Shields and colleagues (2018) maintain that trauma-informed care can reinforce principles of patient safety and quality care, reporting that “providing care that is psychologically safe requires that patients feel safe, have a sense of control over their lives, and have a sense of connection to staff members who are perceived to be available and who see their needs as legitimate” (p. 1854). An interesting study conducted in Australia uncovered positive results associated with trauma-informed education for psychiatric nursing staff. Through a series of ongoing workshops, several key domains of clinical practice were targeted for improvements (Beckett et al., 2017). ● Reducing seclusion and restraint ● Increasing staff confidence by improving skills in deescalation and physical safety ● Ensuring best practice for pharmacological interventions ● Introducing strengths-based philosophy and practices ● Providing sexual safety training and awareness ● Improving access to therapeutic activities on the unit In the three years following the workshops, significant improvements were reported. First, seclusion rates were reduced by 80%. Moreover, the amount of time patients spent in seclusion decreased to less than 60 minutes. Importantly, nursing staff reported feeling more confident and more willing to stay connected and engaged with patients who were displaying high amounts of negative affect and distress (Beckett et al., 2017). The Negative Impact of Market Failures Researchers argue that the quality and safety of care is harmed by specific market failures and features within our behavioral healthcare systems. First, providers and healthcare staff possess the majority of information that affects the quality and safety of patient care, thereby limiting family members’ awareness of and involvement with care while a patient is in psychiatric acute care. For example, family members often visit or meet the hospitalized patient outside of the treatment milieu, effectively shielding the family members from observing any significant facets of the treatment experience. This is typically quite different from general hospitalization, where family members can visit patients in their rooms within their units of care. This critical difference can limit the family’s ability to advocate for the patient if the need to do so arises (Shields et al., 2018). Another constraining example is the lack of patient choice. Often, patients are ambivalent or opposed to psychiatric hospitalization and may be admitted, sometime involuntarily, outside of their community because a bed is unavailable in their first-choice hospital. Another negative factor is the influence of state Medicaid plans or other health plans on the patient’s care. These entities operate as de facto agents on behalf of patients and can have organizational goals that are misaligned with the needs of the patient, thus negatively affecting the quality and safety of the patient’s care. Another dynamic is the possibility that patients may struggle with self-advocacy during psychiatric hospitalization. This can occur because their behavioral symptoms limit their sound cognition, or it can result from power imbalances between staff and patients that are characterized, for example, as the voice of the patient being minimized by providers because of mental illness stigma (Shields et al., 2018; Svensson, 2022). Medicaid 1115 Waivers and Profits Section 1115 of the Social Security Act is a recent clarification of the regulations affecting Medicaid managed care organizations. It changed the mental disease exclusion that did not provide Medicaid payments to mental health facilities with 16 or more beds (Shields et al., 2018). With this change, states may now use Medicaid funds in facilities that treat mental disease. Accordingly, researchers have identified this change as one of the factors contributing to the dramatic increase in for- profit behavioral and substance abuse facilities from 2010 to 2016. In this six-year period, for-profit beds increased by 48%. Researchers argue that for-profit entities earn big profits because
of this change and that this can be a negative factor in the quality and safety of patient care in these facilities. According to Shields and colleagues, for-profit facilities could potentially have motivations that can be misaligned with patient safety. For example, in the quest for preserving profits, psychiatric hospitals can cut corners in a variety of ways that negatively impact patient safety. This can manifest in several practices, for example, sending treatment staff home—unpaid—when the hospital census drops too low. This can negatively affect provider morale because their employment is full-time conditional, that is, conditioned on a certain patient census. Lowered provider morale is associated with lower quality and safety of patient care. Other cost-cutting measures can be noninvestment in evidence-based care and patient safety education as well as less hiring of appropriate numbers of qualified providers, thus clinically underpreparing and overburdening existing psychiatric staff (Shields et al., 2018). Frustrated, overburdened providers working in the for-profit model of care can—unfortunately—put patients at risk. Ignoring burned-out providers can be a critical mistake behavioral health leaders make (Svensson, 2022). In fact, Universal Health Services, the largest U.S.-based chain of for-profit psychiatric hospitals, has been involved in numerous federal and local investigations that allege neglect, abuse, and fraud, meanwhile boasting profit margins of more than 20% for inpatient psychiatric care across 350 acute care hospitals. Furthermore, research suggests that while these same dynamics can exist in not-for-profit facilities, the overall evidence indicates that for-profit entities have more safety violations (Shields et al., 2018). Accreditation and Regulation’s Role in Patient Safety The Joint Commission regulates, monitors, and accredits more than 80% of U.S.-based psychiatric facilities and hospitals. Patient safety standards for psychiatric inpatient care are created and maintained by The Joint Commission; however, these Researchers expressed concern that The Joint Commission, while encouraging facilities to identify their policies for investigating sentinel events—including voluntary reporting of adverse safety events—did not provide policy or language that addressed either trauma-informed care or the importance of safety culture. Shields and colleagues (2018) argued that this exemplified leadership falling short of the needed regulatory guidance and monitoring, practices that ought to be expected from The Joint Commission. Unfortunately, states do not often create regulatory standards that exceed those of The Joint Commission or the Center for Medicare and Medicaid Services. Researchers argue that states are deficient in their regulatory patient safety mandate and are in need of systematic, evidence-based improvements (Frogner et al., 2020). Because of this, researchers have examined the regulatory role of states, which create licensing rules that inpatient facilities must follow. In a sample of six states, research demonstrated that rules varied considerably from state to state, with a mélange of regulations that appear somewhat ambivalent—in practice—toward standards to ensure patient safety. Regulators cannot be complacent and at the same time call for patient safety. For example, for the six states sampled by Shields and colleagues (2018), there was “limited information describing states’ trend analyses of critical incidents, which suggests that states do not systematically track and publicly report aggregated rates of complaints . . . furthermore, states differ in their transparency with critical incidents and regulatory violations” (p. 1857). standards apply to (Shields et al., 2018): ● Processes of seclusion and restraint ● Suicide screening and assessment ● Access to ligature points ● Translation services
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