Form Attachments A-C Attachments A-C Attachments A-C

ATTACHMENT A

Facility/Program Characteristics Inventory (FPCI)

Form Approved

OMB NO: 0930-0271

Exp. Date 11/30/08

See burden statement on last page

Facility ID: ____________

Name of Facility/Program: ____________________________State: _________

Contact Person Completing Inventory: ________________________________________

Title: ________________________________________

Phone ________________________________________

Date Completed: ________________________________________

Section I: Facility/Program Characteristics

1. What is your facility/program type? (Check one)

□ Free Standing Psychiatric Hospital

□ Residential Program

□ Other: ___________________

2. What is the ownership of your facility/program? (Check one)

□ State

□ County

□ Private: Licensed by the State Mental Health Authority

□ Private: Contract with the State Mental Health Authority

□ Other: ___________________

3. What is the total number of operational beds within your facility/program?

__________ Beds

4. What geographic jurisdiction does your facility/program serve? (Check one)

□ Entire state

□ Certain geographic areas (e.g., counties or catchment areas)

□ Other

5. What client population(s) does your facility/program serve? (Check all that apply)

□ Children (4-12 years old)

□ Adolescents (13-17 years old)

□ Young Adults (18–20 years old)

□ Adults (21-64 years old)

□ Elderly (65 years and up)

6. By which of the following organizations is your facility/program accredited or certified? (Check all that apply)

□ Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

□ Center for Medicare & Medicaid Services (CMS)

□ Commission on Accreditation of Rehabilitation Facilities (CARF)

□ Council on Accreditation (COA)

□ Other: __________________________________

□ None

Section II: Characteristics of Persons Served

For each question below, please include all persons served during the most recent year for which data are available and indicate the time frame used here (e.g., August 2006 – August 2007, January – December 2006)

Time Frame: __________ through ___________

(month/year) (month/year)

7. Please provide the following totals:

Number of admissions _____

Number of discharges _____

Average daily census _____

Total served _____

Admissions: Should include all clients who remain overnight.

Discharges: When a client is removed from the inpatient census.

Section III: Staffing Patterns

Full-time Equivalent Staff: Add together the total hours for all staff in a week (include regular leave hours) then divide by the number of hours a regular full-time employee works in a week (typically 35-40).

Direct Clinical Care Staff: Paraprofessional and professional clinically trained staff that provide medical care and treatment services. Includes security staff that are used to transport clients and/or intervene directly with clients if there is a problem. Includes unpaid staff (volunteers and students).

Indirect Care Staff: Ancillary staff that provide indirect care and operational support such as food service, housekeeping, security, etc.

Administrative Staff: Management, finance officers, human resources, information technology.

8. What is the total number of full-time equivalent (FTE) staff during a typical work week during the most recent year? (Do not include temporary employees)

Direct Clinical Care Staff _________

Indirect Care Staff _________

Administrative Staff _________

9. What is the total number of temporary clinical staff employed (such as per diem staff, contracted staff, etc.) at your facility/program during a typical work week during the most recent year? _________

10. For each of the following staff types, what is the number of FTE clinical staff that provided direct care to patients in the most recent year during a typical work week?

Type of Staff	Number providing direct care in typical week	Number of frozen positions	Number of positions actively trying to fill
Psychiatrists
Other Physicians
Psychologists (Ph.D., Psy.D., Ed.D.)
Registered Nurse Practitioners/Physician Assistants (ARNP/APRN/PA)
Registered Nurses
Licensed Vocational Nurses/LPNs
Counselors/Therapists/Social Workers/Psychologists (Masters level)*
Counselors/Therapists/Social Workers (Bachelors level)*
Discharge Planning Social Workers
Substance Abuse Counselors
Psychosocial Rehabilitation Counselors
Activity Therapists
Psychiatric Technicians or Nurses Aides
Child Care Worker/Youth Counselors
Paid consumers, family members and/or advocates
Unpaid consumers, family members and/or advocates
Security staff with direct client contact
Unpaid (other volunteers and students)
Human Rights Officers
Other Clinical Staff

* Excluding discharge planning social workers

Section IV: Unit Data

Note: add extra lines for additional units as necessary

Definitions and Variable Codes for the FPCI Section IV

Variable	Type	Description	Possible Answer Choices
Specialty	Numeric	Specialty of unit – the main focus of the unit's programming.      Geropsychiatry – unit focuses on the diagnosis and treatment of psychiatric or behavior disorders in aging clients who have disturbances of brain structure or function.      Alcohol and drug treatment (for persons with other mental illness) – unit focuses on treating clients with co-occurring alcohol/other drug use disorders and mental illness.      Alcohol and drug treatment only (for persons without other mental illness) – unit focuses on treating clients with an alcohol or drug use disorder only (without another mental illness); if a mental illness is present, it is not the focus of treatment.      Forensic – unit focuses on clients who 1) are not legally responsible for their crime by reason of insanity, 2) are legally considered to be incompetent or are being for evaluated for competency, or 3) who face criminal charges or have been convicted of a crime.	1. General 2. Geropsychiatry 3. Alcohol and drug treatment (for persons with other mental illness) 4. Alcohol and drug treatment only (for persons without other mental illness or a mental illness that is not the focus of treatment) 5. Forensic 6. Other (please specify)
Specialty_Other	Text	Specialty (other)	If selected "6 - Other" from above, please specify….
Policy	Numeric	Unit-specific seclusion or restraint policy	0 - Neither seclusion nor restraint are allowed 1 - Only seclusion is allowed 2 - Only restraint is allowed 3 - Both seclusion and restraint are allowed

Variable	Type	Description	Possible Answer Choices
Locked	Numeric	Indicates whether the unit is usually locked. "Locked" means that patients are prevented from leaving the unit without staff assistance by means of a locked door.	0 - Not locked (less than or equal to 12 hours a day) 1 - Locked (more than 12 hours a day)
Gender	Numeric	Gender distribution within the unit	1 - Female only
			2 - Male only
			3 - Male and female

Public reporting burden for this collection of information is estimated to average 2 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, One Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0271.

Definitions

Seclusion:
	The involuntary confinement of a client alone in a room or an area where the client is physically prevented from leaving which includes but is not limited to: manually or electronically locked doors; one-way doors (i.e., doors constructed so that when closed and unlocked they may not be opened from the inside); the presence of staff proximal to the room preventing exit or the threat of consequences if the client leaves the room. Each occurrence of a seclusion must be reported as a unique event. In some cases, clients may provide “permission” to be secluded either at the time of seclusion or at some previous time. The seclusion event must be reported even if such “permission” has been obtained. It is understood that there are other forms of behavior management systems such as quiet rooms, voluntary time outs and room restrictions. These types of events should not be reported if the client is free to leave the room without consequence. Other exclusions include: quarantine due to infectious disease; restraints while not in seclusion: That is, a seclusion event should not be reported if an individual is prevented from leaving a room secondary to being restrained. In this case, a restraint event should be reported.
Restraint:
	Any manual or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a client to move his or her arms, legs, body, or head freely. Each occurrence of a restraint must be reported as a unique event. In some cases, clients may provide “permission” to be restrained either at the time restraints are applied or at some previous time. The restraint event must be reported even if such “permission” has been obtained. The following are valid restraint subtypes: Mechanical, Non-ambulatory Restraint: Mechanical restraint of an individual in which ambulation is not possible, examples include 4-point restraints and body nets Mechanical, Ambulatory Restraint: Mechanical restraint of an individual in which ambulation is possible. Examples include wrist-to-waist restraints. Restraints used for security purposes during transport of a client out of the building or off the premises to receive therapeutic services or to participate in activities directly related to the client’s illness (such as court proceedings or appointments necessary to acquire human services) are not to be reported. Also, restraint devices employed for medical purposes (Geri-chair, posey, etc..) or as personal protective devices (helmets, bed rails, etc..) should not be reported. In some cases, devices (e.g. mittens) may be employed for either medical or behavioral purposes. Use of such devices should be reported when the restraining device restricts the movement of the whole or a portion of a client’s body for the purpose of preventing intentional harm. Use of such devices should be considered for medical purposes and should not be reported when the device is used as an assistive or adaptive device to restrict the movement of the whole or a portion of a client’s body for the purpose of preventing unintentional harm or used for promoting or maintaining normative body functions. Manual Restraint: A method in which the individual is restrained by the physical force of facility staff. Exclusions include: restraints used for security purposes during transport of a client out of the building or off the premises to receive therapeutic services or to participate in activities directly related to the client’s illness (such as court proceedings or appointments necessary to acquire human services); devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets; other methods that involve the physical holding of a client for the purpose of conducting routine physical examinations or tests; other methods that protect a client from falling out of bed; other methods that permit the client to participate in activities without the risk of physical harm (does not include a physical escort); seclusion while not in restraints. Documentation of the reason for the use of the restraint must clearly indicate whether these exclusions apply.

ATTACHMENT B

Inventory of Seclusion and Restraint Reduction Interventions

ISRRI TABLE OF CONTENTS

COVER SHEET 1

WORKSHEET 1: LEADERSHIP 2

L.1. Leadership: State Policy 2

L.2. Leadership: Facility Policy 3

L.3. Leadership: Facility Action Plan 4

L.4A. Leadership: Recovery Oriented Care 5

L.4B. Leadership: Trauma-Informed Care 7

L.5. Leadership: CEO 8

L.6. Leadership: Medical Director 9

L.7. Leadership: Non-Coercive Environment 10

L.8. Leadership: “Kickoff” Celebration 11

L.9. Leadership: Staff Recognition 12

WORKSHEET 2: DEBRIEFING 13

D.1. Debriefing: Immediate Post-Event 13

D.2. Debriefing: Formal Review 14

WORKSHEET 3: USE OF DATA 16

U.1. Use of Data: Data Collected 16

U.2. Use of Data: Goal Setting 18

WORKSHEET 4: WORKFORCE DEVELOPMENT 19

W.1. Workforce Development: Structure 19

W.2. Workforce Development: Training 20

W.3. Workforce Development: Supervision and Performance Review 22

W.4. Workforce Development: Staff Empowerment 23

WORKSHEET 5: TOOLS FOR REDUCTION

T.1. Tools for Reduction: Implementation 24

T.2. Tools for Reduction: Emergency Intervention 24

T.3. Tools for Reduction: Environment 25

WORKSHEET 6: INCLUSION 26

I.1. Inclusion: Consumer Roles 27

I.2. Inclusion: Family Roles 27

I.3. Inclusion: Advocate Roles 29

WORKSHEET 7: OVERSIGHT/WITNESSING 30

O.1. Oversight/Witnessing: Elevating Oversight 30

Form Approved

OMB NO: 0930-0271

Exp. Date 11/30/08

See burden statement on last page

Inventory of Seclusion and Restraint Reduction Interventions (ISRRI)

Worksheets

Cover Sheet

Description: Start-up date refers to the beginning date of the facility’s implementation of the initiative to reduce the use of Seclusion and Restraint. Date Completed refers to the date when the ISRRI was completed. If a respondent is modifying the ISRRI and/or correcting errors, “Date Completed” does not need to be changed because the submission date, the date when the respondent clicks the Submit button, is saved.

Facility ID:

Name of Facility/Program:

State:

Start-up Date (mm/dd/yyyy): ______/______/________

Reviewer Name:

Title/Position:

Role:

• External Evaluator

• Internal Evaluator (e.g., QI)

• Staff external to the facility S/R program

• Staff part of the facility S/R program

• NTAC Consultant

• Other Consultant

• Other (specify):__________________

Phone: ( )___ -_____ ___

Date Completed (mm/dd/yyyy): ______/______/________

LEADERSHIP 1: STATE POLICY
State DMH Office or relevant state level office directs or supports the reduction of seclusion and restraint in all state run and provider facilities. Description: A developed and communicated statewide mission statement, vision statement, and/or action plan that clearly articulates the goal of the reduction of seclusion, restraint, or other coercive measures; the development of systems of care that are trauma-informed; and a commitment to the principles of recovery including consumer partnerships, assuring safe environments for staff and consumers, peer services and supports, the provision of hope through individualized treatment and full participation in own care; and the promulgation of rules directing or regulating the use of seclusion and restraint that restrict use for safety only.
L.1	Leadership: State Policy
The state has written policies and procedures that include (check if yes):
q	1. A Philosophy Statement (vision statement, action plan, etc.) that specifically identifies goal of reducing seclusion/restraint
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	2. A policy providing for a program of trauma-informed care
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	3. A policy providing for consumer partnerships, peer services and supports
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	4. A policy for ensuring a safe environment for consumers (e.g., a violence prevention program)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	5. A policy providing for a comprehensive individualized treatment planning process that includes the full participation of consumers in their own care (if the consumer is a child/adolescent, this treatment planning process includes parents or guardians)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	6. A policy restricting the use of S/R to emergencies that reach the level of imminent risk of harm to self, staff or other consumers only
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
Comment:

Worksheet 1: Leadership

LEADERSHIP 2: FACILITY POLICY
CEO/Administrator participation is active, routine, observable. Description: The CEO/Administrator directs the S/R reduction initiative by: 1) Participating in S/R Reduction Team meetings; 2) Being perceived by staff as playing a central role at a “kickoff” event for the rollout of the initiative; and 3) Reviewing progress by means of a standing agenda item for management meetings.
L.2	Leadership: Facility Policy
The facility has written policies and procedures that include (check if yes):
q	1. A policy identifying S/R reduction as a goal (may be a position or policy statement, vision statement, or action plan)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	2. A policy supporting the adoption of principles of recovery and/or resiliency
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	3. A policy supporting a trauma-informed system of care (e.g., including universal trauma assessment upon admission, use of crisis/safety plans, staff training in trauma, availability of Employee Assistance Programs)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	4. A policy providing for the creation of violence- and coercion-free environments
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	5. A policy providing for safe environments for staff through a violence prevention approach
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	6. A policy providing for safe environments for consumers through a violence prevention approach
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
Comment:

LEADERSHIP 3: FACILITY ACTION PLAN
Description: 1) Stand-alone plan for reduction, with specific goals, objectives and action steps, assigned responsibility and due dates. 2) Process for regular review and revision. 3) Indication of senior executive oversight and review.
L.3		Leadership: Facility Action Plan
The facility has (check if yes):
q	1. A stand-alone action plan for reduction that includes (check all that apply):
	q Policy statement			q Recovery oriented programming		q Trauma-informed care principles
	q Violence- and coercion-free programming			q Violence prevention		q Goals, objectives
	q S/R Reduction Team
Source of information:
Start Date: / / or:			Date Range:		q Within the past 6 months		Reason for Change:
					q 6-12 months ago
End Date: / /					q More than 1 year ago
q	2. A process for regular review and revision of the action plan
Source of information:
Start Date: / / or:			Date Range:		q Within the past 6 months		Reason for Change:
					q 6-12 months ago
End Date: / /					q More than 1 year ago
q	3. Number of times S/R reduction team has met to date: _____ (do not check the box at left if no meetings were held)
Source of information:
Start Date: / / or:			Date Range:		q Within the past 6 months		Reason for Change:
					q 6-12 months ago
End Date: / /					q More than 1 year ago
q	4. Indications of senior executive oversight and review of the action plan
Source of information:
Start Date: / / or:			Date Range:		q Within the past 6 months		Reason for Change:
					q 6-12 months ago
End Date: / /					q More than 1 year ago
Comment:

LEADERSHIP 4: LEADERSHIP FOR RECOVERY ORIENTED AND TRAUMA-INFORMED CARE
Description: A program that seeks to prevent environmental or staff related triggers for conflict and that follows the principles of a system of care that is Recovery Oriented and Trauma-Informed.
L.4A		Leadership: Recovery Oriented Care
The program documentation includes (check if yes):
q	1. Consumer inclusion in their plan of care, consisting of the following (check all that apply, check box on left if any are present):
	q Training on consumer roles				q Training on how to participate in their plan of care
	q Pre-treatment planning meeting with consumer				q Consumer signature in progress notes
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Informed consent, consisting of the following (check all that apply, check box on left if any are present):
	q Communication of risks, benefits, side effects, adverse effects, alternative treatments (all included)				q Communication of risks, benefits, side effects, adverse effects, alternative treatments (all included)
	q Presented in user-friendly, easy to read (non-technical) language				q Presented in user-friendly, easy to read (non-technical) language
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Allowance for choices (e.g., Activities of Daily Living and treatment activities)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Avoidance of uniform rules and regulations that do not respect individual needs and preferences (e.g., enforced wake-up, eating or visiting times, mandatory participation in treatment activities)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Predominant use of person first language by staff (e.g., using “persons with psychiatric disabilities” instead of “the mentally ill”)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	6. Predominant use of common courtesies in staff-to-consumer communication
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	7. Clear expectation that all people can self-manage illness (e.g., understand illness, monitor symptoms, avoid crises, understand medications and how to manage side effects)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months		Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

LEADERSHIP 4: LEADERSHIP FOR RECOVERY ORIENTED AND TRAUMA-INFORMED CARE
Description: A program that seeks to prevent environmental or staff related triggers for conflict and that follows the principles of a system of care that is Recovery Oriented and Trauma-Informed.
L.4B		Leadership: Trauma-Informed Care
The program includes (check if yes):
q	1. Training for staff in the prevalence and incidence of traumatic experiences in persons served
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Use of universal trauma assessment upon admission
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Integration of trauma assessment findings in treatment plans
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Efforts to encourage staff attitudes, interventions, and practices that promote empowerment and inclusion and that do not re-traumatize
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Access to trauma specific services when needed for persons who demonstrate trauma related symptoms
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	6. Access to expert consultation when needed for persons who demonstrate trauma related symptoms
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

LEADERSHIP 5: CEO
CEO/Administrator participation is active, routine, observable. Description: The CEO/Administrator directs the S/R reduction initiative by: 1) Participating in S/R Reduction Team meetings; 2) Being perceived by staff as playing a central role at a “kickoff” event for the rollout of the initiative; and 3) Reviewing progress by means of a standing agenda item for management meetings.
L.5	Leadership: CEO
The CEO or designated leader (check if yes):
q	1. Number of S/R Reduction Team meetings attended by the CEO or designated leader to date: _____ (Do not check if no team formed)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	2. Was perceived by staff as playing a central role at “kickoff” event for the rollout of the initiative
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	3. Reviewed progress by means of a standing agenda item for management meeting
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
Comment:

LEADERSHIP 6: MEDICAL DIRECTOR
Description: The Medical Director is present at S/R meetings, played a central role at the “kickoff” event, reviews incidents and data at least weekly, attends formal debriefings, and supervises staff usage.
L.6	Leadership: Medical Director
Medical Director (check if yes):
q	1. Number of S/R Reduction Team meetings attended by the Medical Director to date: _____ (Do not check if no team formed)
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	2. Was perceived by staff as playing a central role at “kickoff” event for the rollout of the initiative
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	3. Participated in S/R data reviews and analysis at least weekly
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	4. Attended at least one formal debriefing
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	5. Supervised individual physician usage of S/R on at least a monthly basis
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
Comment:

LEADERSHIP 7: NON-COERCIVE ENVIRONMENT
Description: Highly visible and well-publicized statements promoting non-coercive environments.
L.7	Leadership: Non-Coercive Environment
Statements supporting non-coercion issued in the past year by means of (check if yes):
q	1. Staff meetings
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	2. Newsletters
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	3. Posters
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
q	4. Other: (specify) ____________________________________________________________
Source of information:
Start Date: / / or:		Date Range:	q Within the past 6 months	Reason for Change:
			q 6-12 months ago
End Date: / /			q More than 1 year ago
Comment:

LEADERSHIP 8: “KICKOFF” CELEBRATION
Description: A highly visible, well-publicized public event dedicated exclusively to promoting the reduction initiative, open to and attended by a majority of the facility staff at all levels.
L.8		Leadership: “Kickoff” Celebration
q	1. A “kickoff” celebration has been held (check if yes)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Percent of facility staff attended:___ %(Do not check box, if “kickoff” has not been held)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

LEADERSHIP 9: STAFF RECOGNITION PROGRAM
Description: A formal program for regular (monthly or weekly) public acknowledgment of the achievements or contributions of individual staff to S/R reduction or related goals such as promotion of recovery or non-coercive treatment environment.
L.9		Leadership: Staff Recognition
q	1. Number of times individual contributions to S/R reduction, recovery, non-coercive treatment publicly acknowledged: _______(do not check box at left if zero)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

Worksheet 2: Debriefing

DEBRIEFING 1: IMMEDIATE POST-EVENT DEBRIEFING
Description: An immediate post-event debriefing that is done onsite after each seclusion or restraint event and is led by the senior on-site supervisor who immediately responds to the unit or area. The goals of the post-event debriefing are: to assure that everyone is safe; to ensure that documentation is sufficient to be helpful in later analysis; to briefly check in with involved staff, consumers, and witnesses to the event to gather information; to try and return the milieu to pre-event status; to identify potential needs for policy and procedure revisions; and to assure that the consumer in restraint is safe and being monitored appropriately. Method: Review a minimum of five reports randomly selected from the measurement month. If less than five reports are available, review all for the month and indicate the number reviewed in the comment section. Using the Debriefing Review Tool, count the number of debriefings that contain each item. Items ask for whether a particular aspect of the debriefing was addressed in the report. For further instructions on report selection and aspects of debriefing, refer to the ISRRI Reviewers’ Guide. Review #1 Measurement month: Month at the beginning of year 3 of the grant cycle (October 2006, or within 3 months of October 2006) Review #2 Measurement month: Month towards the end of year 3 of the grant cycle (September 2007, or within 3 months of September 2007)
D.1	Debriefing: Immediate Post-Event
Review #1	Review #2		Number of immediate post event debriefing reports in measurement month that documented that:
q	q		1. Designated mid or senior level clinical staff responded no later than one hour
q	q		2. Immediate Post-Event analyses were held within one hour
q	q		3. Post-Event analysis included direct or indirect input or documented refusal by consumer affected
q	q		4. Post-Event analysis included all staff witnessing or participating
q	q		5. Post-Event response included attention to returning milieu to pre-crisis state
q	q		6. Post-Event response included assessment and management of potential physical or emotional injury or trauma to consumers or staff
q	q		7. Post-Event response includes documentation of staff and/or consumer reports of antecedents to event (such as conflict triggers)
q	q		8. Consumer who experienced event provided personal comments on his/her experience in person or by proxy (peer or parent/guardian)
q	q		Number of reports reviewed
			Review #1: Month and year of reviewed reports(If other than recommended month, explain why below)
			Review #2: Month and year of reviewed reports(If other than recommended month, explain why below)
Comment:
DEBRIEFING 2: FORMAL DEBRIEFING REVIEW
Description: A formal debriefing that occurs within 48 hours of the seclusion or restraint event or next business day and includes a rigorous analysis (e.g., root cause analysis) or rigorous problem solving procedure to identify what went wrong, what knowledge was unknown or missed, what could have been done differently, and how to avoid it in the future. The formal debriefing includes attendance by the involved staff, the treatment team, the consumer and/or proxy, surrogate or advocate representative, and other agency staff as appropriate. Method: Review a minimum of five reports randomly selected from the measurement month. If less than five reports are available, review all for the month and indicate the number reviewed in the comment section. Using the Debriefing Review Tool, count the number of debriefings that contain each item. Items ask for whether a particular aspect of the debriefing was addressed in the report. For further instructions on report selection and aspects of debriefing, refer to the ISRRI Reviewers’ Guide. Review #1 Measurement month: Month at the beginning of year 3 of the grant cycle (October 2006, or within 3 months of October 2006) Review #2 Measurement month: Month towards the end of year 3 of the grant cycle (September 2007, or within 3 months of September 2007)
D.2	Debriefing: Formal Review
Review #1		Review #2		Number of formal debriefing reports in measurement month that addressed the following (i.e. indicated whether or not it occurred): (Leave blank if no formal debriefings held)
q		q		1. Formal debriefing held within 48 hours or next business day (if 48 hour period falls within weekend or holiday)
q		q		2. Led by credentialed facilitator not involved in event
q		q		3. Review of assessment and treatment activities with revisions made and/or additional training or supervision provided
q		q		4. Conflict trigger/antecedents noted
q		q		5. Timely response demonstrated
q		q		6. Individual safety/crisis plan or other similar individualized options utilized
q		q		7. Imminent danger threshold reached
q		q		8. Restraint or seclusion applied safely
q		q		9. Continuously monitored, face to face for restraint
q		q		10. ASAP release
q		q		11. Release criteria are reasonable with the burden on staff, not consumer
q		q		12. Immediate post debriefing activities carried out
q		q		13. Learning occurred and is documented
q		q		14. Follow-up recommendations made
q		q		15. Recommended changes planned for, implemented, and assessed
q		q		16. Consumer who experienced event provided personal comments on his/her experience in person or by proxy (peer or parent/guardian)
				Number of formal debriefings in measurement month that included the following:
q		q		1. Staff involved in event
q		q		2. Treatment team of consumer involved in event
q		q		3. Administration representative
q		q		4. Attending physician
q		q		Number of reports reviewed
				Review #1: Month and year of reviewed reports (If other than recommended month, explain why below)
				Review #2: Month and year of reviewed reports (If other than recommended month, explain why below)
Comment:

Worksheet 3: Use of Data

USE OF DATA 1: DATA COLLECTED
Description: Standard reports on S/R events that include specified data elements.
U.1		Use of Data: Data Collected
1. Standard reports include the following items (check if included):
q	Number of S/R events
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Hours in S/R
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Time of day
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Day of week
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Type of restraint
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Consumer injuries
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Staff injuries
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Use of involuntary medication
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Uses of PRN (voluntary, non-routine) medications either prior to or during event
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	Avoidances/near misses
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Consumer Demographics:
q		Race
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		Gender
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		Age
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		Diagnosis
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

USE OF DATA 2: GOAL SETTING
Description: Using data in an empirical, non-punitive manner by identifying facility baseline, setting improvement goals, and comparatively monitoring use over time.
U.2		Use of Data: Goal Setting
q	1. Goals and current S/R rates were communicated to staff (e.g., posted, newsletters, etc.)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Benchmarking against self (e.g., baseline) was collected and graphed
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Benchmarking against like or risk-adjusted others was collected and graphed
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

Worksheet 4: Workforce Development

WORKFORCE DEVELOPMENT 1: STRUCTURE
Description: The appointment of a committee and chair to address the workforce development agenda and lead organizational changes in safe S/R application training, and inclusion of technical and attitudinal competencies in job descriptions and performance evaluations.
W.1		Workforce Development: Structure
q		1. Formed S/R Workforce Committee (or Taskforce)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Number of times S/R Workforce Committee (or Taskforce) has met to date:____ (Do not check if no committee formed)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Evidence of inclusion of technical and attitudinal competencies regarding S/R reduction initiative in activities of human resources department (e.g., during new hire interviews, new hire orientations, and in job descriptions)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

WORKFORCE DEVELOPMENT 2: TRAINING PROGRAM
Description: A formal program of training specifically in S/R reduction concepts and techniques, provided at least annually.
W.2		Workforce Development: Training
q		1. Training program in alternatives to S/R exists (check if yes)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Training program in alternatives to S/R:
q	2. Principles of recovery/resilience/strength based treatment
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Core therapeutic skills/relationship building
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Principles of trauma-informed care
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Cultural competence
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	6. Myths and assumptions regarding S/R
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	7. Involvement of consumers/parents/guardians/peers as full time or part time staff members
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	8. Role of peer support
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

WORKFORCE DEVELOPMENT 3: SUPERVISION AND PERFORMANCE REVIEW
Description: 1) On-going supervision that supports training philosophy and skill development; 2) Performance reviews that include staff competencies in S/R prevention; 3) Competency demonstrations; 4) Re-training for staff demonstrating lack of competence; and 5) Mechanisms for holding staff accountable for performance (e.g., employment counseling, performance improvement reviews, and/or termination for on-going resistance to change).
W.3		Workforce Development: Supervision and Performance Review
The facility has established processes for the following (check if yes):
q		1. On-going supervision that supports training philosophy and skill development
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Performance Reviews that include staff competencies in S/R prevention
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Competency demonstrations
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Re-training for staff demonstrating lack of competence
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Mechanisms for holding staff accountable for performance (for example, employment counseling, performance improvement reviews, and/or termination for on-going resistance to change
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

WORKFORCE DEVELOPMENT 4: STAFF EMPOWERMENT
Description: The empowerment of staff includes: 1) Formal opportunities to provide input on rules, policies, and procedures; 2) Satisfaction surveys; 3) Formal process for administration follow-up on survey findings, 4) Process for public recognition of achievements; 5) Individualized scheduling (such as opportunities for mental health days, training days, etc.); and 6) Confidential access to EAP or comparable assistance with job-related stress.
W.4		Workforce Development: Staff Empowerment
The facility provides for the following (check if yes):
q		1. Formal opportunities for staff to provide input on rules, policies, procedures
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Staff satisfaction surveys
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Formal process for administration follow-up on survey findings
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Process for public recognition of staff achievements
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Individualized scheduling (such as opportunities for mental health days, training days, etc.)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	6. Confidential access to EAP or comparable assistance with job-related stress
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

Worksheet 5: Tools for Reduction

TOOLS FOR REDUCTION 1: IMPLEMENTATION
Description: The use of the following tools for the reduction of S/R: 1) Assessment of risk factors for aggression/violence; 2) Assessment of medical/physical risks for death or injury; 3) De-escalation/safety plans/crisis plans; and 4) Behavioral scale that assists in determining appropriate staff interventions that match level of behavior observed.
T.1		Tools for Reduction: Implementation
The facility utilizes the following tools (check if yes):
q		1. Assessment of risk factors for aggression/violence
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Assessment of medical/physical risks for death or injury
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. De-escalation/safety plans/crisis plans
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Behavioral scale that assists in determining appropriate staff interventions that match level of behavior observed
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

TOOLS FOR REDUCTION 2: EMERGENCY INTERVENTION
Description: Policies and procedures for emergency seclusion and restraint interventions including: 1) Safe restraint procedures that include restrictions on prone use; and 2) Safe monitoring that includes continuous observation.
T.2		Tools for Reduction: Emergency Intervention
Policies and procedures for emergency intervention include the following (check if yes):
q		1. Safe restraint procedures that include restrictions on prone use
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Safe monitoring that includes continuous observation
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

TOOLS FOR REDUCTION 3: ENVIRONMENT
Description: Environment of care changes implemented by facilities including: 1) Sensory/comfort rooms; 2) Avoidance of signs of coercion in posters or other signs; 3) Evidence of signs promoting violence prevention and safe environment of care; 4) Avoidance of overcrowding (e.g., extra beds, sufficient seating in common areas, etc.); 5) Avoidance of unnecessary noise (e.g., overhead announcements, bells or buzzers, phones ringing, staffing raising voices unnecessarily, etc.); and 6) Process where direct care staff and consumers have opportunity to review institutional rules on routine basis to assure need and effect with evidence of review and resultant change.
T.3		Tools for Reduction: Environment
The facility is characterized by the following (check if yes):
q		1. Sensory/comfort room
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Avoidance of signs of coercion in posters or other signs
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Evidence of signs promoting violence prevention and safe environment of care
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Avoidance of overcrowding (e.g., extra beds, sufficient seating in common areas)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Avoidance of unnecessary noise (e.g., overhead announcements, bells or buzzers, phones ringing, staff raising voices unnecessarily)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	6. Process where direct care staff and consumers have opportunity to review institutional rules on routine basis to assure need and effect with evidence of review and resultant changes
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

Worksheet 6: Inclusion

INCLUSION 1: CONSUMER ROLES
Description: The full and formal inclusion of consumers (or parents/guardians for child/adolescent facilities) in a variety of roles in the organization including: 1) Key executive committees; 2) Paid staff roles with formal supervision; 3) Satisfaction surveys; and 4) Formal follow-up on satisfaction surveys.
I.1		Inclusion: Consumer Roles
The facility provides the following mechanisms for consumer input (check if yes):
q		1. Consumers on key executive committees (e.g., leadership team, safety/risk-management, pharmacy, CQI)
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Consumers in paid staff roles are provided formal supervision
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Consumer satisfaction surveys conducted
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Process exists for formal follow-up on satisfaction surveys
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

INCLUSION 2: FAMILY ROLES*
* This subdomain is only applicable to Child/Adolescent facilities/programs—skip if completing Inventory for an Adult facility/program. Description: The full and formal inclusion of family members in a variety of roles in the organization including: 1) Key executive committees; 2) Paid staff roles with formal supervision; 3) Participating in treatment planning meetings; 4) Satisfaction surveys; and 5) Formal follow-up on satisfaction surveys.
I.2		Inclusion: Family Roles
The facility utilizes family members in the following ways (check if yes):
q		1. Family members on key executive committees
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	2. Family members in paid staff roles are provided formal supervision
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	3. Family members are encouraged to attend treatment planning meetings
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	4. Family satisfaction surveys conducted
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q	5. Process exists for formal follow-up on satisfaction surveys
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

INCLUSION 3: ADVOCATE ROLES
Description: The full and formal inclusion of advocates in a variety of roles in the organization including: 1) Key executive committees; 2) Paid staff roles with formal supervision; 3) Satisfaction surveys; and 4) Formal follow-up on satisfaction surveys.
I.3	Inclusion: Advocate Roles
The facility utilizes advocates in the following ways (check if yes):
q	1. Advocates on key executive committees
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		2. Advocates in paid staff positions are provided formal supervision
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		3. Advocate satisfaction surveys conducted
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
q		4. Process exists for formal follow-up on satisfaction surveys
Source of information:
Start Date: / / or:			Date Range:	q Within the past 6 months	Reason for Change:
				q 6-12 months ago
End Date: / /				q More than 1 year ago
Comment:

Worksheet 7: Oversight/Witnessing

OVERSIGHT/WITNESSING: ELEVATING OVERSIGHT
Description: The leadership ensures oversight accountability by watching and elevating the visibility of every event 24 hours a day/7 days per week by assigning specific duties and responsibilities to multiple levels of staff including: 1) On-call observer competent in S/R policies and procedures and familiar with daily operations; 2) On-call supervisor; and 3) Senior staff responding to event. Review #1 Measurement month: Month at of the beginning of the grant cycle (October 2004, or within 3 months of October 2004) Review #2 Measurement month: Month TOTO of the beginning of year 2 of the grant cycle (October 2005, or within 3 month05)
O.1 Oversight/Witnessing: Elevating Oversight
Review #1	Review #2	During the measurement month the following occurred (check if yes):
q	q	1. Formal Executive oversight available on a 24 hour/7 day a week basis was available
q	q	2. On-call observer competent in S/R policies and procedures and familiar with usual and daily operations of facility/units was available (Denotes use of senior administrator, nursing director, facility manager, clinical director, physician)
q	q	3. Formally designated on-call supervisor was identified and communicated to staff
q	q	4. Senior staff responding to events notified executive on call
		Review #1: Month and year of reviewed reports (If other than recommended month, explain why below)
		Review #2: Month and year of reviewed reports (If other than recommended month, explain why below)
Comment:

OVERSIGHT/WITNESSING: ELEVATING OVERSIGHT
Description: The leadership ensures oversight accountability by watching and elevating the visibility of every event 24 hours a day/7 days per week by assigning specific duties and responsibilities to multiple levels of staff including: 1) On-call observer competent in S/R policies and procedures and familiar with daily operations; 2) On-call supervisor; and 3) Senior staff responding to event. Review #1 Measurement month: Month at the beginning of year 3 of the grant cycle (October 2006, or within 3 months of October 2006) Review #2 Measurement month: Month towards the end of year 3 of the grant cycle (September 2007, or within 3 months of September 2007)
O.1 Oversight/Witnessing: Elevating Oversight
Review #1	Review #2	During the measurement month the following occurred (check if yes):
q	q	1. Formal Executive oversight available on a 24 hour/7 day a week basis was available
q	q	2. On-call observer competent in S/R policies and procedures and familiar with usual and daily operations of facility/units was available (Denotes use of senior administrator, nursing director, facility manager, clinical director, physician)
q	q	3. Formally designated on-call supervisor was identified and communicated to staff
q	q	4. Senior staff responding to events notified executive on call
		Month and year of reviewed reports (If other than recommended month, explain why below)

Public reporting burden for this collection of information is estimated to average 8 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, One Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0271.

ATTACHMENT C

Seclusion and Restraint Event Data Matrix

Measure Lists, Descriptions, and Examples

Definitions

Seclusion:
	The involuntary confinement of a client alone in a room or an area where the client is physically prevented from leaving which includes but is not limited to: manually or electronically locked doors; one-way doors (i.e., doors constructed so that when closed and unlocked they may not be opened from the inside); the presence of staff proximal to the room preventing exit or the threat of consequences if the client leaves the room. Each occurrence of a seclusion must be reported as a unique event. In some cases, clients may provide “permission” to be secluded either at the time of seclusion or at some previous time. The seclusion event must be reported even if such “permission” has been obtained. It is understood that there are other forms of behavior management systems such as quiet rooms, voluntary time outs and room restrictions. These types of events should not be reported if the client is free to leave the room without consequence. Other exclusions include: quarantine due to infectious disease; restraints while not in seclusion: That is, a seclusion event should not be reported if an individual is prevented from leaving a room secondary to being restrained. In this case, a restraint event should be reported.
Restraint:
	Any manual or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a client to move his or her arms, legs, body, or head freely. Each occurrence of a restraint must be reported as a unique event. In some cases, clients may provide “permission” to be restrained either at the time restraints are applied or at some previous time. The restraint event must be reported even if such “permission” has been obtained. The following are valid restraint subtypes: Mechanical, Non-ambulatory Restraint: Mechanical restraint of an individual in which ambulation is not possible, examples include 4-point restraints and body nets Mechanical, Ambulatory Restraint: Mechanical restraint of an individual in which ambulation is possible. Examples include wrist-to-waist restraints. Restraints used for security purposes during transport of a client out of the building or off the premises to receive therapeutic services or to participate in activities directly related to the client’s illness (such as court proceedings or appointments necessary to acquire human services) are not to be reported. Also, restraint devices employed for medical purposes (Geri-chair, posey, etc..) or as personal protective devices (helmets, bed rails, etc..) should not be reported. In some cases, devices (e.g. mittens) may be employed for either medical or behavioral purposes. Use of such devices should be reported when the restraining device restricts the movement of the whole or a portion of a client’s body for the purpose of preventing intentional harm. Use of such devices should be considered for medical purposes and should not be reported when the device is used as an assistive or adaptive device to restrict the movement of the whole or a portion of a client’s body for the purpose of preventing unintentional harm or used for promoting or maintaining normative body functions. Manual Restraint: A method in which the individual is restrained by the physical force of facility staff. Exclusions include: restraints used for security purposes during transport of a client out of the building or off the premises to receive therapeutic services or to participate in activities directly related to the client’s illness (such as court proceedings or appointments necessary to acquire human services); devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets; other methods that involve the physical holding of a client for the purpose of conducting routine physical examinations or tests; other methods that protect a client from falling out of bed; other methods that permit the client to participate in activities without the risk of physical harm (does not include a physical escort); seclusion while not in restraints. Documentation of the reason for the use of the restraint must clearly indicate whether these exclusions apply.
Injury:
	An injury event is reported when a client or staff suffers physical harm or damage as a consequence of a seclusion or restraint event and requiring medical treatment more intensive than “minor first aid” including “medical intervention” or “hospitalization” (see definitions below). Client injury events (CIEs) occur during incidents in which one or more clients are injured. A separate CIE should be reported for each client injured during any given incident. If multiple clients are injured in a single incident, multiple CIEs should be reported. If a single client is involved in multiple incidents resulting in injury to that client, multiple CIEs should be reported. However, if a given client is involved in a single incident which results in multiple injuries to that client, only one CIE should be reported. Staff injury events (SIEs) occur during incidents in which one or more staff are injured. A separate SIE should be reported for each staff injured during any given incident. If multiple staff are injured in a single incident, multiple SIEs should be reported. The use of diagnostic procedures to determine the severity of an injury does not constitute treatment. Exclusions: Injury events should NOT be reported for clients or staff whose injuries: did not result from a seclusion or restraint event; or required “no treatment” or “minor first aid” only (see definitions below) resulted in death; in this case the injury should be reported as a death. “No Treatment”: The injury received does not require first aid, medical intervention, or hospitalization; the injury received by a client (e.g., a bruised leg) may be examined by a clinician but no treatment is applied to the injury. The use of diagnostic procedures to determine the severity of an injury does not constitute treatment. “Minor First Aid”: The injury received is of minor severity and requires the administration of minor first aid. This is meant to include treatments such as the application of Band-Aids, cleaning of abrasions, application of ice packs for minor bruises, and use of over-the-counter medications such as antibiotic creams, aspirin and acetaminophen. “Medical Intervention Required”: The injury received is severe enough to require the treatment of the client by a licensed medical doctor, osteopath, podiatrist, dentist, physician’s assistant, or nurse practitioner, but the treatment required is not serious enough to warrant or require hospitalization; further, the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at a doctor’s private office through treatment at the emergency room of a general acute care hospital. “Hospitalization Required”: The injury received is so severe that it requires medical intervention and treatment as well as care of the injured client at a general acute care medical ward within the facility or at a general acute care hospital outside the facility; regardless of the length of stay, this severity level requires that the injured client be formally admitted as an inpatient to the hospital and assigned to a bed on a unit outside of the emergency room.
Death::
	An injury received as a consequence of a seclusion or restraint event that was so severe that it resulted in - or complications from the injury lead to - the termination of the life of the injured client.
STAT IM Medication::
	A STAT (Emergency) Intra-Muscular (IM) medication event should be reported each time a client is given a STAT dose of a neuroleptic medication administered intramuscularly.

Definitions are based on NASMHPD Research Institute, Inc (NRI) Behavioral Healthcare

Performance Measurement System Implementation Guide, Version 4.0 (Copyright July 20, 2007) and

used with permission.

Public reporting burden for this collection of information is estimated to average 8 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, One Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is xxx-xxxx [*insert new number*].

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