Senate Chairman To Hold Hearing On Abuse Of Seclusion & Restraints In Psychiatric Facilities
GAO Report Released, Citing NAMI's "Cries of Anguish"
We are heartened by the announcement of Senator William Roth (R-DE), chairman of the Senate Committee on Finance-with jurisdiction over Medicare and Medicaid and much of the nation's health industry-that he will hold a hearing later this fall on the abuse of seclusion and restraints in psychiatric hospitals.
The announcement coincided with the release of a General Accounting Office's report on such abuses. The GAO report credits NAMI in three instances for its compilation of cases over the last year in "Cries of Anguish," a report which summarized more than 40 incidents from 20 states.
People sometimes tell Congress that if something isn't broken, then please don't fix it. But what the GAO report tells Congress is not only that the system is broken-but frankly, there is no system. The GAO report confirms the findings of the investigative series published in The Hartford Courant in October 1998, which was inspired by reports from NAMI Connecticut families. Since the series appeared, more people suffering from mental illnesses have been killed or injured through the improper use of restraints.
The GAO report confirms what NAMI families already know from experience:
The status quo is a national disgrace and a national crisis. How many more must die before Congress passes legislation? The GAO Report must be used as a foundation for action. Congress must not let another year go by without putting in place standards and a system to protect people with mental illnesses against such abuses.
The U.S. General Accounting Office (GAO) is the investigative arm of the Congress. Their report, "Mental Health: Improper Restraint or Seclusion Use Places People At Risk," is available free from GAO by faxing a request to GAO at 202-512-6061 or writing GAO, PO Box 37050, Washington, DC 20013. The GAO Web site is www.gao.gov. Be sure to mention not only the report title, but report number GAO/HEHS-99-176, September 1999.
The GAO report was requested by Senators Joseph Lieberman (D-CT), Christopher Dodd (D-CT), Daniel Patrick Moynihan (D-NY), and Pete Domenici (R-NM) and Representatives Nancy Johnson (R-CT), Christopher Shays (R-CT), James Maloney (D-CT), Sam Gejdenson (D-CT), Rosa DeLauro (D-CT), and Pete Stark (D-CA).
Attending today's press conference were Senator William Roth (R-DE), Chair of the Senate Committee on Finance who announced his intention to conduct hearings on this issue this fall; Senator Lieberman, Senator Dodd, Rep Shays, Rep Gejdenson, Rep DeLauro, and Representative John Larson (D-CT). Senators Lieberman (S. 736) and Dodd (S.750) have previously introduced companion legislation in the Senate. The Dodd bill was added as an amendment to the Substance Abuse and Mental Health Services Administration (SAMHSA) reauthorization legislation (S.976) by a unanimous Senate Committee on Health, Education, Labor, and Pensions (HELP). In the House, legislation has been introduced by Representatives Diana DeGette (D-CO), Stark, and DeLauro (H.R. 1313.) Today, at the press conference, Rep Shays announced that he was introducing the Lieberman legislation in the House. H.R. 1313 is a more comprehensive bill than the Lieberman bill.
GAO's first sentence finding is that "improper restraint and seclusion can be dangerous to both people receiving treatment and staff, but the full extent of related injuries and deaths is unknown. There is no comprehensive reporting system to track such injuries and deaths or the rates of restraint and seclusion by facility." NAMI advocates mandatory reporting of all deaths and serious injuries to state based legal entities which can investigate these events and their circumstances.
GAO identified 24 deaths associated with restraint or seclusion in 1998. They caution the reader: "Because reporting is so fragmentary, we believe many more deaths related to restraint or seclusion may occur." This GAO research confirms that death and serious injury remain major problems in the nation.
NAMI endorses the GAO conclusion that "independent oversight and investigation contribute to patient safety."
NAMI advocates the use of independent third party monitoring groups to conduct unannounced inspections of facilities providing psychiatric treatment, including consumer and family staffed monitoring teams. On Tuesday, October 28, NAMI conducted a briefing at HCFA (Health Care Financing Administration) headquarters on consumer and family monitoring teams. NAMI brought into the HCFA HQ NAMI teams from Delaware, New Hampshire, Oklahoma, and Pennsylvania. The GAO report concludes: "External monitors complement internal quality control systems by providing an independent perspective...Some states allow trained lay monitors to visit mental health facilities unannounced and assess environmental conditions. In Delaware, for example..." (See pages 21-22 of the report for this description).
NAMI has called for enforceable national standards on the appropriate use of restraints representing best clinical practices. The GAO report concludes: "Federal and state regulations governing restraint and seclusion for individuals with mental illness and mental retardation are inconsistent across types of facilities. In July 1999, HCFA issued an interim final rule with revised Medicare conditions of participation for hospitals that address restraint and seclusion use. Although this is a positive step, people in residential treatment centers and group homes...have limited federal protection. While some states have regulations in place governing the use of restraint and seclusion, often these regulations do not apply to privately operated facilities."
NAMI has called for replication of evidence-based best practices. Specifically, NAMI has endorsed the practices used in Pennsylvania's state psychiatric hospitals. The GAO observes: "Pennsylvania reduced the use of restraint and seclusion by over 90 percent between 1993 and 1999 in state mental health facilities."
GAO further recommends: "To improve patient safety, we believe HCFA should, at a minimum, consider extending the same policies - tailored to the needs of individuals - on the use of restraint and seclusion that now protect individuals in long term care and hospitals to people in any treatment setting funded by Medicare and Medicaid. We also recommend that HCFA improve reporting of restraint and seclusion use and any related deaths or injuries and require staff training in safely applying restraint or seclusion as well as alternative methods for dealing with potentially violent situations." NAMI not only advocates mandatory reporting to state based legal entities and national standards based on best practice, NAMI also advocates allocation of funds for the expressed purpose of training treatment staff in alternatives to restraints and seclusion and the appropriate use of restraints and seclusion.
Pages 7 and 8 of the report cite NAMI's Cries of Anguish report of incidents reported by NAMI members to NAMI national. Please continue to send us these incidents. Send to the attention of Bob Carolla at firstname.lastname@example.org.
GAO observes that the "accreditation process relies on voluntary reporting, which tends to be incomplete." The hospital industry argues that existing accreditation, particularly that of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is adequate. But GAO challenges this reliance as limiting "information available for independent review" and notes that 21 of the deaths reported by the Hartford Courant since 1996 occurred in JCAHO accredited facilities.
GAO concludes that "the safeguards currently in place are not comprehensive and fail to fully ensure the rights and safety of these individuals."
JCAHO's Board-appointed Restraints Use Task Force has developed a set of draft standards that address the use of restraint and seclusion with behavioral health care patients. Draft proposals for revised standards have been prepared; however, the Task Force has not reached a consensus agreement on certain issues. The Joint Commission anticipates that this Field Evaluation will provide further insight into issues that have elicited persistent concern and lead to the approval of a set of standards that are comprehensive and effective for both implementation by provider organizations and protection of consumers of behavioral health services.
The Field Evaluation will consist of a questionnaire which will be mailed to provider organizations and their associations, professionals and professional organizations, government agencies, advocates, consumers of behavioral health services, and others with an interest in this issue. The anticipated mailing of this Field Evaluation will take place in mid-October and the draft standards will be posted on the Joint Commission Web site (www.jcaho.org) at that time. If you would like to receive a copy of this Field Evaluation, please submit your name, address, and telephone number to Amy Wilson, Joint Commission Department of Standards, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181 (e-mail: email@example.com) or fax your information to (630) 792-5876.
NAMI National board member Darlene Prettyman, R.N., and immediate past NAMI board member J. Rock Johnson, J.D., serve on the JCAHO restraints task force.