D.70 NMVAHCS Memo 11-103 Disruptive Behavior Committee.docx

New Mexico VA Health Care System Memorandum 11-103 Albuquerque, New Mexico December 27, 2017

11/JG/CL

DISRUPTIVE BEHAVIOR COMMITTEE (DBC)

1. Policy: It is the policy of this medical center to maintain a Disruptive Behavior Committee (DBC) which will provide consultation to practitioners and administrative staff regarding the management of disruptive behavior demonstrated by patients and visitors. The DBC will make recommendations to the Chief of Staff (COS) and/or the health care team as necessary, to improve the quality and integration of care delivered to Veterans with complex health care issues. The mission of the DBC is improvement of coordinated care for complex, difficult, and disruptive patients who have come into conflict with their health care teams.

2. Responsibility: The New Mexico Veterans Affairs Health Care System (NMVAHCS) DBC operates under the direction of the Office of the COS. The DBC is comprised of a multi-disciplinary team of senior health care providers identified by the COS.

3. Procedure: The DBC will oversee, administer, and maintain the Disruptive Behavior Reporting System (DBRS), and the Patient Record Flags (PRF) in accordance with the 2014 Deputy Under Secretary for Health for Operations & Management (DUSHOM) Memorandum Notification of the DBRS, and Veterans Health Administration (VHA) Directive 2010-053, Patient Record Flags. The DBC will direct the process of completing the annual Workplace Behavioral Risk Assessment (WBRA), in accordance with DUSHOM Memorandum, Workplace Behavioral Risk Assessment, dated October 19, 2012.

a. Definitions:

(1) Disruptive Behavior Reporting System (DBRS): A nationally utilized reporting system available to all NMVAHCS staff for the purpose of reporting incidents of disruptive behavior for review by the DBC. The DBRS is accessible via the NMVAHCS Intranet Homepage. Training regarding how to use the system is available through Prevention and Management of Disruptive Behavior (PMDB) training and Talent Management System (TMS) modules titled, How to Complete a Report in the Disruptive Behavior Reporting System.

(2) Disruptive Behavior: Behavior by patients, patient families, patient representatives, or visitors that is intimidating, threatening, or dangerous and may pose a threat to the health or safety of other patients, VHA employees, or visitors at the facility. This includes behavior that interferes with the delivery of safe medical care to other patients at the facility or behavior that impedes the operations of the facility. Specific examples of disruptive behavior include, but are not limited to: verbal abuse; sexual harassment; loud or profane language; direct, indirect, or implied threats; physical abuse; unwanted approaches toward or contact with others; possession or brandishing of weapons; persistent or intense outbursts, excessive behavior that interferes with the ability of other patients to access care such as excessive calls to providers or nurse lines without a clear medical need.

(a) Disruptive behavior can be displayed in a personal encounter, via telephone calls or messages, e-mail, website postings, social media, video, or written or printed form.

(b) Disruptive behavior is defined by whether its occurrence would create fear in a reasonable person or would be perceived by a reasonable person to interfere with the delivery of health care or the performance of employee duties.

(c) The definition of disruptive behavior does not depend upon the disruptive individual’s stated intentionality or justification for the behavior, or the presence of psychological or physical impairments, whether the patient has decision-making capacity, or whether the patient later expresses remorse or offers an apology.

Memorandum 11–103 Subj: Disruptive Behavior Committee (DBC) December 27, 2017 2.

(d) Note: Non-adherent behavior is NOT considered disruptive behavior and does not constitute grounds for the use of behavioral restrictions. The same patient may display both types of behaviors either at the same or a later time.

(3) Non-Adherent Behavior: Patients have the ethical and legal right to accept or refuse any proffered treatments or procedures. When patients refuse to accept medical advice this is considered non-adherent behavior. Non-adherent behavior may include, but is not limited to, failure to comply with a practitioner’s recommendations or orders or program rules, inappropriate use of controlled substances, or electing to leave a medical facility against medical advice. Non-adherent behavior may risk adverse health outcomes for the patient who conducts it, but by definition does not constitute a danger to the safety of other patients, staff or visitors; interfere with the delivery of care to other patients; or interfere with facility operations.

(4) Therapeutic Limit-Setting: Therapeutic limit-setting are accepted approaches used by the DBC in cooperation with patients and health care practitioners and others staff to address disruptive and non-adherent behaviors. Therapeutic limit-setting is only appropriate following, and on the basis of, a good faith effort to determine the causes at an individual and systems level of the behavior. The goals of this limit-setting are therapeutic:

(a) To enhance the quality of health care for the patient;

(b) To increase safety for patients, employees, and others;

(c) To assist the patient to correct his/her own behavior;

(d) To maintain the Veteran’s access to VA health care.

(e) Therapeutic limit-setting is an effort to choose the most appropriate intervention to decrease disruptive and non-adherent behavior in order that health care services can be safely delivered without causing undue frustration or anger to patients or staff. Such interventions include, but are not limited to the following:

(5) Counseling: The first step in addressing behavior is a counseling encounter between the responsible practitioner and the patient to try and correct the behavior. Counseling is appropriate for low-risk behaviors that interfere with care.

(6) Letters of Concern: Used when individual practitioner counseling of the patient has either not been possible or successful in correcting the behavior, or the behavior has reached a level where adverse outcomes are likely. The letter will describe the behaviors and prior efforts to constructively address them as well as written recommendations to the patient for effectively accessing health care services. A wide variety of VA staff can generate and present to a patient the Letter of Concern, depending on the nature of the problematic behavior. The Letter of Concern may notify the patient that a consultation from the DBC has been requested. When clinical staff are the authors of these letters they should be included in the patient’s health record.

(7) Behavioral Agreements: May be used by an individual health practitioner, ward or clinic manager, to set limits on behavior. The Behavioral Agreement is a written document that specifies the patient’s behavioral obligations in the respective clinical setting and the corresponding obligations of the responsible practitioner, ward or clinic staff, once the patient has met his obligations. The Behavioral Agreement should be copied into a progress note.

(8) Orders for Behavioral Restriction (OBR): OBRs are a restrictive form of therapeutic limit-setting and therefore should only be used when previous less-restrictive efforts to modify disruptive behavior have failed or when the index behavior poses a high risk of harm to others warranting such a restriction. An OBR may restrict the time, place, and /or manner of the Memorandum 11–103 Subj: Disruptive Behavior Committee (DBC) December 27, 2017 3.

provision of the patient’s medical care in accordance with (38 CFR Chapter 1, Part 17.107, VA Response to Disruptive Behavior of Patients). An OBR must be specifically targeted to address the patient’s disruptive behavior and avoid unnecessary interference with the patient’s receipt of care. An OBR is presented only after a systematic and expert review of the patient’s behavior has been completed. When the COS has approved an OBR, it will be documented in the form of a certified letter. The letter should be delivered when at all possible during a face-to-face interview with the patient or disruptive individual.

(a) Documentation: For any OBR, a Category I Patient Record Flag will be entered into the patient’s record in accordance with VHA Directive 2010-053. The flag shall conform to this directive and the narrative should include a brief statement of the “Problem” and the “Plan”. The signed OBR letter should be scanned in the CPRS Vista Imaging to server as the official record of the OBR.

(b) Provisions: OBRs may include, but are not limited to, the following:

1 Arranging for medical and other services to be provided in a specific area;

2 Specifying the health care providers or other staff involved in the patient’s care;

3 Authorizing VHA providers to terminate an encounter immediately if certain behaviors occur.

(c) Elements: ORBs must contain each of the elements below:

1 A summary of the pertinent facts on which the determination of restriction has been made;

2 The specific restrictions imposed;

3 The effective date of the restriction;

4 The duration of the restriction;

5 The criteria and process for termination of the restrictions;

6 The availability of emergency services;

7 The process of appealing the ORB to the Network Director.

(d) Patient Record Flags (PRF): alert VHA employees to patients whose behavior, medical status, or characteristics may pose an immediate threat either to that patient’s safety, the safety of other patients or employees, or may otherwise compromise the delivery of safe health care in the initial moments of the patient encounter. PRF enhance both the right of all patients to receive confidential, safe, and appropriate health care, as well as the right of employees to a safe work environment. PRF permit employees to develop strategies for offering health care to even the most behaviorally challenging patients who, in an earlier era, might have been excluded from receiving VHA health care.

1 Patient Record Flags are placed under the guidance of VHA Directive 2010-053.

2 The DBC will oversee placement of all PRF throughout NMVAHCS.

3 The DBC will evaluate any staff requests for placement of PRF in a patient record in order to determine appropriate use of this communication system.

4 Ability to place a PRF is limited to DBC Chair and Co-Chair, and identified clinical or administrative staff as deemed appropriate by the DBC.

5 The use of PRF for administrative or law enforcement purposes is strictly prohibited.

Signaling a Veteran’s theatre or era of service, unresolved felony warrants, or fee-basis eligibility would be examples of prohibited uses of PRF. Only safety issues of an immediate clinical nature (e.g., recurring violence, high risk for suicide, missing patient) are permitted.

Memorandum 11–103 Subj: Disruptive Behavior Committee (DBC) December 27, 2017 4.

4. References: 38 CFR Chapter 1, Part 17.107, VA Response to Disruptive Behavior of Patients; DUSHOM Memoranda: Workplace Violence Prevention Guidance Regarding Management of Disruptive Patient Behavior at Veterans Health Administration Facilities; and Federal Regulation Prohibiting the Practice of Banning Disruptive, Threatening and Violent Patients from VHA Care; VA Office of Inspector General (OIG) Report, Management of Disruptive Patient Behavior at VA Medical Facilities; VHA Directive 2010-053, Patient Record Flags.

8. Rescission: None.

9. Expiration Date: December 27, 2020

Signed MCM in D/FMO File Andrew M. Welch, MHA, FACHE Director

Distribution: “M”

Memorandum 11-103 Attachment A

Sample DBC Behavior Warning Letter

John T. Veteran 111 Main St Albuquerque, NM 501/11

Dear Mr. Veteran:

I have received information from the New Mexico VA Health Care System (NMVAHCS) Disruptive Behavior Committee (DBC). While I understand you were quite upset when you could not get an early refill on a certain medication, it was not appropriate to respond to the staff member by becoming argumentative and raising your voice. Your conduct negatively affected other patients in the area and the staff members who were trying to assist you.

I take the matter of providing a safe and healthful environment for patients, visitors, and staff members very seriously. I expect you to interact with all staff members in a respectful manner. Further behavior of this nature may require me to establish certain restrictions regarding your access to care such as specifying the time and location at which you may receive non-emergent care, designating a specific health care treatment team, requiring you to check in and out with VA Police, and/or authorizing any staff member to immediately terminate encounters with you and contact the VA Police if you become threatening and/or disruptive.

Our goal is to provide you with high quality medical care in a timely manner. I would appreciate your assistance in keeping the environment within our medical center safe for all patients, visitors, and staff members.

Sincerely, Chief of Staff

A-1

Memorandum 11-103 Attachment B

Sample DBC Notice Regarding Prohibition of Weapons on NMVAHCS Property

John T. Veteran 1111 Main St.

501/11

I have received information from the New Mexico VA Health Care System (NMVAHCS) Disruptive Behavior Committee (DBC). According to this information, on January 14, 2017, you checked into the Emergency Department with a large knife in your possession.

I realize that patients may forget that weapons of any kind are not allowed on hospital grounds. Thank you for helping us maintain safety for all Veterans and staff by not bringing weapons onto VA property in the future.

B-1

Memorandum 11-103 Attachment C

Sample DBC Order of Behavioral Restriction Letter with Appeal Procedures John T. Veteran 1111 Main St.

501/11

I have received information from the New Mexico VA Health Care System (NMVAHCS) Disruptive Behavior Committee (DBC). According to this information, you struck two staff members and attempted to punch another staff member while attempting to leave the Emergency Room on July 7, 2015. Your behavior negatively affected other patients in the area and those staff members who were trying to assist you.

Based on your behavior, I am placing the following restriction on your access to care within the NMVAHCS. Effective immediately, your primary care has been transferred to the main Albuquerque Campus. Dr. VA will be your Primary Care Provider (PCP). You will receive a separate letter in the mail with information about how to schedule an appointment with him and/or contact your new primary care treatment team. Additionally, after consultation with your treatment team from the Farmington Community Based Outpatient Clinic (CBOC), you may continue to schedule appointments with Dr. SF until you are admitted into the P.A.C.E. Program. I have also scheduled you for a mental health assessment in the Behavioral Health Intake Clinic (BHIC) on July 28, 2015, at 10 a.m. You will receive a separate letter in the mail with the details for this appointment.

You may only come to the Albuquerque Campus if you have a valid reason to be here. This includes visiting walk-in clinics, attending scheduled appointments or seeking care in the Emergency Department. Upon arriving at the medical center, you must immediately report to the VA Police Operations Office near the Emergency Department prior to going to any clinic or checking into the Emergency Department. A representative of the VA Police will sign you in and issue a yellow card that will be your responsibility to present to the clinic or Emergency Department when you check in to be seen. You are not allowed to stop anywhere between the VA Police Operations Office and the clinic you are going to or the Emergency Department. This means you may not stop at places like the coffee shop, Canteen Retail Store or food court. When you have completed your business, including any required pharmacy or lab needs, you must check out, and return the yellow card to the VA Police Operations Office and immediately depart the medical center grounds. If you deviate from this restricted access plan, your appointment for that day may be terminated and if necessary, rescheduled.

This restricted access to NMVAHCS Medical Center grounds will remain in effect for a period of at least 1 (one) year at which time I will ask the DBC to review your case. Based upon their assessment and recommendations at that time, I will decide to continue, discontinue, or modify your restricted access. The most effective way to influence my future decision is to interact with C-1

Memorandum 11-103 Attachment C

Sample DBC Order of Behavioral Restriction Letter with Appeal Procedures (Continued) my staff in an appropriate manner, consistently check in and out with VA Police, and only present yourself on medical center grounds when you have a valid reason to be here.

A Patient Record Flag (PRF) has been created for your electronic medical record which serves as a reminder to your treatment team and others that there are restrictions placed on your access to medical center grounds. The flag will make it clear that you remain able to access health care but will describe the restrictions as stated in this letter.

Restricting your access to medical center grounds does not affect your eligibility for VA health care or emergent services which are medically appropriate.

If you wish to appeal this restriction, you have 30 days from the date of this letter to do so. You may appeal by doing the following:

a. Send a letter to me stating your disagreement and the reasons you disagree. Address your letter to:

Chief of Staff Raymond G. Murphy VA Medical Center 1501 San Pedro Drive SE Albuquerque, NM 87108

b. I will forward your letter to the Veterans Integrated Services Network (VISN) 22 Director’s Office and ask for an independent review. Once a decision has been made, you will be notified.

c. No additional appeals of this restriction will be accepted and it will remain in effect during any appeal.

For life-threatening emergencies, you should go to the closest VA Medical Center Emergency Department or go to the closest non-VA emergency department at your own expense. If you have thoughts about suicide, I encourage you to call the Veterans Crisis Line at 1-800-273-TALK (8255) at any hour of the day or night.

We look forward to providing you with the health care service to which you are entitled as a Veteran in a mutually respectful manner that is safe for everyone.

C-2