How Tight and Loose Cultures are Connected to the Current Challenges Inpatient Psychiatric Units Face to Meet Joint Commission National Patients Safety Goals

By Paul Perryman, MSN, MS, RN, NE-BC

On November 19, 2019, the Associated Press published an article describing the perceived burden psychiatric hospitals face as they attempt to align their practice and environments with Joint Commission National Patient Safety Goal (NPSG) 15.01.01 Element of Practice (EP) 1 that went into effect on July 1, 2019.  In the circles I frequent, this article was circulated eliciting what appeared to be agreement that the therapeutic environment is being compromised in the name of safety upgrades that are based on a level of evidence including an expert panel and one study carried out by the Veterans Administration (The rationale for these can be viewed in The Joint Commission's R3 Report, Issue 18).

The article took a puzzling turn when the Associated Press republished the article in December 2019 to correct their statement that the safety interventions described in the article as mandated by the Joint Commission, were not specifically mandated by the Joint Commission.  Herein lies a challenge that needs to be explored.  At a high level, an organization must have a risk assessment and a plan to mitigate identified risks (this is mandated).  Makes sense.  However, as an organization works out a detailed plan to mitigate those risks, uncertainty exists as to whether or not the risk is effectively mitigated or that the current mitigation strategy is acceptable in the eyes of The Joint Commission.  This lack of clarity may lead to excessive risk mitigation (e.g. placing patients on 1:1 supervision unnecessarily) or insufficient mitigation (ligature risks in unsupervised areas) and, as a result, impact the ability to deliver therapeutic care in a safe environment.  

The main impetus behind the updated Joint Commission NPSGs is that suicide rates in inpatient hospital settings have not decreased to the desired degree over the past 20 years even with the heightened sense of urgency The Joint Commission has implied through the National Patient Safety Goals during that same timeframe.  The recent updates to the NPSGs can be boiled down to The Joint Commission seeing a "threat".  This "threat" could be defined as, "environments in psychiatric units continue to pose a danger to suicidal patients".

In her book on how the looseness and tightness of culture affect many aspects of our world, author Michelle Gelfand argues that in a culture where a threat is imminent, the culture is generally tight.  Tightness means a lot of rules exist and the consequences for not following these rules are severe.  The idea being that serious consequences lead to rules being followed more closely thus decreasing the risk of the perceived or real threat.

The downsides to a tight culture as described by Gelfand are that they tend to be less tolerant and less innovative.  If this is true, it makes sense that behavioral healthcare workers are nervous about this new tightness being promoted by The Joint Commission is impacting their ability to provide therapeutic and differentiated patient care.  The Recovery Model developed by the Substance Abuse and Mental Health Services Administration is one example of a plan of care that understands that different patients take different pathways towards recovery.  This therapeutic and humanizing plan of care takes a nuanced, patient-centered approach often requiring innovation and tolerance.  Can this model be effectively implemented in this tighter  culture of safety the Joint Commission is promoting?

What we are seeing in real time in the current environment of Joint Commission surveys is the push and pull between tightness and looseness, between safety and therapeutic care.  The end goal for both approaches is to keep patients safe and help them land on their feet.  The question we must ask with this push and pull is have we have pushed too far towards safety and compromised care or have we not accommodated safety enough in the name of therapy and hence put our patients at risk.  The question the Joint Commission should ask is whether they can provide better clarity on approved means for mitigating risk because what good is a tighter culture if it isn't completely understood.

As we move forward with what appears to be the inevitable tightening of our safety culture in inpatient psychiatry, the behavioral health community should consider the following questions:

1.  Has deinstitutionalization changed the nature of the patient populations traditionally served in inpatient psychiatric hospitals not run by states?  Are patient populations overly mixed making it harder to implement tighter cultures when appropriate?

2.  If the patient population has changed, is the acuity of the patient higher and, if so, has the culture within inpatient psychiatric hospitals evolved with that change?  Have inpatient psychiatry institutions simply shoe-horned the changing inpatient psychiatric population into its current infrastructure making it difficult to allow for looser cultures for patients who need it?

3. Are we moving towards an overly tight culture that extends to residential settings, such as those providing substance abuse treatment?

4.  If the safety culture has changed or is rapidly changing, how are institutions working to maintain a therapeutic environment that does differentiate to the different needs of patients?

5.  The new tightness being enforced by the Joint Commission is described as being evidence-based.  Do professionals agree with this assessment and, if not, how can this new push towards tightness be implemented and how effective will this new tightness be in decreasing the rate of suicide within inpatient psychiatric hospitals?

References:

1.  Associated Press Article on Psychiatric Hospitals Response to new JC Standards Effective July 1, 2019 - https://apnews.com/066d55e71c6a4b3f9ec088e91fa4b32d

2.  Behavioral Health Care:  National Patient Safety Goals 2020 - https://www.jointcommission.org/standards/national-patient-safety-goals/behavioral-health-care-2020-national-patient-safety-goals/

3.  Gefland, Michelle.  (2018).  Rule Makers, Rule Breakers.  Scribbner: New York, New York.

4.  OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence". Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653

5.  The Joint Commission. (November, 2018, Last Updated November, 2019).  National patient safety goal for suicide prevent.  R3 Report: Requirement, rationale, reference   Retrieved from https://www.jointcommission.org/standards/r3-report/r3-report-issue-18-national-patient-safety-goal-for-suicide-prevention/ 

6. Watts BV, et al. (2017).  Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services, 68(4), pp. 405- 407.  Retrieved online from https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201600080