1. Illinois Division of Mental Health Quality & Safety Improvement Initiative Charter Team Topic: Risk Assessment: Elopement Hospital: Chester Mental Health Center QCSI III Charter Teams Report Out Meeting June 24, 2013 – Springfield, IL DRAFT: For Review and Discussion1

2. Charter Team Members Charter Team Leader: Rhonda Wilson, RN, MS Quality Manager Tim Mueller, BS, Acting Assistant Hospital Administrator Eric Butz, STAIV Dave Horn, Activity Therapy Coordinator Bobby Misuraca, STAIV Dr. Maitra, Medical Director Mark Troue, RN, BS, Training Coordinator DRAFT: For Review and Discussion2

3. Topic: Elopement: Overview of Deliverables Develop a risk assessment for elopement upon admission and during stay. Develop an oversight process to ensure identified risk is evaluated and determine needed outcomes. Develop preventative interventions to deter elopement while inpatient and during transport and ongoing elopement assessment. Develop training curriculum to train the risk assessment and prevention plan. DRAFT: For Review and Discussion3

4. QCSI Charter Team Work Process Literature Review – Elopement Risk Literature search – Fields SHACK Site Review of other facility Elopement Risk Assessment Tools/Processes – Elgin, Madden, Chicago Read, McFarland, TDF Face to Face Meetings with Charter Members Policy and Risk Assessment Tool Revision/ Development DRAFT: For Review and Discussion4

5. Difficulties/Barriers Time constraints as no facility had a current policy on Elopement assessment and interventions to prevent elopement. Assessments were completed by psychiatrist on admission in the IPE. A few facilities has a few questions to identify risk on admission but no other formal policies were identified with the exception of how to grant patient movement privileges and how to address a patient once they have eloped. The committee developed objectives and met to achieve the charter expectations. DRAFT: For Review and Discussion5

6. Deliverables/Work Products Developed a policy/program directive to address identification of risk, determining an elopement risk level and implement strategies to prevent elopement once an elopement risk individual is identified. Development of an Elopement Risk Assessment Tool (ERAT). Developed Training curriculum and knowledge based tests to evaluate and ensure staff are knowledgeable in the policy and appropriate risk reduction strategies. DRAFT: For Review and Discussion6

7. Outstanding Questions/Issues Tried to make the ERAT assessment questions weighted to place more importance on history of attempts or obvious behaviors indicating patient plans to elope. Found it too difficult to develop a score that would accurately reflect if patient is at high versus medium risk that isn’t affected by multiple risk factors including the patients history, physical capability, and the patients current presentation. Ultimate level of risk is at the psychiatrists discretion. DRAFT: For Review and Discussion7

8. Lessons Learned/Recommendations Found the creation of something new was challenging yet rewarding. Found it was beneficial to have direct care staff work on the rough draft that resulted overall in a great policy and assessment tool. Charter team worked with QA, Medical Director and Training Coordinator to develop the deliverables with a final product being a quality elopement policy and process. DRAFT: For Review and Discussion8