Supporting service provider organizations in reducing restraints in The Netherlands Marjolein van Vliet, RN, PhD, Project manager Vilans, Centre of expertise for long-term and social care Utrecht,

Definition of restraints or coercive methods All kinds of measures, physical and verbal, to restrict cliënts and patients in their freedom of movement and to live their life as wanted. This includes: belts, padded cells, individual rules and engagements, house rules, electronic measures, medication.

Case ‘We thought it wasn’t that bad with restraints in our organization. However when we listed them we were shocked to learn that we restrict the freedom of our clients in many ways. We just never realized. For example, clients were allowed to drink coffee at designated places and times and nowhere else. Or a wheelchair which was always parked with the brake on, doors of homes that were always locked. We weren’t happy with these discoveries, so we knew: we have some work to do.’

Framework Care for Better, large improvement program in long term care in The Netherlands Initiated and payed for by Ministry of Health Topics on patient safety and patient autonomy, e.g. medication safety, preventions of falls Reducing restraints

Background reducing restraints An increase of severe incidents Report Inspectorate of Healthcare (2008) Declaration of intent (2008) Upcoming new Dutch legal framework (2009)

Reducing restraints In eight collaboratives 134 teams Aim of project: To prevent or reduce restrictive measures on clients and to apply less severe restraints or alternatives

Participating service provider organizations

Results A reduction of 30% - 60% in restraints More client friendly approaches (technology) Client focused approach End of rituals and routines! Great diversity in alternatives Less medication use No increase of falls or aggression

Methods Multidisciplinary improvement teams Analysis of quality criteria Measurements: awareness Exercises to raise awareness Thorough analyzing each individual case Search for alternatives Improvement method: breakthrough, PDSA cycle

measuring = knowing (better) Instructions Reducing restraints

Awareness ‘The first measurement provided useful information. The Geeltjesmeting /sticky pad measure and the analysis of quality criteria provided insight in what we do well and where there was room for improvement. It seemed that staff lacked expertise and the preconditions were poor.’

Outline of the programm Several national conferences in Utrecht Presentation of good practices Goal oriented Learning and sharing knowledge Evidence based and practice based Improvement method, PDSA cycle

Outline of the project Plan DoStudy ActPlan DoStudy ActPlan DoStudy Act 1 st working conference 2 nd working conference Final meeting Kick-off Intakes 1st action period First measurement and analysis Improvementplan Internal kick-off 2nd action period Improving Measuring Communicating 3rd action period Improving Measuring Communicating Sustaining & Spreading good practice Expertmeetings

Support by project team Vilans Phone (monthly) Monthly reports Extranet Toolkit Meetings Expertteam/best practices

Discussion: Success and failures Measure Communication Step-by-step (PDSA) Involving clients and family Celebrating successes Thorough analysis Exchanging experiences Changes in staff Incidents Resources Pressure on organizations Resistance and opposition (both in staff and family)

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