Restraints Compliance Reporting

ENTERPRISE-WIDE JOINT COMMISSION RESTRAINT ASSESSMENT REPORT ESTABLISHED

The Challenge

Our client, a large, academic medical center, had an issue not uncommon to other health systems – keeping track of patients with restraints. Placement of patients on restraints, restraint discontinuation, type of restraints, and other conditions related to the hospital stay are important reporting criteria to capture for the Joint Commission. Restraint flowsheets in the electronic health record (EHR) were in place for clinicians to capture the correct data, but the information was, then, manually collected and tabulated from the flowsheets requiring an excessive number of laborious hours to complete; a high potential for human error was a concerning factor.

The Solution

To help mitigate the risk of misreporting and reduce the number of man hours to complete the regulatory reporting, the JC Restraint Log Violent and Non-Violent Assessment Report was created. Using custom input parameters, the end user can enter specific criterion, such as dates, locations, and whether the report is for violent or non-violent restraint scenarios. It also has the ability to be generated on an as needed basis. The output includes a display of caregiver compliance, including percentages for patients in restraints, patient responses, and whether family notification was completed. It also reports whether there were orders in place for initiation of the restraints and if an order for discontinuation was present when the restraints were removed. This custom solution provides the ability to “drill down” to view the patient-level flowsheet documentation showing times the restraints were added and removed along with the administrator of the activity.

The Benefit

The report took a manual process and automated it in its entirety. Reporting to the Joint Commission is now completed in a timely manner with a much higher rate of accuracy and confidence in its validity. In addition, the report assisted in identifying opportunities where additional training for the nurses and caregivers was needed to improve data entry into the EHR system. Serving as a vehicle to demonstrate commitment and compliance to Joint Commission guidelines, the organization continues its efforts to improve how it adheres to the existing regulations and improve patient safety.

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