Improving Compliance and Documentation of Violent Restraint Use: A Strategic Initiative at a Large Health System for Enhanced Safety and Standards Adherence

Background: A health system in the West conducted a project to improve violent restraint use documentation, necessitating a strategic initiative to align practices with Centers for Medicare & Medicaid Services (CMS) and Det Norske Veritas (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO) guidelines. This paper outlines the project's objectives, methods, results, and implications for practice. Methods: The project employs qualitative and quantitative methods to enhance compliance and documentation standards, utilizing Tableau for data collection and analysis. Ethical considerations surrounding restraint use are addressed to uphold patient-centered care principles. Results: Research identified areas for improvement, leading to the development of integrated order panels and education strategies. A "Go Live" phase is planned, followed by ongoing evaluation through data analysis to measure compliance increases and document unintended consequences. Conclusions: The initiative holds promise for enhancing patient safety and regulatory adherence at the health system. By addressing compliance gaps and integrating order sets, the project aims to streamline documentation processes and foster a culture of standardized care delivery. Future studies could explore additional factors influencing compliance and further optimize documentation standards.