The current environment has highlighted the increased demand for both mental health and substance use disorder care needs. Recently, Michelle Foster Earle, president and CEO of OmniSure Consulting Group, sat down with a well-respected industry leader in risk management in these clinical areas, Monica Cooke, BSN, MA, RNC, CPHQ, CPHRM, DFASHRM. Their insightful exchange on risk mitigation in these settings follows.
Michelle:
Monica, you’ve been in this field a long time. Tell me a little bit about your background. How did you get into risk management for mental and behavioral health?
Monica:
I’ve been in mental and behavioral health for a total of 44 years. I am a nurse; I started my career in the alcohol treatment setting. It was the initial nursing position for me, and then I moved into psychiatry a few years later. Clinically it’s been my entire background. I’ve worked in child and adolescent inpatient settings, adult residential, and state facilities where people are there for a long time. I’ve had a lot of clinical experience. And after 30 years, I went into leadership management. I became a director of nursing, director of risk, and director of quality, all in the last few years of my pre-consulting career, when I had a real job as my husband would call it. I kept seeing the same things repeatedly, everywhere I worked.
I saw it as a matter of working to reshape culture when it comes to risk management and quality care. I decided that I really needed to get the word out on a broader scale. So, I did; in 2006, I started my own business in risk management and quality. I am certified in both as well as a certified psychiatric mental health nurse. I have worked clinically up until COVID-19. I was working with substance use patients before their dropped census. For the past 15 years, I have been doing risk management as well as legal nurse expert work across the country in behavioral health and substance use.
I think my interest in it is that risk is always going to be there. For most organizations, it is a matter of doing a good assessment, looking at where they’re at now, what are the risks, thinking it through, and offering recommendations on how they could improve and minimize the risk while also helping them decide what risks they’re willing to tolerate. There are a lot of risks we must tolerate in mental health and substance use settings or care and treatment across the board. So, as we know in any healthcare arena, we can’t get rid of all the risk; we can’t mitigate it all. But we can look at what we have and decide on how to prioritize the risks.
The detective work, figuring out what’s going on in an organization, that’s what I enjoy doing. A lot of it has to do with the culture of the organization and the leaders. Where are they coming from, what is their philosophy of care, and what is their attitude toward workplace violence and taking care of staff? As we know, workplace violence is a big concern in healthcare across the board.
Michelle:
Well, I’m going to ask you a lot about risk management, patient safety, and taking care of staff in a few minutes, but you mentioned just now that you were working in a clinical capacity until COVID and that the census went down. I received a question yesterday from an underwriter about claims during the COVID period, and I explained this particular class of business census went down, and because of that, they’re going to see fewer claims because there were fewer patients. Is the reduction in the census something you think has happened across the board in behavioral and mental health or was it just in addiction treatment?
Monica:
No, I think it happened across the board. I think that part of the dilemma, and more so with mental health inpatient type settings and partial hospitalization settings, was the risk of exposure due to patients coming in and going out on a daily basis and potentially being admitted with COVID. Most organizations do test routinely prior to entry because we have issues with compliance; patients that are at times psychotic are often unable to cooperate with hygiene and care policies associated with COVID precautions.
I live in Maryland, and the Metro DC Baltimore area saw a lot of substance use settings close or the census lower. For instance, the facility I worked at had a 40-inpatient-bed detox and rehab unit, went down to 10 initially, then started bringing census up so that each patient could have their own room, with minimized contact, COVID testing, isolation, retesting, etc. consistent with COVID guidelines. That takes a lot of energy because it requires redesigning the entire treatment program.
Interestingly, it had a good impact in our facility by changing the program to more focused small group care and treatment, as opposed to large groups of 40 patients. But certainly, access to care, in 2020, was prohibitive. The emergency rooms were flooded with mental health patients because facilities lowered their censuses, and inpatient beds were not available. Certainly, care access went down because of COVID, but programs are beginning to, I think, come back and be more available.
Michelle:
I’m just intuitively assuming mental health and substance use treatment needs to be more available now because it’s been such a hard couple of years on so many people. I’m sure that there were many more relapses from people being triggered, depression, anxiety, from all that everybody has endured, from not seeing friends and family members. And for those working in health care, the trauma of seeing so many patients and colleagues get sick and die. It’s been a tough couple of years.
Monica:
And, interestingly Michelle, one of my bigger concerns was with care providers. Because of the stress on them and their families, the increased use of substances . . . alcohol, marijuana, pills, anti-anxiety meds, other things that may or may not be prescribed, yes, increased substance use in healthcare providers is a risk. I often speak to groups and share the need to educate everybody. Care providers need to be aware of their own risk, to watch their peers, and the people they work with: are they acting differently, do they smell alcohol on their breath, have they noticed any differences in their behaviors? These are very real scenarios that are happening because healthcare providers are trying to manage the increased care load; home, kids, and families; and the healthcare crisis. It is so very, very, very stressful. It is critical they receive support from a mental health perspective.
Michelle:
Let’s get to the initial topic of risk management. You’ve undoubtedly seen the best and the worst situations. What stands out as one of the worst situations?
Monica:
Probably the worst scenario was both a liability and a law enforcement issue. It involved an inpatient psychiatric unit for adults where a patient had hanged herself in the bathroom and was not found for about two hours. When the staff found her, they took her down and sat her on the floor to make it look like she had just died. Then they told their charge nurse that the patient was sitting on the floor and wasn’t breathing. Because she died, it also became a police matter.
Initially, the ligature marks were not visible; however, when the police arrived, the ligature marks on the neck were visible. Then of course, the real story came out after a review of video from the hallway cameras. No one was monitoring the patient every 15 minutes according to protocol. The staff, mostly techs, are assigned to monitor the patient. They attempted to cover up the lapses out of fear they would lose their jobs. As a result of the falsified reporting, the investigation turned into a possible homicide.
Of course, it turned into a liability issue for the family of the deceased. It is understood someone can die from strangulation in a few minutes and that established safety parameters are for rounds every 15 minutes. However, if they had been conducting the rounding, they may have prevented it or may have been able to resuscitate her. The corporate parent company asked me to meet with the staff and assess the culture. The question was, is this a culture issue, a culture of care issue?
I determined the culture was very bad, much like what I had previously seen in some inner-city hospitals. While the staff had the required competency, they were not very sophisticated. The leadership was facing a tremendous challenge to shift the culture, and that was going to require hard work and time. I think that’s probably the worst situation I have seen. Sadly, it wasn’t just that someone failed to do a required safety check. The attempt to cover up the failures was a significant cultural red flag.
Michelle:
In hospital settings, there’s been a lot of work to change and shift away from the blame culture, which is our human nature really. When something goes wrong, and especially when the most egregious things go wrong, we want someone to blame. Somebody needs to pay the price. People at the top, especially if a scapegoat helps ease the situation, can be quick to fire a wrongdoer. So then when unintentional mistakes happen, people get scared and think, what could possibly happen here? Someone could lose their job and be terminated. The person who made the mistake has a family to support and can’t afford to lose a job. So, if they can, they brush it under the rug. But that does nothing to help others keep from making the same mistake. It causes people to falsify records, hide, lie, or run, in fear and be scared. Blame culture doesn’t have anything to do with intention; it just has to do with the outcome.
In a just culture, you look for systems to fix. How did the system fail the clinician at the point of care? If the clinician was supposed to be checking on the patient every 15 minutes, was there some reason that the clinician wasn’t doing that? Was it a staffing issue? Was it an issue with the location of the patient room? Was there a clear handoff from the previous shift with specific action items? Who knows what the system fixes could have been had the staff not felt the need to cover it up? The shift from blame culture to fust culture hasn’t happened across the board at all hospitals. We’ve done a good job of it, but I’m interested in how many psychiatric and behavioral health settings have even heard of just culture. Is that something they are looking at and thinking about?
Monica:
Certainly, for the most part in my early career, thinking through systems was not yet a concept. But at this point, it is. When I do risk assessments, that’s what I look for: is it a just culture? What do staff understand about what follows when something negative happens? What happens to them? Digging into incident reporting and near-miss reporting practices are a big focus issue for risk managers.
I grew up in nursing in the ‘70s as an RN, where if you put in an incident report, it went in your personnel file. If you made an error on medication or anything, it went into your personnel file, and then annual reviews came up, and oh, you made three med errors, and you’re not getting your raise or your merit increase. I think we’ve done well. I think that for the most part, psychiatric settings are keeping on par with hospitals. The hospital where the patient hanged herself certainly knew about just culture. But changing the culture takes a year or two years; it doesn’t happen overnight. Everyone must buy-in. Everyone must believe in it. Everyone must practice it every day. It takes a lot, and they knew that was an issue. And in fact, that was a contributing factor to what occurred. And of course, there was intentional deceit, and intentional deceit is unacceptable in any just culture. Just culture lays the foundation for the questions, is there a system issue to explain why they couldn’t do the rounds every 15 minutes, do they not have enough staff, do they feel overloaded? All those things must be considered and investigated without bias when a sentinel event occurs.
Michelle:
Right. In a blame culture, people are more likely to do what this staff member or team did, which was to hide the error. And then it becomes intentional falsification of records, which takes on a whole new life of its own. Within the just culture, you reward and encourage people for speaking up. That staff member who found the patient might not have tried to cover it up in a just culture and would’ve said, “Oh my goodness, I haven’t been in that room in two hours. Look at what happened! I was busy helping Jane who had this problem over there, and I feel so horrible.” Everyone would have looked for ways to keep it from happening again. In a just culture, she was not necessarily going to be terminated; she would have been handled fairly. The whole organization would look to learn from the situation that led to this sentinel event, a patient’s death, and hopefully prevent it from happening ever again. There’s no tolerance for deceit; that would be grounds for termination.
Monica:
That’s right, they did have to terminate them.
Michelle:
Exactly. Once you’ve falsified records, you can’t go back. So then, what would you say might have prevented that error from happening or that outcome? Obviously, we know the 15-minute rounds might have helped. Do you think that leadership embracing a just culture would’ve been the number one thing to have in place beforehand to keep that from happening?
Monica:
I think just culture plays a big part in it. We need staff to know they can make a mistake and not lose everything they’ve worked for. Prior to just culture, if we made a medication error, not only could we be fired, but people were fired. I think that the change has been a huge influencer toward open and honest communication and improved patient outcomes. In the sentinel event we discussed, I think that the system failures included a lack of adequate supervision.
I am aware of mental health facilities that have increased supervision because of the liability associated with failure to meet the 15-minute check standards. If there’s a legal case, that’s the first thing I want to see: the Q 15-minute checks logs. There are many ways they can be problematic, ranging from being blank to being falsified, which makes having a double-check system in place vital. The mental health techs are usually accountable for completing these rounds, managing the milieu of the patients, and reporting concerns to the nurses. Because nurses are busy doing admissions, medications, and providing clinical care, supervision is often lacking.
I recommend a system where the nursing staff is directly involved in those Q 15-minute rounds on a regular basis. For example, once an hour, the rounds are completed by the nursing staff. This promotes their engagement and ownership of the team’s accountability and allows for increased vigilance and supervision while elevating the importance of the duties. That’s one approach, and because most facilities are very much aware that a failed system leads to high risk and high severity outcomes, Q 15-minute checks are a top priority to ensure patient safety, and teams are being trained and systems implemented to reduce these risks.
Michelle:
OK, let’s go to the opposite side of the risk spectrum. Share something about going into a setting where maybe you said, “Wow, this place has really done a great job with risk management and patient safety!” And what were they doing that impressed you?
Monica:
I don’t get wowed too much. Beautiful and newly designed facilities that meet current standards can mitigate about 80% of our risk. That is accomplished with design, just design. The higher quality organizations are most commonly newer facilities that are designed with safety as a priority, as opposed to an old med-surge unit that’s been converted into a psych unit. Some of the best facilities are the ones with more resources; however, resources alone are not the answer.
The thing that really impresses me, which really tells me that they have strong risk management, is if the staff can speak to it, is data monitoring, if they can speak to data, what they’re monitoring, what their high-risk concerns are. And not just leaders because leaders get it drilled into their heads but the staff. I’ll ask a nurse or a tech what are your biggest risks? What are you monitoring here? What are you trying to make sure doesn’t happen? They’ll say things like, “We really watch out for contraband. And we’ve implemented this strategy to take care of it at the door.”
The staff’s ability to speak to it is evidence of their involvement, and that is huge. Everyone’s a risk manager. I know we’ve all heard this before, but everybody really is a risk manager. For a risk management department, it is about getting the frontline people, the people that are doing the job every day, getting them on board with what are we trying to get better at what we are wanting to do about it. What does our data show, for example, about how many restraints incidents they have had and how incidents have lessened because of what they have implemented?
Michelle:
Yes, and not only are they getting real-time feedback on the things that everybody is concerned about and wants to see improved, but they can also be part of the solution. We all need feedback to improve. When I was an administrator, we would intentionally bring in the nursing assistants and the frontline workers to help solve problems because they were the only ones who really could solve the problems right there at the point of care. They saw and knew what was happening in ways that we did not, what equipment was available, why they needed assistance with a particular type of client, what works, and what doesn’t. So, you’re right. That’s an excellent point that if the frontline staff is part of the risk management performance improvement projects and the data from the quality assurance and performance improvement are shared with them, they know how they’re performing, they are being involved, and they are on the same page with the solution. That’s excellent.
Let’s talk about the newest design you mentioned and its importance. If you’ve got the facility itself designed to solve several risk problems, that’s absolutely beneficial. However, aren’t those going to be more expensive than the treatment facilities?
Monica:
It’s not necessarily expensive in terms of the cost of care. At our hospital, we take public assistance, and yet, it’s a newly designed hospital. It’s not that these are more elite facilities but rather that they are designed for improved safety, which gives them a huge advantage over the traditional psych facilities that are either inpatient units in a hospital or freestanding, but they were not built for that purpose. Because they were built for something else and repurposed, they have their own risk challenges. Even a recently built rehab building that has been repurposed will have increased risks because the design is not the best environment for this population and their safety needs. Do you see what I’m saying?
Michelle:
I totally do. We have a facility in our city where they took one of those nursing homes that had a layout like the spokes of a wheel. They had the central nursing unit and all the hallways where they had specific designations. One became the adult female hallway, one became the co occurring disorders hallway, and so on. You could tell it was an old nursing home that I guess didn’t make it as a nursing home, but they had converted it into a drug and alcohol treatment facility.
Monica:
Yes, that’s exactly what happened. With the Joint Commission and CMS guidelines, the trend is toward a mandatory safe design. Retrofitting that design is not as good as if it were built specifically to meet the current standards. Because units could still have a lot of blind spots and the bedrooms are far away from the nursing station, like with those spokes, not only does observation become a problem, but the need for maximized observation cannot be accomplished. The nursing station you referenced likely was not nice, low, and open or positioned centrally where everyone is interacting, with a big day room out in front of it where patients can socialize.
I think that now we have a lot more pressure from regulatory and accreditation bodies, things have gotten better regarding design. But people have put millions of dollars into rehab units, and we know that mental health dollars are lean. There’s no parity. Nobody’s making money in mental health. Well, I can’t say nobody—but most. I mean, they’re barely getting by.
Michelle:
Yes, I really like the idea of the question: Was it designed for the purpose it’s being used for? And that’s a more important question than “Is it a luxurious facility or one that serves the lower income?” because I know that is a question people are asking. You look at some of the drug and alcohol treatment facilities, and they look like a destination vacation on the beach with horseback riding, but those are all private pay. So that is a question that comes up: Are they less risky than a facility that has a minimal budget but treats a lot of people that are underserved and don’t have the resources for something like the “really nice” rehab?
Monica:
Well, for the most part, substance abuse facilities have different risks. The risks aren’t the same as they are with mental health. There is a much higher risk in a mental health setting than in a substance abuse setting. And yes, there are the luxurious, resort-type, go swimming every day and get massages and all those things, in substance abuse settings. And there are a few, though not many, very, very private elite mental health facilities too. So, what they offer is not necessarily a better design or even a safer design, but what they offer is more and multiple clinical treatments. For instance, Betty Ford is an old facility, but they offer things that you wouldn’t get at a typical substance abuse treatment facility, like massages, acupuncture, and yoga, all these kind of relaxation therapies that absolutely do help.
The problem is that they help during the stay, but does the person then go home and do those beneficial things to help them to maintain their sobriety? The other types of facilities that don’t offer all those perks, they most likely suggest these modalities to patients or something equally relevant. If they’re in a detox/rehab setting for, say, three weeks, they work to establish a recovery plan for somebody based on what they have access to. Now people with a lot of money have access to yoga and massages and all those things that can and do help, whereas somebody with funds that are severely limited or nonexistent . . . they’re not going to get a $100 massage to prevent a relapse. I think that’s the difference.
And of course, we know there’s a lack of parity in terms of health care: just being able to pay for what you want. I mean, we have concierge doctors, right? People can pay for a concierge doc to call at any time of the day, but you pay a fee for that. I believe that the biggest difference between them is not so much the design because there are some bad designs. Substance abuse freestanding settings are very well known, trust me. But they offer more. They have more of a variety of services, more staff, and they have greater access to all different types of resources in the community. So that’s what really makes them different. Now the question is, are they better because they help all that? From a risk perspective, the question is do some of these other available services come with their own risks?
Michelle:
We have one consultant who was an administrator at a drug-and-alcohol-treatment residential facility, which had equine therapy. And so, what kept her up at night was not somebody relapsing, but it was someone getting thrown off the horse or getting kicked by one of the horses.
Monica:
Well, Michelle, equine therapy or therapeutic riding is wonderful therapy. We have a gym here for our substance use patients, and we have more injuries in that gym. It’s a younger population often, and they’re substance users and haven’t done any exercise or played basketball in 10 years, and suddenly, they’re clean for a week and want to go down and do high jumps, and then they fall and sprain their ankle. I think those are always risks. And again, it’s what risk can we bear? What risk can we accept? If those risks do exist, then we must have a sense for them: which ones are we able to accept for what is best for patients?
We have a challenge course outside where they climb up ropes, they swing on ropes at high distances, they walk a tight rope with a harness, and they do all kinds of things. Is that risky? Yes, that’s risky. We have never, ever had a harmful event in 30 years of the challenge course at this substance abuse facility. And I credit that to the good therapists that are doing it. They’re consistent with being very stern about what all the safety rules are. It’s not a joke, and we don’t play around. They really keep things in check. We have people sign a release when they come in stating you’re going to get adventure therapy, it
involves this, you consent to that, we won’t be liable, etc. They can consent to physical activity.
Michelle:
Here’s another scenario: We all hear about substance abuse settings where patients discharge perhaps prematurely, due to limited benefits or resources, and then they relapse and die of an overdose a day or two later. What’s at play there, and what can we do to prevent that type of tragedy?
Monica:
I think substance use is a chronic illness, and it’s a very relapsing illness, and we all know that in the industry. We accept public funds as well as private funds or private insurance. And there certainly are patients where the insurance says, no, they’re only getting five days of detox, we’re not paying for rehab, etc. Those patients then become a high priority for establishing a good recovery plan at the point of discharge. We need to ensure we have established good assessments and, of course, that they are medically stable at the point that we discharge them. We work with them on a good recovery plan that has many components, such as AA, medication, individual therapy, or outpatient group therapy. And most of our patients successfully step down from inpatient to intensive outpatient, where they come in three times a week for a couple of hours. If they refuse it, that’s one thing. If they don’t refuse it but don’t stay with the plan, that kind of falls back on them. From a liability perspective and a risk management perspective, I’ve never been very concerned about that. Those tragedies do happen. People who are substance users are not incompetent; they are able to make their own decisions. If they decide to start using, there are consequences for that, and they are aware of those consequences; there are known consequences.
We do have patients that leave AMA (against medical advice), and there are a lot of substance users that go into treatment and a day later say, “I don’t like this; I want to use some more,” and they decide to leave. From a liability perspective, we don’t worry about the AMA cases as much.
Michelle:
It sounds like the best thing is to have some sort of system in place so that there is a good transition. You’ve done a good handoff to the step that’s right for them, either to continued treatment, to the primary care physician, or to an AA program with a sponsor, whatever that plan is, just making sure that you do a complete handoff. Like at the ER, the goal is to keep the person from having to be readmitted within 24 or 48 hours because that signifies that maybe the treatment wasn’t provided sufficiently, or they were prematurely discharged. I would say, then, that for treatment for drug and alcohol abuse, it’s probably the same thing. You want to make sure that there is a good handoff in the continuum of care. The ERs call the patients 24 to 48 hours later and say, “Now when we discharged you, we discharged you with a prescription for this particular antibiotic and instructions to get in touch with your primary care physician. Have you been able to schedule that appointment?” The ER is making sure that they’ve done a good handoff.
Monica:
It’s a good practice. It’s not universally done; some health systems are better at it than others. I think what’s important, again from a liability perspective, and what most ERs do in their discharge instructions, is they make it clear that “if you have any problems, come back to the ER.” What we say here is, “If you start having any issues, call us. Call us, and you may need to come back, or we can give you more resources, or we can facilitate you getting what you need.” So, they know that at the point that they leave, they can always call back.
Michelle:
That’s great. Thank you, Monica. It’s been an enlightening conversation.
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