Journal of Patient Safety and Risk Management

Lamb et al. developed the metric for the observation of decision-making tool (MTB-MODe) to evaluate the quality of urologic multidisciplinary cancer conferences (MCCs) in the United Kingdom. We used generalizability theory to assess the reliability of a modified version of MTB-MODe in a North American context. Specifically, we wished to determine if the tool could distinguish between high- and low-quality MCC decision-making.

Two assessors independently evaluated two MCCs (MCC1, MCC2) using the modified MTB-MODe. Generalizability theory was used to assess overall tool reliability and to identify sources most likely to contribute to variance in reliability scores. A total of 60 cases were evaluated.

The overall reliability scores of MCC1 and MCC2 were 0.72 and 0.74, respectively. Inter-rater reliability scores were reasonable (>0.55) and raters did not contribute significantly to variance in reliability scores. Internal consistency of the individual MTB-MODe items was low, demonstrating that items were not highly correlated.

The MTB-MODe reliably assessed the quality of individual MCC cases. Raters did not contribute significantly to reliability scores, suggesting that the tool can be successfully implemented using a single rater. Low internal consistency of the MTB-MODe items demonstrates that the tool can be used to provide feedback on individual tool items. Such data can be used by stakeholders to help improve MCC quality.

Seclusion and restraint are procedures utilized in youth psychiatric settings. While a number of agencies have called for a reduction and ultimate elimination of the use of these practices, there has been limited research on behavioral programs to reduce seclusion/restraint. This is particularly true for research on behavioral programming in youth psychiatric partial hospital settings. As such, the current study sought to examine the effectiveness of a modified version of Positive Behavioral Interventions and Supports (M-PBIS) implemented on a youth psychiatric partial hospital service to reduce seclusion/restraint.

This naturalistic, prospective study covered a 26-month period and utilized a pre–post design. M-PBIS features include a defined set of positive behavioral expectations, a system to teach behavioral expectations, reinforcement of appropriate behaviors, data collection/evidence-based decision making, individual support for those not responding to the unit-wide system, active support by all stakeholders (including all staff members agreeing to the program), and positive recognition among staff.

With a sample of 442 admissions, there were meaningful reductions in the percent of patients who were in seclusion/restraint (from 47.6 to 6.7%) as well as the overall seclusion/restraint rate (from 3.56 (SD = 1.94) to 0.48 (SD = 0.64)). Furthermore, there was a significant reduction in the use of Pro Re Nata (PRN) medication for agitation/aggression (percent of patient who received a PRN decreased from 33.3 to 12.9%).

This naturalistic study suggests that M-PBIS is a promising intervention for use in youth psychiatric partial hospital services to reduce seclusion/restraint and PRN medication for agitation/aggression. Reduction and ultimate elimination of seclusion/restraint is a critical objective in improving the quality and safety of acute mental health services for youth.

Communication and resolution programs have emerged as central to organizational responses to serious patient harm events, with demonstrated evidence of patient safety and medicolegal outcome improvements within a handful of healthcare systems. Hospitals, including those with open medical staffs, have struggled implementing communication and resolution programs, particularly around the components supporting resolution. Here, we describe our lessons learned early after implementing the resolution (“R”) component of Communication and Optimal Resolution, a comprehensive contemporary communication and resolution program at MedStar Health, a large community health system in the United States.

MedStar Health is a regional healthcare system with 10 hospitals, 250 ambulatory care delivery sites, and 20 diversified businesses in the mid-Atlantic region of the United States. MedStar Health initiated Communication and Optimal Resolution implementation in 2015.

Our approach to resolution following patient harm yielded seven strategies supporting our resolution process. These included infrastructure and processes to (i) provide immediate support to patients and families, (ii) hold and waive bills, (iii) activate event review processes early to inform resolution, (iv) embrace a paradigm shift in legally defensible cases, (v) develop a communication and resolution program legal community, (vi) accept sacrifices with a principled resolution, and (vii) commit to address challenges with open medical staffs.

The resolution process in response to serious patient harm is complex. Our early experience in implementing the “R” of Communication and Optimal Resolution required enhanced infrastructure, embracing the clinician, legal, and insurance communities and instructing them in the principles of communication and resolution program, and a strong organizational commitment to “doing the right thing” for patients and families.