Achieving Restraint Reduction in a State Psychiatric Hospital:
A Lean Six Sigma Project
Kenneth T. Kinter, MA
Jeffrey Uhl, Psy.D.
Ancora Psychiatric Hospital
Kinter K.T. & Uhl J.. (2017) Achieving Restraint Reduction in a State Psychiatric Hospital:
A Lean Six Sigma Project International Journal of Psychosocial Rehabilitation. Vol 21 (1) 10-16
authors would like to thank all of the people who participated in this
project and without whom none of this would be possible. This includes
the Lean Six Sigma QI Team Members – Eunice Ajayi, RN, Fola Ajayi, RN,
Elisa Boisseau, RN, Lisa Givens, RN, Luna Pascua, RN, Andre Conquest,
Ania Crawford, Brenda Davis, Dennis Faliciano, Maurice Fredrick, Don
Mentor, Danetta Perry, Tessa Rice, Carla Wallace and the LSS Project
Sponsors – Denis Ahr and Ethel White, RN, as well as Dena Young, Psy.D,
Dhea Santana and April Priestley.
details a project initiated and performed by staff at a state
psychiatric hospital to reduce the use of physical restraints on
one unit using Lean Thinking and Six Sigma quality improvement
facilitation principles (LSS). It was hypothesized that the use of
these principles would overcome some of the institutional barriers
which have reduced the effectiveness of previous change efforts to
reduce physical restraint. The article discusses the implications of
this project for both the hospital and the state hospital system.
Keywords: Lean Thinking, Six Sigma, Restraint reduction, psychiatric hospital
of the most challenging issues that face psychiatric hospitals is the
issue of violence on the units. The prevention of violence in
psychiatric hospitals has been a well-documented area of concern for
many years (Cornaggia et al., 2011). At one time about one in every
three psychiatric hospital staff are assaulted every year (Applebaum
& Dimieri, 1995). The risk of injury in public mental health
hospitals is estimated to be greater than the injury rates from
agriculture, mining, manufacturing, transportation, and construction
combined (Dinwiddie & Briska, 2004). Consequences of violence
include staff and consumer injury, increased use of restraint, reduced
staff and consumer morale (Wildgoose et al., 2003; Bonner et al.,
2002), and even deaths. There have been numerous efforts to reduce
violence and restraint episodes but many have been either unsuccessful
or short-lived. Some efforts have been geared towards training the
staff (Aberhalden et al., 2007), others toward changing the physical
environment, and still others have involved external consultation
(Sclafani et al., 2008). What all of these change efforts had in common
is that they used the hospital’s existing structure to attempt to
change the problem of violence.
Lean Six Sigma (LSS) is a
hybrid of Lean Thinking and Six Sigma (de Koning et al., 2006). Lean
Thinking was developed by the Ford Motor Company of the 1920s and has
become a staple in manufacturing since the 1990s (de Koning et al.,
2006). Lean Thinking’s primary concern is the detection, measurement,
and elimination of non value-added activities, or activities which add
no benefit to the customer (Jacobson, 2006). A tool used to do this is
the value-stream map, where every step in a process is detailed and
divided into value-added and non value-added. Some non value-added
pieces are necessary and others may be unnecessary. Completion of
the value-stream map leads to the “5 S method”, which stands for sort,
straighten, scrub, standardize, and sustain. The map involves arranging
and changing (and possibly deleting) these processes in such a way that
turns waste into increased productivity (de Koning, 2006). Lean
Thinking’s methods are described in more detail in the literature
(George, 2003; Standard & Davis, 1999).
Six Sigma began as
a Quality Improvement project at Motorola in 1987 and has been further
developed by General Electric in the late 1990s (Breyfogle, 1999; de
Koning & De Mast, 2006; Black & Revere, 2006; Harry 1997;
Pyzdek, 2001). Six Sigma is characterized by its development of a
structure of change initiatives and a corresponding structure of
“bottom up” change agents called alternately “Black Belts, Green Belts,
or Champions”, as well as its synthesizing of a company’s mission into
measurable goals. A notable feature of Six Sigma is DMAIC, which stands
for the five sequential phases of define, measure, analyze, improve,
and control. Each of these phases has specific structures and goals
before the next phase can begin (de Koning & De Mast, 2006). The
first stage of DMAIC is Define the problem, wherein the team selects
problems to work on. Measure refers to evaluating the data being
collected. Analyze means evaluating the data to seek out the root cause
of the defect under investigation. There should not be more than three
root causes. The third stage is Improve, which means optimizing the
current process by eliminating or controlling the cause of the
inefficiency. The final stage, Control, refers to maintaining the
change by continuously monitoring the new process. Table 1 illustrates
these stages in greater detail.
Both Lean Thinking and Six Sigma
have documented weaknesses. De Koning (2006) describes Lean Thinking as
having deficits in the areas of structure, tools, and measurement while
Six Sigma can be ponderous in its process and overlook practical
solutions while it runs its course. Lean Thinking also fails to take
into account the pressure it puts on other parts of the system while
implementing its very specific projects. Goh (2002) also criticizes Six
Sigma for its reliance on its system to make change, eliminating
employee creativity and its lack of regard for “knowledge work”, or
quality of professional experience not easily measured by Six Sigma’s
data collection tools.
To address weaknesses of the two
methods identified in the literature (Goh, 2002: de Koning, 2006), many
organizations in business and in healthcare have embraced a combination
of Lean Thinking’s focus on efficiency into Six Sigma’s DMAIC process
to yield faster, yet comprehensive and measurable change. In fact, the
combined focus is called “Lean Six Sigma” or LSS. The literature is
beginning to show numerous examples of outpatient and private inpatient
medical facilities benefitting from LSS implementation (de Koning,
2006; Viau, 2007; Kearney, 2010; Kim, 2006; Stahl, 2003; Craven, 2006).
For example, through its 2000 strategic partnership with General
Electric in 2000, Virtual Hospital brought in LSS (Black, 2006) and its
principles to be the driving force behind its process improvement
initiatives. Virtua was one of the first healthcare organizations to
adopt LSS. They have experienced measurable positive results in such
areas as delivery of care, employee morale, and the organization’s
“bottom line”. To date, Virtua has seen results of more than $27
million since implementing the LSS methodology (Virtua, n.d.). In 2008,
Rich Miller, the CEO and President of Virtua Hospital was recognized by
Worldwide Convention and Business Forums as the Lean Six Sigma CEO of
the Year for his leadership of the Lean and Six Sigma business models.
Thus far, the existing literature has
discussed primarily private medical facilities, both outpatient and
inpatient. There is no documented effort of implementing Lean Six Sigma
at a state-run psychiatric hospital. A state psychiatric hospital
provides a unique challenge to change initiatives in restraint
reduction. These hospitals are occupied by people with severe and
persistent mental illness, often accompanied by substance abuse issues,
cognitive deficits, intellectual disabilities, severe medical problems,
traumatic brain injury, as well as forensic and legal issues. There are
also numerous obstacles from the staff’s side, including: unions which
have historically tended to value job security over change,
departmental “silos” which divide care, the civil service process which
can lead to promotion by seniority and can result in positions being
vacant for years (Smith & Bartholomew, 2006). State hospitals are
frequently over their stated patient capacity and are unmotivated to
change until there is a high-profile escape or incident of violence
resulting in media attention (Geller, 2000). The net result of this is
an enclosed culture that tends to be unaware of new practices and
reacts with suspicion if not with overt resistance to change
initiatives (Institute of Medicine, 2001; Bartholomew & Kensler,
This paper reports on the application of LSS techniques
and principles in a state psychiatric hospital unit to reduce restraint
usage, time in restraints, and staff injury.
LSS strategy targeted a 30 bed unit within the 600 bed state
psychiatric hospital. This particular unit was female and many
consumers were diagnosed with developmental disabilities in addition to
mental illness. As previously mentioned, the hospital was 25% over
capacity at the beginning of this project. The pilot unit was comprised
of 24 female with a mean age of 41.54 years and a mean length of stay
of 3.33 years. Twenty-two of the twenty-four consumers were diagnosed
with Mental Retardation, 15 were diagnosed with thought disorders, nine
with mood disorders, and seven with Borderline Personality Disorder and
there were also diagnoses of Dementia, Substance Abuse, Factitious
Disorder, and Impulse Control Disorder. The implementation was
unit-wide within a state psychiatric hospital and was also explained
that, if successful, the initiative was intended to be permanent and
would be expanded to other units.
Two staff trained
in LSS at Virtua Hospital proposed a pilot project to test these
methods in a state psychiatric hospital. Hospital Administration
supported the grass-roots interest in developing a new change
initiative based on the LSS model. The hospital CEO and Deputy CEO of
Clinical Services reviewed the proposal and gave the work group
approval to move forward. Education was provided to the project
sponsors (management leaders) and to the selected stakeholders (team
members). The plan was to use several LSS techniques, such as workout
meetings, benchmarking, process mapping, DMAIC, and the use of a
dashboard to create “bottom-up” interventions to be created by the
people who would actually be implementing them.
Intervention Stage of the project began September of 2009 with baseline
measurements and training taking place the six months previous.
The first step was the initiation of Quantum Change Sessions (QCS):
two-day brainstorming sessions in which the work groups explored and
reengineered hospital processes to reduce waste and deflect
opportunities for errors. The QCS meetings were run by the two
LSS-trained facilitators and the work groups consisted of a 10 member
team which included three charge nurses, six direct care staff
representing all three shifts, and one Behavioral Support Technician.
LSS facilitators oriented the team to LSS methodologies and techniques
and provided them with national ward-specific restraint data and
related staff injury data. Restraint reduction literature such as MANDT
TM and other programs currently promoted and taught by the hospital
training department were reviewed for integration purposes and to
increase team member knowledge about current restraint reduction
research and methodologies.
Lean Six Sigma Strategies
comprehensive strategy and implementation plan was developed by the
workgroup. The team spent two weeks prior to the September, 2009 start
date preparing training materials, reengineering physical ward space,
and training staff from all three shifts. The training materials
included a procedure manual called “Tools to Replace Two- and Four-
Point Restraints” which was written by unit nurses (Givens &
Boisseau, 2009). The physical ward space was altered to accommodate the
setting up of a de-escalation area known as the “Walk It Off Zone” (see
Figure 1.). Part of the staff training involved the development
of the “Point Person” position, an assignment only given to a seasoned
Human Services staff member who is free at all times to respond to a
potential crisis. The primary responsibility of the Point Person was
“to recognize…identify…and intervene…to promote patient and staff
safety” (p. 4). This was done via monitoring on all three shifts and
access to an array of interventions (e.g. quiet room access, active
listening). Another benefit of the Point Person was to have a single
“go-to” person for agitated clients access, rather than getting
conflicting messages from other staff who may be already occupied in
After 6 months, a one-day follow-up team meeting
was held to discuss the progress of the plan and make adjustments. The
“Script”, a loosely structured conversation designed to emphasize
consumer choice to avoid violence was introduced by staff to assist the
Point Person or Human Services staff to use with a person in crisis.
The Script and the Walk It Off Zone were combined to create a
supportive environment that offers options to the consumers, the belief
being that having the freedom to make a choice helps the person in
crisis reestablish their sense of control. The team also trained new
During the pilot period (September 2009 – March 2010),
restraint data and staff injury data were retrieved daily from the
Quality Improvement and Risk Management Departments on existing
hospital documents. Severity and frequency of staff injuries were
monitored daily to minimize the risk of continuing to implement a
flawed plan. Monthly statistics were posted on the wall in the nurse
station with large poster paper.
single-case design was used to analyze the data (Carr & Burkholder,
1998; Lundervold & Belwood, 2000). The results of this project (see
Figure 2) showed restraints decreasing from an average of 44 per month
to 19 per month, a 58% reduction within a 7-month period. In
addition to this, the time consumers spent in restraints was reduced
from 39 hours per month to 18 hours per month, a 54% reduction (see
Figure 3). An unexpected finding indicated that staff injuries also
were greatly reduced, from 16 during the 8-month baseline evaluation to
1 during the 7-month intervention period, a 93% reduction (see Figure
It was also found that of the 131 restraint episodes
that occurred during the Implementation Phase, no Point Person was
available during 58 (44%) of the restraint episodes due to staff
methods initiated significant reductions in restraint usage. As
predicted, restraints were reduced, with the month of highest restraint
being 38% below baseline. The drastic reduction in staff injury was
also not expected. The significance of staffing issues also became
evident, as the data indicated a strong relationship of Point Person
availability to incidents. There was suggestion of a cultural
shift of the staff through participation in the process as indicated by
a nurse who had been involved in the most restraints actually became a
champion of the process after increased involvement in the project.
reduction in restraint began at the conclusion of training, two months
prior to the formal start of the initiative, where the number of
monthly restraints dropped from 54 to 7. The staff had been trained on
the new methods and immediately began implementation prior to the
formal start date. Whether this change is partially attributable to a
Hawthorne Effect or entirely due to the training is a matter for
further evaluation in future projects.
Integral components of
the success of this project were identified as: multi-level redesign
involving giving the project its own structure within the hospital
hierarchy, a committed team, the development of the training/procedure
manual, the development of the “Point Person” position, training all
three shifts on the restraint reduction concepts utilizing seasoned
Human Services staff members to model the training, education for
consumers about the availability and purpose of the Point Person,
posting of monthly statistics on the Nurses Station walls to provide
project feedback and maintain staff morale, the development of the
“Walk It Off Zone” and “Script” to de-escalate crises and the support
of the LSS Implementation Team who believed in the project and stayed
with it throughout the one year assignment.
Other reasons for
success were, we believe: the adherence to the concepts of Lean
Thinking and Six Sigma as methods to increase efficiency and quantify
hospital processes so that quality of care and safety could be enhanced
and the idea that this change came from the staff, which enhanced
buy-in as opposed to change processes which are imposed by
Administration or from outside the hospital. One implication of this
study confirms Black and Revere’s (2006) assertion that “if a
healthcare organization does not completely change its culture to total
and continuous quality improvement, then the quality effort is doomed
to failure” (p. 261). This project was an example of the organization
at all levels, backing a quality improvement project with proven
facilitation methods and is a model for further change at this hospital
A potential limitation
of this study is the possibility that restraint reduction was related
to consumer transfers or discharges, or new consumers being introduced
to the unit. No consumers with repeated restraint episodes were
discharged during the intervention period; however one such consumer
was transferred off-unit during the baseline period and returned during
the intervention period. Another such consumer was discharged during
the baseline period.
Another potential limitation to the
generalizability of the methodology and result is related to the
specialized population served by this ward. While it would be
hoped that the Lean Six Sigma process could improve restraint usage
with all populations, this evaluation is limited to women with dual
diagnoses of developmental disabilities and severe and persistent
mental illness. Also, in a hospital of this size, at any given time,
there are numerous change efforts going on, many not coordinated with
each other. There was no way to control for those in this study.
can be an effective practice in promoting change in state psychiatric
hospitals. Due to the success of this project, there was more buy-in
from staff members who generated ideas for additional projects. Areas
of future research include: replicating this project on male and co-ed
units, and on units with people without intellectual disabilities, as
well as in other state psychiatric hospitals.
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