Greeley Reflections

Accreditation Connection, June 29, 2009

Time to start working on restraint

Part 2 of 3:

Last week we began our discussion on restraints policies. We recommend measuring compliance with your policy. Focus on the “direct impact” requirements summarized below:

(Note: All direct impact requirements for this subject are Category A, meaning a single deviation noted will yield an RFI.)

PC.03.05.01: All five elements of this standard are “direct impact” and focus on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.

Suggestion: Drive documentation of indications into very simple forms or templates that do not rely on check boxes.

PC.03.05.03, EP1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.

Suggestion: Do not make a separate policy or procedure related to techniques. Rely instead on a well-designed education program. This education, which can be available to all staff in real time, ensures alignment of practice across the organization and avoids the need to develop duplicative procedures.

We’ll return next week with more examples which speak to specific standards.

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