7. QUALITY MONITORING, ACCOUNTABILITY, AND ACCREDITATION
7.1 Governing Boards
(7.1.1) NAMI recommends that 51 percent of the members of all public and private governing boards of organizations that make decisions or recommendations affecting the lives of persons with brain disorders be other than providers.
(7.1.2) NAMI advocates that the Congress, state legislatures, and state executives require, through legislation and/or executive order, significant and meaningful consumer and family representation on, but not limited to, the following boards and councils: all policy-making boards and commissions having jurisdiction over private and public programs providing services to persons with brain disorders, advisory councils for SAMHSA and the Center for Mental Health Services, State protection and advocacy boards and advisory committees, State mental health planning councils, State planning councils for developmental disabilities, and all governing bodies that regulate licensing and quality assurance in the private sector.
(7.1.3) While NAMI welcomes opportunities for consumers and family members to participate in task forces, study commissions, and advisory bodies related to the service delivery system for brain disorders, NAMI does not consider such membership to be a substitute for full membership on governing bodies themselves.
(7.1.4) NAMI further urges associations of elected officials to similarly support such representation. While the appropriate number of such representatives will vary depending upon the function, purpose, and size of individual governmental and private entities, NAMI believes meaningful participation demands more than token representation. Therefore, such membership should be numerically adequate to assure an effective voice in deliberations, equity and balance in relation to other family perspectives, and opportunity to impact significantly upon the outcome of deliberations.
(7.1.5) NAMI also encourages private sector care providers to include consumer and family representation on their governing bodies. Where financial hardship presents an impediment to full participation, funds should be provided to facilitate attendance at meetings.
(7.1.6) NAMI strongly encourages consumers and family members to seek appointments to, and to participate in, relevant governmental activities at the local, state, and federal levels, including service on general purpose governing bodies and the pursuit of elective office.
7.2 Hospital Standards
(7.2.1) NAMI demands that admission, length of stay, treatment, and discharge policies of public and private hospitals must ensure that the basic rights of persons with brain disorders are protected. NAMI requires that, upon intake, the results of a thorough physical and psychiatric examination be incorporated into an individualized treatment plan. These examinations should include a psychosocial history taken from available records, families, and significant others. An intake evaluation that fails to consider these records and resources is inadequate because such records may be helpful in determining patterns of illness.
(7.2.2) NAMI urges the state departments with regulatory authority to enforce the same hospital standards upon the private sector as stated above.
(7.2.3) The team that develops an individual treatment plan should include the consumer, the consumer's service manager, medical personnel, and, when appropriate, family members. As the consumer progresses, the plan must be changed as needed to include appropriate psychosocial rehabilitation, education, and pre-vocational skills training compatible with the combined goals of the consumer and the community. The hospital discharge plan must ensure adequate housing, medical care, and continuation of the individual treatment plan with community support services and a services manager.
(7.2.4) NAMI deplores abuses such as false and misleading advertisements and the provision of unnecessary treatment. NAMI believes that the offer, payment, solicitation, or acceptance of a referral fee in relation to delivery of medical services is an unethical act of the most severe magnitude. Such fees should be prohibited by the canons of ethics of all relevant professional organizations. Any practitioner, facility, or organization that engages in such practices should be ineligible for reimbursement by private or public insurance and should be subject to criminal prosecution and penalties.
NAMI encourages all state psychiatric hospitals and other psychiatric facilities to provide within each facility a designated smoking area for consumers who smoke. We recognize the need that many consumers have to smoke. Most consumers use cigarettes as a calming agent or to ease the side effects of medication. A ban on smoking does not recognize the inconvenience placed on those who cannot leave the facility or where smoking outside offends facility neighbors. Further, it may cause some who need services to avoid seeking them in a building that bans smoking entirely. To expect someone who is psychotic to give up smoking suddenly is cruel.
7.4 Deaths in Institutions
NAMI demands systematic reporting of deaths in institutions as an aid to improving quality of care. Deaths in psychiatric hospitals, correctional institutions, and other residential facilities can be important indicators of the quality of care provided to patients, inmates, and residents, especially when such deaths result from accident or suicide.
7.5 Protection and Advocacy Services
(7.5.1) NAMI supports federal laws that recognize the value of family and consumer representation on the governing bodies of protection and advocacy agencies, require protection and advocacy services in all treatment settings, allow for the filing of grievances against the priorities of a protection and advocacy agency, ensure family and consumer input into federal regulations, and provide for consumer and family training of staff.
(7.5.2) NAMI holds protection and advocacy systems accountable for protecting consumers from sexual and physical abuse while in hospitals and/or other facilities.
7.6 Training of Professionals
(7.6.1) NAMI believes that all professional and other providers who care for persons with brain disorders need to be educated about these disorders and related, high-quality treatment and services. They must be sensitive to those affected. Staffing for facilities for persons with brain disorders must be sensitive to the cultures and ethnicities being served.
(7.6.2) NAMI believes that there is a severe shortage of competently prepared professionals in all disciplines to treat persons with brain disorders. NAMI calls on the appropriate government agencies to provide new institutional grants to universities for facility development and recruitment of persons with culturally diverse backgrounds and those who have worked with persons with brain disorders.
(7.6.3) NAMI supports federal budget expenditures for the clinical training of professionals that provide stipends to students in psychiatry, psychiatric rehabilitation, psychiatric social work, psychiatric nursing, and psychology programs at the baccalaureate, masters, and doctoral levels. NAMI believes that all grants must include a pay-back provision for two-years of service in a public sector setting.
(7.6.4) NAMI asks that all academic curriculum and training programs preparing providers to serve persons of all ages with brain disorders include knowledge based on scientific research, proven psychosocial skills for psychiatric rehabilitation in the community, and attention to the development of compassionate, caring, and accepting attitudes towards consumers and their families.
(7.6.5) NAMI requests that all pre-service training and continuing-education programs for providers be multi-disciplinary, culturally diverse, and targeted toward the development of clinical expertise in working with under-served people, including elderly persons with brain disorders, children and adolescents with brain disorders, and adults disabled by brain disorders.
(7.6.6) Fellowships must be provided to residents and junior faculty members in child psychiatry programs with adequate financial stipends for their training.
(7.6.7) NAMI identifies as an urgent priority the awarding of federal and state training grants for fellowships and stipends for advanced education of all professionals who want to specialize in the care of children with brain disorders.
(7.6.8) Educational materials must reflect current knowledge about the treatment of brain disorders.
(7.6.9) Consumers and family members should be encouraged to participate in the educational process of professionals and other providers who treat or work with persons with brain disorders.
(7.6.10) NAMI calls upon faculty of seminaries and schools of religion of all denominations to prepare clergy for service by including content about brain disorders in their curricula.
(7.6.11) NAMI endorses an affirmative action policy for recruiting consumers with brain disorders as students in educational programs that will prepare them for careers in the service delivery system.
7.7 Accreditation of Facilities and Programs
(7.7.1) NAMI urges that all facilities and programs serving persons with brain disorders, including: hospitals, community mental health centers (CMHCs), clinics, day centers, psychosocial rehabilitation programs, vocational programs, community housing, correctional institutions (jails, prisons, and diversion programs), nursing homes, other institutions, and networks and programs seek accreditation as a means of avoiding at least some of the most conspicuous shortcomings they might possess.
(7.7.2) NAMI also urges that all facilities and programs serving persons with brain disorders should use vigorously the devices of periodic self-study with impartial, external review to seek continuously the improvement of their performance. The self-study process should include full participation of consumers and family members. Such participation as well as membership on the governing boards should be one standard for accreditation. Such external review should include broad and convenient opportunities for confidential interviews with consumers and members of their families.
7.8 Use of Restraints and Seclusion
(7.8.1) The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one’s self or others. These extreme measures can be justified only so long as, and to the extent that, the individual cannot commit to the safety of themselves and others. (Revised February, 1999)
(7.8.2) Restraint and seclusion have no therapeutic value. They should never be used to "educate patients about socially acceptable behavior;" for purposes of punishment, discipline, retaliation, coercion, and convenience; or to prevent the disruption of the therapeutic milieu. (Revised February, 1999)
(7.8.3) Restraints shall be used only on the order of a physician with competency in psychiatry or a licensed independent practitioner recognized by state law. These professionals must be competent in providing alternatives to restraint, eliminating circumstances which give rise to the possible need for restraint, and applying restraints in safe and appropriate use. Restraints shall only be used for emergency safety use. Within an hour of initiating restraint, the physician or licensed independent practitioner shall complete a face-to-face evaluation of the patient. While in restraint the patient shall be continually and directly observed, person-to-person, by an appropriately trained professional. Specific behavioral criteria written by the physician, including the patient's verbal assurance of safety, shall specify when the restraints will be discontinued, to ensure minimum usage. (Revised April, 2000)
(7.8.4) Every restraint shall generate an incident analysis. An incident analysis is a process of identifying the basic or causal factors that underlie variation in performance, including occurrence or possible occurrence of a reportable event. The incident analysis shall be available to the designated legal entity within the state which will investigate reportable deaths and serious injury. Any death or serious physical injury associated with the use of restraint shall be reported to a designated legal entity within the state for investigation. (Revised February, 2000)
(7.8.5) The family, client, and involved staff should undergo a debriefing after each restraint or seclusion incident, within 24 hours. The circumstances leading to the restraint or seclusion and a discussion of why alternatives to restraint or seclusion failed should be documented in the clinical record. Future suggested interventions should be discussed at these debriefings. Following each use of restraint and seclusion, the patient should receive counseling specific to the incident. (Revised February, 2000)
(7.8.6) Treating professionals must adhere to the patient’s advance directive, if there is one. (Revised February, 1999)
(7.8.7) Medication is typically important for the treatment of the symptoms of mental illness. However, medication should never be used for the purposes of discipline, staff convenience, immobilization, or reducing the ability to ambulate.
(7.8.8) Any institution using seclusion, restraint, time-out, or brief physical holds must provide appropriate initial and recurrent training of staff, not only in the safe application of these interventions, but also in techniques of de-escalation which reduce the need for these interventions. No staff member should be involved in seclusion or restraint before completing the required training. (Added April, 2000)
(7.8.9)When treating children and adolescents with mental illnesses, facilities and governing policies should differentiate between seclusion, inclusionary time-outs, and exclusionary time-outs. (Added June 2000)
(126.96.36.199)Seclusion is the involuntary placement of a child or adolescent, for any period of time, in a locked room where the child or adolescent is alone and is physically prevented from leaving. (Added June 2000)
(188.8.131.52)Inclusionary time-out is an involuntary procedure where a child or adolescent is separated from his/her peers in the presence of his/her peers. (Added June 2000)
(184.108.40.206)Exclusionary time-out is an involuntary procedure where a child or adolescent is separated in a designated area away from his/her peers but is not physically prevented from leaving. (Added June 2000)
(7.8.10)If children and adolescents are to be secluded, the order must be by a physician or a licensed independent mental health practitioner competent in these procedures and recognized by state law. (Added June 2000)
(7.8.11)While in seclusion and/or restraint, the child or adolescent should be constantly, visually monitored by staff. Video monitoring, if used by itself, is not sufficient. (Added June 2000)
(7.8.12)When treating children and adolescents with mental illnesses, mechanical restraint, brief physical holding, and "therapeutic holding" should be differentiated. (Added June 2000)
(7.8.13)Mechanical restraint should be generally avoided and used only in rare circumstances to protect the child or adolescent from self-harm and harm to others in emergency situations. (Added June 2000)
(7.8.14)Brief physical holding is a form of temporary physical restraint and is different than "therapeutic holding." "Therapeutic holding" is not supported by adequate scientific evidence or detailed practice guidelines, and, therefore, is not supported by NAMI as an accepted form of treatment. (Added June 2000)
(7.8.15)Brief physical holding should only be carried out by professionally recognized and trained mental health professionals licensed by a governmental body. (Added June 2000)
(7.8.16)Escorting and immediate physical separation of children and adolescents in conflict are not considered restraint. (Added June 2000)