Evaluation of a Program Model for Minimizing Restraint and Seclusion

Table 1 summarizes data on frequency of restraint and seclusion by organizational components between 2003 and 2016. There was a 99% decrease in the number of restraints from 2003 through 2016 and, extending beyond Sanders (2009), there was a 91% decrease in restraint frequency from 2008 to 2016 including a 97% decrease of restraint in community-based programs and a 90% decrease in restraint in residential treatment centers. Grafton acquired another residential treatment facility during January 2011and 184 restraints (54% of the total) in 2012 and 84 restraints (21% of the total) in 2013 from that new facility affected that number. Community-based programs have showed that a similar increase in restraint use, from 14 in 2011 to 58 in 2013.

Table 1 Restraint and seclusion frequency, 2003–2016, and percentage change

Seclusion fell from 253 in 2003 to 0 in 2015 and 2016 for a 100% reduction. Seclusion frequencies were variable because community-based programs have not engaged in seclusion during 2003–2016, but the practice had been utilized intermittently in residential treatment facilities. In 2006, seclusion was eliminated, but it returned in 2007. Between 2012 and 2013, Grafton acquired another residential treatment facility and there were 135 seclusions (68% of the total) in 2012 and 109 seclusions (29% of the total) in 2013 from the new facility. In 2015, the practice of seclusion was again eliminated and has remained eliminated.

Table 2 shows data on staff injuries from restraint which dropped by 97% (110 to 3) from 2004 to 2016 and by 82% (17 to 3) from 2008 to 2016. Since 2004, community-based programs have experienced a 100% decrease in the amount of staff injuries (63 to 0), and residential treatment facilities have experienced a 93% decrease in the amount of staff injuries (43 to 3) related to restraint and seclusion. Since 2008, community-based programs have kept the amount of staff injuries related to restraint stable at 0, and residential treatment facilities have experienced an 81% decrease in the number of staff injuries related to restraint (16 to 3).

Table 2 Frequency of staff injury from a restraint, 2004–2016, and percentage change

Table 3 summarizes data on client-induced staff injuries. The number of client-induced injuries to staff decreased by 64% since 2004 and 41% since 2008. Since 2004, community-based programs have experienced an 88% decrease in the number of client-induced injuries (220 to 73), and residential treatment facilities have experienced a 60% decrease (111 to 44). Since 2008, community-based programs have experienced a 53% decrease in the number of client-induced injuries (154 to 73) and residential treatment facilities have experienced a 33% decrease in number of client-induced injuries (66 to 44).

Table 3 Frequency of client-induced injury to staff, 2004–2016, and percentage change

Table 4 summarizes the data on number of lost and modified days. Grafton had an 81% decrease in the total number of lost time in days from client-induced injuries or staff injuries from restraint or seclusion since 2004 (1750 to 335) and a 38% overall decrease since 2008 (544 to 335). Since 2004, community-based programs have experienced an 84% decrease in the number of lost days (1221 to 196), and residential treatment facilities have experienced a 72% decrease in number of lost days (477 to 132). Since 2008, community-based programs have experienced a 172% increase in the number of lost days (72 to 196), and residential treatment facilities have experienced a 72% decrease in number of lost days (472 to 132). Since 2004, the organization has utilized modified days as a means to get staff back to work in an expedited manner to avoid an increase in lost time. Grafton saw a 267% increase in the number of modified days used from 2004 to 2016 (254 to 932 days) and an 18% increase since 2008 (788 to 932). Since 2004, community-based programs have experienced a 165% increase in the number of modified days (202 to 536), and residential treatment facilities have experienced a 590% increase in the number of modified days (48 to 331). Since 2008, community-based programs have experienced a 41% increase in the number of modified days (380 to 536), and residential treatment facilities have experienced a 19% decrease in number of modified days (408 to 331).

Table 4 Number of lost and modified days, 2004–2016, and percentage change

Figure 1 shows that Grafton reported lost time expenses decreased 75% from $473,340 to $120,339 over the years from 2004 to 2016 and decreased 28% from 2008 to 2016 ($166,420 to $120,339). Figure 2 shows that since 2004, community-based programs have experienced a 79% savings in lost time expenses ($330,256 to $70,407), and residential treatment facilities have experienced a 63% savings in lost time expenses ($129,019 to $47,417). Figure 3 shows that Grafton reported a 27% decrease in the cumulative monetary impact of the intervention on the organization’s annual workers’ compensation policy cost over the years from 2004 to 2015 ($1,600,000 to $1,173,409). Figure 4 shows that in 2007, the cost of turnover was $2,170,000. The cost-of-turnover formula included the cost to hire (recruiter salary, ads, background checks), training (trainer materials, time in training, coverage), and lost quality and efficiency while a position is vacant. Cost-saving assumptions included one third the annual salary plus benefits for a 2080-h employee. With that as a baseline value, there was a $642,693 savings in 2008, a savings of $890,517 in 2009, $1,484,674 in 2010, savings of $989,184 in 2011, savings of $573,937 in 2012, a savings of $545,491 in 2013, a savings of $594,787 in 2014, a savings of $359,548 in 2015, and a savings of $519,838 in 2016. From 2007 to 2016, the years that these savings were calculated, the total cost savings associated with employee turnover was approximately $6,600,000. Overall, Grafton has saved nearly $16,420,661, which is based on $5,981,571 in workers’ compensation policy cost savings, $3,838,420 in lost time savings, and $6,600,670 in turnover savings.

Fig. 1figure1

Organizational lost time expenses, 2004–2016

Fig. 2figure2

Lost time expenses, 2004–2016, community-based settings, and residential treatment facilities

Fig. 3figure3

Workers’ compensation policy cost, 2004–2015

Fig. 4figure4

Costs associated with employee turnover, 2006–2016

Along with increased safety, decreased restrictive practices, and positive financial benefits, Grafton was also able to impact client outcomes. Figure 5 shows that in 2005 the client goal mastery rate was at 34%. Along with the initiative to decrease restrictive practices, an initiative was undertaken to improve teaching and outcomes. In 2008, the goal mastery rate improved to 66%, and in 2016, 80% of all goals completed at Grafton were mastered. Overall, this was a 133% increase in outcomes for those served by the agency.

Fig. 5figure5

Physical restraint compared to total organizational savings and goal mastery achievement by fiscal year

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