Why Safety Checks are so Hard.
The unexpected difficulty of safety check compliance for inpatient and residential behavioral health providers. (Q15s, etc.)
Safety checks (visually observing each patient) are one of the best ways to ensure patient safety for behavioral health programs. In fact, a brief review of CMS-reported safety incidents will show that missed safety checks are almost always a contributing factor or cause for sentinel events (patient suicide, self harm, violence, elopement, etc). In addition to ensuring patient safety, frequent checks give caregivers a regular opportunity to monitor patient well-being & comfort.
Safety checks are a required component of any high acuity or residential behavioral health program, but nobody (CMS/Joint Commission/etc.) provides instructions for how to do them. It’s up to the organization to decide what type of system to implement and how to monitor for compliance.
What is a safety check?
It depends on your program and clients. Let’s look at two broad categories. Residential addiction treatment programs and inpatient psychiatric hospitals.
Residential Treatment
Residential Treatment Safety Checks
At residential treatment centers (addition treatment, recovery, etc.), safety checks are conducted every 30 minutes or every 60 minutes depending on the program & client need. They are typically referred to as “30-minute checks”, “hourly checks”, or “safety rounds”. Addiction programs treat lower acuity patients than inpatient psychiatric programs and have more ‘open’ programming and facilities. As such, the practical purposes for safety checks are:
Regularly locating all patients on campus
Reducing sexual/inappropriate encounters between clients
Reducing elopement
Monitoring client-specific risks (ie. purging, isolation, etc.)
Psychiatric Hospitals
Psych Hospital Safety Checks (Q15)
Inpatient psychiatric programs are typically double-locked door units with higher staff-to-patient ratios and anti-ligature precautions. A safety check, called “Q15” in psych settings, is conducted every 15-minutes on each patient. Patients may also be placed on higher-level observations like “Close Observation,” where the patient is to be within line of sight at all times, or “1-on-1”, where an individual tech, “sitter,” is within arms reach of the patient at all times. Compared to the addiction programs, elopement is relatively rare (though it does occur). The goals of Q15s on a psych unit are:
Reducing Suicide
Reducing Self-Harm
Reducing Homicide/Violence
Monitoring patient-specific risks (falls, swallowing, etc.)
Safety checks seem easy...
In theory, safety checks are easy; get eyes on each patient on a regular interval. But, as with most things, the devil is in the details and in practice there is surprising difficulty in implementing and managing a fully compliant (read “100% compliant”) safety check process.
Why are safety checks so hard?
There are a number of factors that turn ‘easy’ Q15 checks into something complex and difficult.
Documentation Requirements:
Most programs require caregivers to document:
patient name
patient location
patient activity or affect
time of day or time period
caregiver signature/initials
Multiply those requirements across an average 25-bed unit, and you can quickly see how it may become one or two health techs’ full time job to conduct and document Q15s.
Scale:
A 100-bed psych hospital conducts at least 9600 Q15 checks per day. 😳
A single staff member may be responsible for conducting 400+ safety checks during their shift.
Repetition:
After the 300th Q15 check, it may be hard for a health tech to remember, “Did I just see John Doe, or was that last round?”
Things Happen:
Unexpected crisis events interrupt safety checks frequently.
Two patients start fighting.
A client can’t be located.
All-hands-on-deck are needed to restrain a patient.
Responsibility:
Which caregiver is responsible for each patient? What if the caregiver needs a bathroom break?
Variability:
Over the course of a day a unit may have 2 patients on 1-on-1s, 1 patient on close observations, 20 patients on Q15s, 1 patient in court, 1 patient in dialysis. The unit may need to flex caregivers in from an adjacent unit or send caregivers home early if the staffing ratios are too low or too high.
Maybe it is a full moon; the ER is maxed out and there are 4 admits waiting at 11pm.
The Hard Truth
The hard truth of safety checks is that there are thousands to complete per day, they are hard, they are repetitive and … they are not happening. This will come as a shock to almost no-one in the industry. It is an unfortunate reality with the current safety check systems; paper & EHRs.
Paper is efficient but easy to cheat.
Paper can be an efficient and flexible documentation system for safety checks. However, the term “pencil whipping” has been associated with this system because of how common it is for health techs to pre-fill, back-fill, fill-without-doing-the-round, etc. Falsification is a known issue with paper rounding, but is also very hard to monitor. Managers are forced to do spot-checks, random audits, and all sorts of inefficient monitoring, in hopes(?) that they might happen to catch a situation where the tech didn’t leave the nurses station, backfilled, or falsified their checks.
EHRs are accurate but impossible to complete.
Moving this failing paper process to an EHR seems like a no-brainer. The EHRs must have a safety check module, right? Usually, no. Many EHRs will charge your program for a ‘custom build’ that may take a few weeks months or years to complete. Furthermore, these EHR systems typically require computer data entry - so the MHT would need to go back to a computer between each check? Maybe the system will work on a tablet, but then you get the worst of both worlds… Using a system on a tablet that was designed for a computer + lugging around an iPad that doesn’t easily fit in a pocket for quick use of hands. The systems usually require multiple clicks/pages/typing for each safety check which means that they take longer to complete. When rounding on 25 patients, a health tech would need to be constantly documenting just to have a chance at getting their rounds submitted on time.
There is another way (mobile technology)
Advancement in mobile technology has unlocked new possibilities for behavioral health programs. The best parts of mobile tech can be used to simplify and improve safety checks; hand-held, mobile, real-time, efficient, alerts & notifications, GPS + Bluetooth capable, the list goes on. These tools can be used, and are being used, to solve the problem of non-compliant safety checks.
But it’s not perfect…
Moving towards a mobile solution is what we recommend, but it still has challenges. The app used for safety checks needs to be simple and efficient to use. The devices need to be GPS tracked so that they are not stolen or accidentally taken home by staff. They need to be managed/locked for HIPAA security reasons (i.e. no Facebook, no camera, etc.). They need to be hand-held so that caregivers can have quick access to both hands (not a tablet). They need to have reliable internet connectivity (harder than it sounds!). They need to be affordable and durable. They need to be a useful power-tool for staff, not a distraction. All of these issues need to be considered prior to implementing a mobile Q15 system.
Can’t electronic systems be cheated?
Yes 😔. A mobile app can be just as easy to ‘pencil-whip’ as a piece of paper. What would stop a health-tech from documenting patient checks without leaving the nurses’ station? These things can happen. Fortunately, with electronic rounding there are options available to solve this problem.
Timestamps: The time that each check is documented can be monitored. When there are signs of pencil-whipping (20 checks in 1 minute?!? Seems fishy.), an alert/flag can be sent to the management team to follow up with that staff member.
Bluetooth Proximity: With the Bluetooth capabilities of mobile devices, Bluetooth patient ID bands can be used to measure the proximity between patients and staff during each safety check. This allows for safety checks to be verified.
Do more with Q15 data.
It sounds odd, but the “best case scenario” with paper Q15 data is that you will never see or use it again. You send it to the records office to store or scan and hope that it is never needed for an audit/lawsuit/etc. Over 50,000+ data points per day containing valuable information about your patients, their activities, their locations, and your caregivers are seldom, if ever, seen again.
With electronic Q15 systems, this data can actually be used for business & clinical benefit. Data from safety checks can answer critical questions.
How are your patients sleeping? (it’s in the Q15s)
Who are my high and low performing staff? (it’s in the Q15s)
What times or shifts are high risk for my facility? (it’s in the Q15s)
Which units are performing better and can we replicate those best practices across my campus? (it’s in the Q15s)
Summary
Safety checks are hard. Surprisingly hard! In most facilities compliance is a constant struggle. Managers are settling for ‘good enough’ and losing sleep hoping for no safety incidents. Just as there are challenges in creating safe & compliant environments for behavioral health programs, it is similarly difficult to implement a documentation process that meets the needs of your program. Paper, EHRs, Mobile? They all have challenges. The good news - If you can overcome the challenges, not only will units be safer, but you will unlock new value & insights from previously unused safety check data.
If you want to quickly implement solutions for the safety check challenges described above, you might try VisibleHand. Our mission is to help residential and inpatient behavioral health providers reach and maintain 100% safety compliance. We use the latest technology to make safety checks easier for your caregivers and give your teams information to address safety risks BEFORE sentinel events occur. If time is of the essence (recent sentinel event?) VisibleHand can be implemented in as little as two weeks. Our clients trust us to solve this problem and we would love the opportunity to earn your trust, too.