8. Quality Monitoring, Accountability and Accreditation

8.1 Governing Boards

(8.1.1) NAMI recommends that at least 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 serious mental illnesses be persons with serious mental illnesses, their families and friends.

(8.1.2) 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 serious mental illnesses, 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.

(8.1.3) 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 serious mental illnesses, NAMI does not consider such membership to be a substitute for full membership on governing bodies themselves.

(8.1.4) 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.

(8.1.5) 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.

(8.1.6) 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.

(8.1.7) NAMI urges its members to join institutional review boards that review current research studies and research grant committees as advocates for persons with mental illness, their families and friends.

8.2 Hospital Standards

(8.2.1) 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 serious mental illnesses 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.

(8.2.2) NAMI urges the state departments with regulatory authority to enforce the same hospital standards upon the private sector as stated above.

(8.2.3) 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. NAMI believes that the offer, payment, solicitation, or acceptance of a referral fee in relation to delivery of medical services is unethical.

(8.2.4) People living with mental illness should have ready access to their natural supports while receiving hospital treatment. NAMI supports the increased availability of telephone access for individuals in their hospital rooms. As with any other ward in a hospital, psychiatric hospital rooms should have telephones in their rooms allowing private, confidential telephone conversations. This can avoid the frustration, for patients and family and friends of patients, of missed calls, long waits, busy signals and having to ask permission for access to a standard patient right. During group therapy or class activity time, these phones can be shut off from a central location so as not to disturb the therapeutic milieu.

Patients have the right to send and receive mail. Because of technological advances, most people use email. Psychiatric hospitals should allow for access to email accounts for people who use email as a primary link to friends, family and other supports. Also because of our reliance on technology to store information we encourage access to cell phones so that individuals may locate their electronic address books for their contact numbers.

A goal of the inpatient environment is to have an experience similar to that of their community. Most other hospital rooms provide televisions. NAMI believes that people who are hospitalized for mental health treatment should similarly have televisions in their rooms.

In certain instances, it may be determined in person centered clinical meetings that unlimited access to phones, electronic communications, and/or television would be harmful for an individual. This should be considered on a case by case basis and not become a default action or used for punitive purposes.

NAMI strongly encourages the expansion of visiting hours for family and friends in recognition of the long drives and difficulties experienced by family members and friends making visits to their loved ones. This supports the importance of encouraging family involvement in treatment whenever possible. 

8.3 Tobacco Addiction

(8.3.1) NAMI is committed to supporting in every way the wellness of people with mental illness and in recovery. NAMI recognizes that cigarette and other tobacco use is a dangerous form of addiction. Such addiction creates more significant health problems for people with mental illness and in recovery. People with mental illness and in recovery have the right to be smoke free and tobacco free. Effective prevention and treatment, including treatment of the effects of withdrawal, are available and should be part of effective mental health care treatment and recovery. People with mental illnesses must be given education and support to make healthy choices in their lives.

(8.3.2) Research shows that people with serious mental illnesses are twice as likely to smoke as the general population and that people with schizophrenia are three to four times as likely to smoke as the general population. The negative health effects of cigarette smoking and other tobacco use on personal health are well documented, including increasing risks of respiratory problems, cardiovascular disease, and certain forms of cancer. The negative health effects of exposure to “second hand” smoke are also well documented.

(8.3.3) Smoking has been inappropriately accepted and even encouraged in therapeutic settings for treatment and recovery. Access to smoking is sometimes used coercively and can be a source of disruption in treatment facilities. Smoking and other tobacco use also increase stigma.

(8.3.4) Therefore, NAMI supports and encourages smoke free and tobacco free environments in treatment and other health care facilities, group centers and common areas in housing, including prohibiting smoking and other tobacco use by health care providers, caregivers and others working in and visiting such facilities, centers and housing. NAMI opposes any practice that uses access to smoking and tobacco as a form of coercion or reward.

(8.3.5) At the same time, NAMI recognizes that the best time to provide and support smoking and other tobacco use cessation is not when consumers are in crisis because such treatment may exacerbate psychiatric symptoms and other conditions. Nicotine addiction is powerful and withdrawal is difficult for the general population, so it is particularly difficult for individuals experiencing a psychiatric crisis. Research indicates significant interactions of smoking and smoking cessation with certain psychotropic medications that can be improved through effective dosage regulation and nicotine replacement. Research further indicates certain secondary, health issues associated with smoking and other tobacco use cessation, including weight gain, that require effective monitoring, counseling, peer support, self-help and treatment.

(8.3.6) Therefore, NAMI supports consumers in seeking smoking and other tobacco use prevention, cessation and recovery as essential to overall wellness in treatments and in programs available in the community. NAMI calls upon physicians and other health care providers, in community and inpatient settings, as well as group centers and programs, to implement educational and tobacco use cessation programs to help consumers stop and avoid tobacco addiction. Treatment and other facilities instituting smoke free policies must provide effective tobacco addiction treatment and support to consumers as well as health care providers, caregivers and others working in such facilities, who use tobacco products. Effective treatment and support must include:
(a) Smoking and other tobacco use cessation strategies and ongoing support;
(b) The most effective nicotine substitution products for individuals with nicotine dependence, as well as other medical approaches with proven effectiveness;
(c) Socialization, recreational and other structured activities;
(d) Counseling, peer support and other therapeutic supports;
(e) Careful assessment, monitoring and adjustment to medication regimens as appropriate; and
(f) Effective assessment, monitoring and assistance with respect to diet, nutrition and exercise to avoid weight gain and other common secondary effects of smoking and other tobacco use cessation.

(8.3.7) NAMI further supports incorporating tobacco usage in the definition of dual diagnosis; integration of mental health care and overall health care; more effective research at all levels on smoking, tobacco addiction and mental health treatment; and funding (including Medicaid and other public sources) to provide access to effective smoking prevention, cessation and recovery.

8.4 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.

8.5 Protection and Advocacy Services

(8.5.1) 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.

(8.5.2) NAMI holds protection and advocacy systems accountable for protecting consumers from sexual and physical abuse while in hospitals and/or other facilities.

8.6 Training of Professionals

(8.6.1) NAMI believes that all professional and other providers who care for persons with serious mental illnesses 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 serious mental illnesses must be sensitive to the cultures and ethnicities being served.

(8.6.2) NAMI believes that there is a severe shortage of competently prepared professionals in all disciplines to treat persons with serious mental illnesses, particularly in low income communities or rural areas, or who can serve people of all diverse racial, ethnic, linguistic, disability and sexual orientation backgrounds. 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 serious mental illnesses.

(8.6.3) 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.

(8.6.4) NAMI asks that all academic curriculum and training programs preparing providers to serve persons of all ages with serious mental illnesses include knowledge based rehabilitation, recovery and resiliency models in the community, and attention to the development of compassionate, caring, and accepting attitudes towards consumers and their families.

(8.6.5) NAMI believes that all academic curricula and training programs, to be successful, must involve family members and consumers.

(8.6.6) NAMI requests that all pre-service training and continuing-education programs for providers be multi-disciplinary, culturally competent, and targeted toward the development of clinical expertise in working with under-served people, including elderly persons with serious mental illnesses, children and adolescents with serious mental illnesses, and adults disabled by serious mental illnesses.

(8.6.7) Fellowships must be provided to residents and junior faculty members in child psychiatry programs with adequate financial stipends for their training.

(8.6.8) 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 serious mental illnesses.

(8.6.9) Educational materials must reflect current knowledge about the treatment of serious mental illnesses. Professionals and other providers must understand and value recovery from mental illness and integrate its concept into their professional practice. All professionals serving persons with mental illness should encourage implementation of advance directives or healthcare proxies.

(8.6.10) 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 serious mental illnesses.

(8.6.11) NAMI calls upon faculty of seminaries and schools of religion of all denominations to prepare clergy for service by including content about serious mental illnesses in their curricula.

(8.6.12) NAMI endorses an affirmative action policy for recruiting consumers with serious mental illnesses as students in educational programs that will prepare them for careers in the service delivery system.

8.7 Accreditation of Facilities and Programs

(8.7.1) NAMI urges that all facilities and programs serving persons with serious mental illnesses, 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. The accreditation process can be a means of avoiding at least some of the most conspicuous shortcomings all such facilities and programs might possess.

(8.7.2) NAMI also urges that all facilities and programs serving persons with serious mental illnesses 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.

8.8 Use of Restraints and Seclusion

(8.8.1) 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.

(8.8.2) 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.

(8.8.3) 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.

(8.8.4) 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.

(8.8.5) 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.

(8.8.6) Treating professionals must adhere to the patient’s advance directive, if there is one.

(8.8.7) 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.

(8.8.8) 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.

(8.8.9) When treating children and adolescents with mental illnesses, facilities and governing policies should differentiate between seclusion, inclusionary time-outs, and exclusionary time-outs.

( 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.
( 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.
( 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.

(8.8.10) 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.

(8.8.11) 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.

(8.8.12) When treating children and adolescents with mental illnesses, mechanical restraint, brief physical holding, and "therapeutic holding" should be differentiated.

(8.8.13) 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.

(8.8.14) 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.

(8.8.15) Brief physical holding should only be carried out by professionally recognized and trained mental health professionals licensed by a governmental body.

(8.8.16) Escorting and immediate physical separation of children and adolescents in conflict are not considered restraint.

8.9 Application of Less Lethal Weapons by Law Enforcement Officers

(8.9.1) The National Alliance on Mental Illness (NAMI) believes that the use of conducted energy devices (including stun guns, tasers, impact delivery systems, or any other similar non-firearm weapons)used by law enforcement officers responding to individuals with serious mental illness should be permitted only if the responding officer concludes that an immediate threat of death or serious injury exists, which cannot be contained by lesser means, and/or is likely to be hazardous to the officer(s), the individual, or a third party. Such devices should not be deployed when other means or methods of de-escalations are appropriate, available, and suitable for the crisis event, nor should these devices ever be used as a means of intimidation or inappropriate coercion.

(8.9.2) NAMI further believes that states should include, in statute, a requirement for the development and enforcement of standards and minimum training requirements for all law enforcement, corrections and other personnel who use or may potentially use these devices in the performance of their duties. This mandatory training must include information about effective methods of responding to people with mental illness in crisis with verbal and non-verbal crisis de-escalation techniques.

(8.9.3) States should also strictly define in statute categories of professionals who are authorized to use these devices in the performance of their duties and should strictly prohibit usage of these devices by those not identified as authorized users in statute.

(8.9.4) NAMI calls upon the states and the federal government to fund and promote research that documents the incidence of use of these devices and investigates both the short term and long term physical and psychological impact on people who have experienced the application of such devices. This research also should determine the potential dangers associated with risk factors, including but not limited to age and pre-existing medical conditions.

(8.9.5) Each use of these devices should be investigated by the respective law enforcement agency or institution in the same way that use of a firearm would be investigated by a law enforcement agency.