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Quality Improvement Information: Providing a Quality Life While Avoiding Restraints

PDF Version of BQA 00-020 (PDF, 7 KB)

Date: February 11, 2000 -- DSL-BQA-00-020

To: Hospitals HOSP 10

From: Jan Eakins, Chief, Provider Regulation and Quality Improvement Section

cc: Susan Schroeder, Director, Bureau of Quality Assurance

This clinical practice guideline is being sent to hospitals to provide educational resources for restraint reduction training in the acute care setting, and to assist hospitals in the implementation of the new federal Hospital Conditions of Participation, Patient’s Rights at 42 CFR 482.13. The concepts and resources in this guideline can be adapted to clinical practice in hospitals.

Efforts are being made by leaders in nursing homes to reach out to hospitals to facilitate joint training using the module Education of Hospital Staff. This module and the modules entitled Physician Education and Educating Residents and Families may be of the most interest to hospitals. The recommended reading list for hospitals has good resource articles and there are also recommended reading lists for important topics such as side rails and fall prevention.

Providers, provider associations, the Board on Aging and Long Term Care (the Ombudsman program) and the Bureau of Quality Assurance (BQA) collaboratively developed this resource. The guideline was successfully piloted in five different types of Wisconsin nursing homes and these nursing homes were able to reduce restraints without an increase in serious injuries. These piloting nursing homes also provided outreach education to hospitals, physicians, families and staff with excellent results.

This guideline is not a regulatory requirement, but it is consistent with federal and state regulations if properly implemented. It is a tool for quality improvement that providers can integrate into their policies, procedures and training programs for clinical practice. The guideline will soon be available on the Department of Health and Family Services (DHFS) web site at:

A videotape of provider presentations about their piloting experience is available. This video is not a training video that would "stand alone," but it would be useful for trainers to view before using the guideline. For information on borrowing this video, please call Leann Graffin at (608) 267-1438.

Information on obtaining the videotape training series "Everyone Wins" is in Appendix B of the guideline.

Questions about the guideline may be directed to Dinh Tran, Social Services Consultant, Provider Regulation and Quality Improvement at (608) 266-6646.

You are encouraged to copy and distribute this information.

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