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NAMI Members Speak Out At Forum Held By The Joint Commission On Accreditation Of Healthcare Organizations

Chris Marshall 703-524-7600
For Immediate Release
4 Feb 99

Earlier this week, the Joint Commission on Accreditation of Healthcare Organizations held a Consumer Forum designed to solicit input from consumers on quality oversight issues. J. Rock Johnson, J.D., and Jim McNulty, both consumers and NAMI board members, spoke at the conference, as well as Diane Engster of NAMI Virginia and Ray Federici of NAMI Chester County, PA. Although restraints and seclusion abuses and deaths were not on the agenda, all NAMI members addressed this issue and implored the Joint Commission to improve its evaluation process.

The Joint Commission offers accreditation to health care organizations that meet standards of care determined by an evaluation process that measures a health care organization’s ability to provide patient care and the functions that most affect patient health outcomes. NAMI has been concerned that this process of evaluation by the Joint Commission is not measuring or properly examining instances of death of patients with severe mental illnesses, abuse of or excessive use of restraints that degrade patients’ health and well-being, and treatment of patients in psychiatric facilities. At the forum, NAMI members expressed the urgency for the Joint Commission to increase its focus on patients with severe mental illnesses by changing outdated standards for proper use of restraints, improving the evaluation and survey process, enhancing the reporting of "sentinel events" (such as patient deaths), and dramatically increasing outreach to local communities.

For further information on NAMI’s position on the Joint Commission call Clarke Ross, deputy executive director of public policy at 703-524-7600, or by email at Clarke@nami.org. For more information on the Joint Commission on Accreditation of Healthcare Organizations go to http://www.jcaho.org/. To receive materials explaining your rights as a hospital patient or to make a complaint, call Hospital Complaints of America at 717-586-7900, or email at hcoa@hotmail.com.

Below is the written statement of J. Rock Johnson, J.D. and Jim McNulty submitted to the Joint Commission’s Consumer Forum.

February 1, 1999

Statement of the National Alliance for the Mentally Ill (NAMI) to JCAHO Consumer Forums on Quality Oversight

J. Rock Johnson, J.D., Member of the NAMI Board of Directors
Jim McNulty, Member of the NAMI Board of Directors

Washington, DC, February 1, 1999

Further Information: Clarke Ross, 703-524-7600; e-mail: clarke@nami.org. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042

Through NAMI’s research and publication of its managed care report card, Stand Deliver, through its sponsorship of the Outcomes Roundtable, and through NAMI’s executive director Laurie Flynn role as Chair of the Foundation for Accountability (FACCT), NAMI has been actively engaged in the area of performance measures and quality oversight.

However, for the purposes of this forum, we want to use the national crisis of the use of lethal force (commonly referred to as restraint) and seclusion to point out problems we have with JCAHO’s approach to the issue of quality oversight. In October 1998, The Hartford Courant published an investigative five-part series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric facilities.

The Harvard Center for Risk Analysis estimates that between 50 and 150 deaths occur every year across the country as a result of the inappropriate use of restraint. And what of the role of JCAHO? Three JCAHO inspectors issued the highest ranking available for human rights to Central State Hospital, Virginia on June 28, 1996. And the next day, Gloria Huntley, restrained for periods of 48 hours at a time over the course on many months, died in that same hospital. In her last two months of life Gloria Huntley had been restrained 558 hours, the equivalent of 23 full days. The case of Gloria Huntley demonstrates that JCAHO’s quality oversight is seriously flawed.


"The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one’s self or others. These extreme measures can be justified only so long as, and to the extent that, the individual cannot commit to the safety of themselves and others."
--- Adopted by the NAMI board of directors, October 25, 1998

To implement this NAMI advocacy policy, NAMI is seeking national legislation which would:

  1. Mandate the Health Care Financing Administration (HCFA) to strengthen existing regulatory protections and consistency across all facility types so that the same standard applies regardless of the classification of the facility.

  2. Mandate that all facilities report to a third-party legal entity within the state whenever there is death or significant injury.

  3. Mandate that all facilities utilize the services of non-legal citizen and family monitoring groups who can conduct unannounced visits.


Two components of JCAHO - the standards themselves and the process for reporting sentinel events - are significantly flawed.

JCAHO standard TX 3.1 states that a facility may use restraint and seclusion "as an adjunct to planned care…and in some cases, as part of standard practice." Each facility defines for itself what restraint and seclusion activities will be allowed. This policy is inadequate because all it requires is that a facility has a written policy and that policy is consistently followed. To NAMI, there is no appropriate treatment and care use for involuntary restraints. Restraints are appropriate only for responding to emergency situations involving safety.

But even this inadequate policy is meaningless, because it is not enforced. JCAHO standard TX states that restraints may only be imposed for 4 consecutive hours for adults and only for 24 hours under continuation orders. But as discussed earlier, Gloria Huntley received 558 hours of restraint over a two month period using 48 hour increments of restraint. JCAHO awarded Central State its highest rating for human rights implementation instead of enforcing TX

The second area of significant flaw in JCAHO quality oversight is the October 23, 1998 announcement changing the sentinel event reporting process. NAMI applauded the Commission’s initial announcement that sentinel events should be reported to the Commission, followed by the submission of a root cause analysis. But then in October JCAHO reversed itself and said that a facility could only place a phone call to the Commission and inform the Commission that a sentinel event had occurred but that no paper would be transferred. And further, JCAHO was only interested in sentinel events which became publicly known, as through media reporting. As The Hartford Courant reported, few of these events ever become known to the public.

How can consumers trust JCAHO and the status of JCAHO accreditation given these undefined standards are not enforced and which do not require the reporting of sentinel events? How can the public and consumers trust a system which affords a facility its highest form of accreditation the day before a consumer dies after having been restrained almost continously for the last weeks of her life? An important legal principle is the theory of reliance. Consumers choose JCAHO accreditated facilities for consumer protections and quality. Can the public rely upon JCAHO for quality and protection? This reliance appears to be misguided.

The use of physical restraint and seclusion in the name of restraint is a national crisis. NAMI distrusts the current procedures used by JCAHO. That is why we are seeking a national legislative solution to this crisis. We call on JCAHO to demonstrate that it can indeed be trusted.


NAMI has learned of many initiatives designed to significantly reduce involuntary restraints and seclusion. Lessons learned include:

  1. Use of citizen, consumer, and family monitoring groups, which mostly to date are NAMI chapters in state psychiatric hospitals in Delaware, Massachusetts, New Hampshire, and Pennsylvania.

  2. Use of statewide performance measurement and monitoring systems on the use of restraint and seclusion and the consequences of their use. The Pennsylavania Office of Mental Health and Substance Abuse Services holds hospital administrators and unit clinical and administrative staff accountable for their performance. Pennsylvania tracks incidents per 1,000 days, number of hours of restraint and seclusion, falls, fractures from falls, injuries from assaults, and chokings. Units which are outliers are held accountable for their performance.

  3. Reliance on a R.N. monitoring care rather than other less credentailed nursing staff. This is the experience of the New Hampshire Hospital and the NAMI-California/Telecare Corporation initiative. The New Hampshire Hospital declares that "The practice of state-of-the-art psychiatric nursing care would virtually eliminate the abuses cited in The Hartford Courant articles."

  4. Use of specially trained staff, certified in assessing and monitoring restraints with competencies in crisis management interventions as used in the Pennsylvania Office of Mental Health, New Hampshire Hospital, NAMI-California/Telecare Corporation initiatives.

  5. Use of detailed and specific criteria for the use of less restrictive interventions, as used in the NAMI-California/Telecare Corporation initiative.

  6. Use of patients as safety monitors to notify staff when situations with their peers were escalating, such as used in the NAMI-California/Telecare Corporation initiative.

  7. Next day convening of clinical staff to discuss potential treatment plan changes given the previous day’s use of restraint or seclusion (R/S) and a focus on what could the clinical staff have done differently to avoid the use of R/S , such as used in Southern Virginia Mental Health Institute in Danville.

  8. Introduction of behavioral control interventions which focus on non-physical control approaches, such as used in Southern Virginia Mental Health Institute in Danville.

  9. Use of population profiles, which identify commonalities in the persons being restrained and secluded, such as used in Southern Virginia Mental Health Institute in Danville. Or use of most frequent reasons for the use of restraints, such as at Huntington Memorial Hospital, California.

  10. Using the patient’s family as a treatment partner and emergency response, such as at Huntington Memorial Hospital, California.

Restraint-free facilities identified by NAMI members (which have not been confirmed by NAMI) include: Crisis Triage Center, Tacoma, Washington; First Call for Help, Napoleon, Ohio; Boston Higashi School, Massachusetts; Valley Healthcare, Morgantown, West Virginia; and Mendota Psychiatric Hospital, Madison, Wisconsin. NAMI asked the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, National Association of Psychiatric Health Systems, National Association of State Mental Health Program Directors, and National Council for Community Behavioral Healthcare to confirm these best practice sites and to suggest other best practice sites.


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