Getting started

Prior to starting, it is important to determine a realistic timeline for the improvement work – lasting changes will often require an investment of time. As a guide, it can take 6 to 18 months to test and implement a lasting change using improvement science methodology.

This timeline may be shorter if previous improvement efforts or investments have been made and may be longer if the change is complex and/or involves different teams and services.

The improvement method involves multiple small tests of change: PDSA cycles (Plan, Do, Study, Act).

The Problem: The use of seclusion and restraint is traumatic and an infringement of a person's normal rights to autonomy and self-determination. The Australian Institute of Health and Welfare reports that there were 13,495 seclusion events nationally in 2019-20.¹

The average duration of a seclusion event excluding Forensic services, was 4.9 hours in 2019–20. New South Wales reported the longest average seclusion duration of 6.3 hours per seclusion event in 2019–20.¹

The challenges of seclusion in practice: While seclusion can be used to provide safety and containment at times when this is considered necessary to protect patients, staff and others, it can also be a source of distress for the patient and support persons, representatives, other patients, staff and visitors. Wherever possible, alternative less restrictive ways of managing a patient's behaviour should be used, thus minimising the use of seclusion.¹

Seclusion and restraint should only be used within approved protocols by properly trained professional staff in an appropriate environment for safe management of the individual.²

Leadership and culture: Continuing to work towards minimising, and where possible eliminating, the use of seclusion and restraint is achievable. It requires leadership, commitment and motivation, and a change in culture underpinned by the recovery model and trauma informed care with a focus on workforce and training, prevention and early intervention, good clinical care, and supporting practice change.²

Motivated, capable and enabled staff working in a culture of safety are the key to safer, more resilient systems of care.

At this stage of the project, it is about identifying the problem you aim to improve NOT brainstorming solutions. When determining the focus of an improvement project, some common errors include:

• Selecting a problem no one is interested in.
• Implementing a solution rather than investigating a problem.
• Focusing on a process that is currently in transition or unstable, for example, manual to electronic process.
• Selecting a problem that is beyond your capability to change or outside your sphere of influence.

All improvement requires change. However, change is not always welcomed or accepted by individuals or teams, even when it is improvement focused. Improvement projects can often struggle to gain momentum if there is considerable resistance from those who will be impacted most by changes.

Assessment of the current unit/ward context is essential to clearly establish the readiness for change. The assessment should investigate the existing culture, communication and team practices, and safety and quality concerns.

If there is an overall lack of enthusiasm and a resistance to change, it is vital this is addressed before proceeding further with the improvement project.

For more information see the CEC Safety Culture webpage.

Data will assist in identifying the problem and building the evidence base about why this is an important problem to focus on. Seek guidance from your Clinical Governance Unit or the CEC to identify appropriate sampling numbers and data sources.

Existing data: You can examine your health service’s seclusion related data from sources such as your incident management system (e.g. ims+), Seclusion Registry.

Note that you may require permission from your clinical governance unit to access certain data.

The CEC Mental Health Patient Safety Team can assist LHD/SHNs to develop a Mental Health Safety dashboard which will allow monitoring of important measures of patient safety. A mental health safety dashboard is a form of safety intelligence that can indicate where to focus system improvement effort.

Baseline: Completing a baseline audit is also an effective way to help identify the problem and its extent.

Note: Prior to implementing any change ideas (later in the quality improvement process), the Institute for Healthcare Improvement suggests that you conduct a retrospective audit on sample size of 30 or a proportion of your consumer cohort.

Evidence base

In 2006, a Cochrane review⁴ and an extensive systematic review by the Agency for Healthcare Research and Quality⁵ were reporting a lack of evidence for strategies that purport to reduce seclusion and restraint. More recently an evidence base for strategies that are effective in reducing seclusion and restraint in mental health services is emerging.

The selected readings include implementations of the Six Core Strategies, Safewards, REsTRAIN Yourself, and Behaviours of Concern approaches. The Agency for Clinical Innovation has provided an evidence check and a framework for change in relation to trauma-informed care and practice. Also included are some selected articles on consumer experience and the importance of culture

Consumer and Staff Stories: It is worthwhile collecting anecdotal evidence about how seclusion reduction has impacted on staff and consumer safety and well-being. These stories help us to understand different perspectives of the health care given or received and can shed light on different areas for improvement.

It is strongly recommended that you engage with your District/Network Clinical Governance Unit or Mental Health and Drug & Alcohol Clinical Governance Unit or Mental Health and Drug Alcohol Service to seek support for and during your improvement project.

Your Mental Health and Drug & Alcohol Clinical Governance Unit will be able to link you with local quality improvement experts or groups with an interest in improving seclusion outcomes e.g. Local/district Seclusion reduction working group, clinical champions, clinical leads, improvement coaches (eg Mental Health Improvement Coaches).

You may also choose to reach out to colleagues in other health services to find out how they approached their improvement work, including their successes and learnings.

Present your local application form (QIDS summary if there is no local application form) and follow local process for approval of a project sponsor. The role of the project sponsor is to provide support and guidance to the project team, receive regular reports on progress and help remove barriers when needed.

They should believe that the problem is worth solving, have authority to make changes and ensure that appropriate resources are provided.

Ideally, your project sponsor is someone who does not work directly on the improvement project but is in a senior position. The level of seniority of the project sponsor will depend on the scope of your improvement project (e.g. Team Leader or Service Manager, Executive Director).

Ideally you should communicate closely with the project sponsor and provide regular updates to them on the progress of your project.

Ask your project sponsor to provide guidance on where the governance for your improvement project should sit within your health service.

This will ensure there is operational responsibility for your Seclusion reduction improvement project and a channel to report back on how it is progressing. For example:

• At unit/team level: If your project aims to improve outcomes in the community or inpatient mental health, you could integrate project reporting with existing mental health and drug & alcohol service meetings
• At health service/LHD/SHN level: If there is intention for your project to be scaled across your service, reporting could be integrated with the Service/District/ Network Clinical Quality and Governance or Safety and Quality Committee.

Note that who you report your project progress to is not the same as who is part of your project team. Your project team will consist of members who carry out the project interventions.

• Team leader
• Quality improvement advisor/expert/ Mental Health Improvement Coach (contact your clinical governance unit if unsure)
• People from all areas of the process that the improvement project will target e.g. senior and/or junior staff from relevant mental health and non-mental health specialties on the unit/ team/service where your project will take place
• Consumer and Carer representatives (or interview/survey consumers) (see A Guide to Build Co-design Capability)
• Consider inviting colleagues who are likely to challenge your project. They can often raise different perspectives or barriers that you may not have considered
• Data or Information Management Coordinator/Expert
• Admin support: someone will need to coordinate team meetings and keep notes, minutes and/or an action log
• The team leader role is essential, and they will organise and lead the team meetings, ensure delegation of responsibilities and be the 'voice' for the improvement project.

As the team leader, it is essential to assemble a dedicated team who are a committed to actively supporting the improvement project. Improvement projects often fall down when team members are unable to sustain interest or participation in the improvement project, leaving the team leader to carry the improvement project.

The role of the project team includes:

• Evaluating current seclusion reduction processes
• Identifying and enlisting clinical champions
• Establishing general goals
• Developing, implementing and evaluating seclusion reduction improvement strategies
• Disseminating results and findings.

Once the project team has been established, it is important to make sure everyone is on the same page regarding the problem the improvement project is targeting and what is IN and OUT of SCOPE.

Without a well-defined scope, improvement projects tend to grow beyond what is achievable, lose focus of the problem, and fail.

1. Australian Institute of Health and Welfare. Mental health services in Australia
2. Wright M. Review of seclusion, restraint and observation of consumer with a mental illness in NSW Health facilities. December 2017.
3. McDonald KM, Shojania KG, Wachter RM, et al., 2004 ‘Closing the quality gap: a critical analysis of quality improvement strategies (Volume 1 – Series Overview and Methodology)’. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University – University of California, San Francisco, Evidence-based Practice Center).
4. Muralidharan S Fenton M. Containment strategies for people with serious mental illness (Review).Cochrane Database of Systematic Reviews. 2006(3 Art. No. CD002084):1-17.
5. Gaynes B N et al. Strategies To De-escalate Aggressive Behavior in Psychiatric Patients. Comparative Effectiveness Review No. 180. Rockville MD: Agency for Healthcare Research and Quality; 2016.