
gram Directors (NASMHPD) (9) have recommended the
elimination of restraint and seclusion and have voiced con-
cerns about their deleterious effects.

The New York State Office of Mental Health (OMH) over-
sees a mental health system serving approximately 700,000
persons annually. Since the 1990s, OMH has taken a pro-
active approach to reduce the use of restraint and seclusion
through data analysis, policy and cli

National Association of State Mental Health Program Directors

66 Canal Center Plaza, Suite 302, Alexandria, VA


Six Core Strategies for Reducing

Seclusion and Restraint Use©

Note: This document contains the following items: (1) a Snapshot of the Six Core

Strategies ; (2) a Planning Tool; and (3) an Example of Debriefing Policies and


A Snapshot of Six Core Strategies for the Reduction of S/R
(Revised 11/20/06 by Kevin Ann Huckshorn)

These strategies were developed through extensive literature reviews (available upon

request from [email protected]) and dialogues with experts who have

successfully reduced the use of S/R in a variety of mental health settings for children and

adults across the United States and internationally.

1. Leadership toward Organizational Change

This first strategy is considered core to reducing the use of seclusion and restraint (S/R)

through the consistent and continuous involvement of senior facility leadership (most

specifically the CEO, CNO, and COO). Leadership strategies to be implemented include

defining and articulating a vision, values and philosophy that expects S/R reduction;

developing and implementing a targeted facility or unit based performance improvement

action plan (similar to a facility “treatment plan”); and holding people accountable to that

plan. This intervention includes the elevation of oversight of every S/R event by senior

management that includes the daily involvement of the CEO or COO in all S/R events

(24/7) in order to investigate causality (antecedents), review and revise facility policy and

procedures that may instigate conflicts, monitor and improve workforce development

issues and involve administration with direct care staff in this important work. The

action plan developed needs to be based on a public health prevention approach and

follow the principles of continuous quality improvement. The use of a multi-disciplinary

performance improvement team or taskforce is recommended.

This is a mandatory core intervention.

2. Use of Data To Inform Practice

This core strategy suggests that successfully reducing the use of S/R requires the

collection and use of data by facilities at the individual unit level. This strategy includes

the collection of data to identify the facility/units’ S/R use baseline; the continuous

Just Culture 1

PPoossiittiioonn SSttaatteemmeenntt

Just Culture

Effective Date: January 28, 2010

Status: New Position Statement

Originated By: Congress on Nursing Practice and Economics

Adopted By: ANA Board of Directors

Related Past Action: 1. ANA Position Statement (2007): Safety
Issues Related to Tubing and Catheter

2. ANA Position Statement (2006): Assuring
Patient Safety: The Employers’ Role in
Promoting Healthy Nursing Work Hours for
Registered Nurses in All Roles and Settings

3. ANA Position Statement (2006): Assuring
Patient Safety: Registered Nurses’
Responsibility in All Roles and Settings to
Guard Against Working When Fatigued

4. 2000 ANA House of Delegates Report
Adopted: Building Safe Health Care Systems
for Informed Patients

Purpose: The purpose of this position paper is to interpret the Just Culture concept and

its application for nursing and health care in a variety of settings.

Statement of ANA Position: The American Nurses Association (ANA) supports the
Just Culture concept and its use in health care to improve patient safety. The ANA

supports the collaboration of state boards of nursing, professional nursing associations,

hospital associations, patient safety centers and individual health care organizations in

developing regional and state-wide Just Culture initiatives.

Just Culture 2

History/Previous Position Statements: This is the first ANA position on the Just
Culture concept. In regard to patient safety, ANA has published the positions Safety

Issues Related to Tubing and Catheter Misconnections (2007), Assuring Patient Safety:

The Employers’ Role In Promoting Healthy Nursing Work Hours for Registered Nurses

in All Roles and Settings (2006), and Assuring Patient Safety: Registered Nurses’

Responsibility in All Roles and Settings to Guard Against Working When Fatigued

(2006). ANA through its National Center for Nursing Quality has long been working with

patient safety initiatives, including the National Database for Nursing Quality Indicators,

Handle With Care Campaign, Safe Staffing Saves Lives Campaign, and its work with

the National Quality Forum, the Joint Commission, and the National Priorities

Partnership. The 2000 ANA House of Delegates adopted the report “Building Safe

Health Care Systems for Informed Patients”.


CAMBHC, January 2018 SSIS – 1

Safety Systems for Individuals
Served (SSIS)

* The Institute of Medicine defines quality as the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current
professional knowledge. Source:Source: Committee to Design a Strategy for Quality Review and Assurance in
Medicare, Institute of Medicine. Medicare: A Strategy for Quality Assurance, vol. 1. Lohr KN, ed.
Washington, DC: The National Academies Press, 1990.

The quality of care and the safety of individuals served are core values of The Joint
Commission accreditation process. This is a commitment The Joint Commission has
made to individuals served, patients, and families, as well as behavioral health care
practitioners, staff, and organization leaders. This chapter exemplifies that commitment.

The intent of this “Safety Systems for Individuals Served” (SSIS) chapter is to provide
behavioral health care organizations with a proactive approach to designing or
redesigning services that aim to improve the quality of care and safety for the individual,
an approach that aligns with the Joint Commission’s mission and its standards.

The Joint Commission partners with accredited behavioral health care organizations to
improve behavioral health care delivery to protect individuals. Therefore, this chapter is
focused on the following two guiding principles:
1. Assisting behavioral health care organizations with advancing knowledge, skills, and

competence of staff and individuals served by recommending methods that will
improve quality and safety processes.

2. Encouraging and recommending proactive quality and safety methods for the
individuals served that will increase accountability, trust, and knowledge while
reducing the impact of fear and blame.

Quality* and safety are inextricably linked. Quality behavioral health care is the degree
to which its processes and results meet or exceed the needs and desires of the individuals
it serves.1,2 Those needs and desires include safety.

To ensure quality and safety in the behavioral health care setting, components of the
management system should include the following:

CAMBHC, January 2018SSIS – 2

Comprehensive Accreditation Manual for Behavioral Health Care

Ensuring reliable processes
Decreasing variation and defects (waste)
Focusing on achieving better outcomes
Using evidence to ensure that a service is satisfactory

Safety of the individual emerges as a central aim of quality. Safety is what individuals
served, patients, families, staff, and the public expect from Joint Commission–accredited
organizations. While safety events may not be completely eliminated, harm to
individuals can be reduced, and the goal is always zero harm. This chapter describes and

Promoting Alternatives to the Use of Seclusion and Restraint

Issue Brief #4 Making the Business Case
M A R C H 2 0 1 0

About the Series:
Promoting Alternatives to the Use
of Seclusion and Restraint
The Substance Abuse and Mental
Health Services Administration
(SAMHSA) has developed, in
collaboration with partners at the
Federal, State, and local levels,
consumers, and national advocacy
organizations, a series of issue
briefs on the use of seclusion and
restraint. The purpose of this
series is to provide information on
the use of seclusion and restraint
throughout the country, efforts to
reduce their use, and their impact
at the individual/family, program,
and system levels. For an overview
of the background and history of
the initiative to reduce the use of
seclusion and restraints, please refer
to the first issue brief in the series,
entitled Promoting Alternatives to
the Use of Seclusion and Restraint—
Issue Brief #1: A National Strategy
to Prevent Seclusion and Restraint in
Behavioral Health Services, which
is available at http://www.samhsa.

Seclusion1 and restraint2 are coercive, high-risk containment procedures that
contribute to the problem of violence against consumers and staff members
in behavioral health care settings. In fact, an estimated 50 to 150 individuals
die each year as a result of seclusion and restraint practices in facilities, and
countless others are injured or traumatized (Weiss et al., 1998). These practices
are detrimental to the recovery of persons with mental illnesses and adversely
affect the quality of care and the safety of all involved (di Martino, 2003;
Huckshorn & LeBel, 2009). Equally important, yet often less recognized, is
the multilevel economic burden that is inherent in their use (Flood, Bowers, &
Parkin, 2008; LeBel & Goldstein, 2005).

Based on clinical best practice, inpatient and residential mental health facilities
in the United States and other countries have implemented initiatives to reduce
seclusion and restraint use (National Association of State Mental Health
Program Directors [NASMHPD], 2009; Nunno, Day, & Bullard, 2008). Several
programs that have reduced their use have reported fiscal benefits (LeBel &
Goldstein, 2005; Murphy & Bennington-Davis, 2005; Sanders, 2009). These
facilities have changed their organizational cultures and practices and report that
benefits and savings exceed the costs associated with the use of seclusion and
restraint (LeBel, 2009). Given the potential savings, health care organizations
should reconsider reducing seclusion and restraint from a “best business
practice” imperative.

This issue brief, the fourth in a series, provides a summary of a recently
developed white paper,The Business Case for Preventing and Reducing
Restraint and Seclusion Use, authored by J