The clinical reality of implementing formal risk assessment and management measures within high secure forensic care

Abstract

This paper describes the successful implementation of a formal violence risk assessment and management strategy within a high secure forensic care facility. The aim of the implementation was to ensure that each patient had a formal violence risk assessment and management plan that was shared and applied to clinical practice by the patient's clinical team. The process as a whole, from risk assessment to risk management including appropriate care and treatment documentation, is outlined. In this way, this paper also describes the difficulties and problems encountered within the organizational reality of implementation projects. Suggestions and recommendations on how to avoid and manage these are made.

Introduction

Health professionals in forensic psychiatric care are often confronted with ethical dilemmas. While there is a clinical duty to care and treat forensic patients in the least restrictive environment necessary (Mental Health [Care and Treatment] [Scotland] Act, 2003),¹ clinicians are also required to ensure the safety of staff and the wider public.² The standardized assessment of risk factors is thought to enable clinicians to gauge the likelihood of future violence in an individual, i.e. to identify the problems and needs a person may have³ and thereby manage future risk of harm. While research and practice encourage the use of structured professional judgement (SPJ) tools such as the Historical Clinical Risk Management – 20 scale (HCR-20),⁴ the predictive power of these risk measures varies greatly according to population, setting and culture studied.^5–7 The issue of imperfect risk prediction has been a focal point of debate since the 1980s⁸ as is the extent to which findings at group level can be applied to individuals.⁹ This leads to a moral conflict as clinicians are bound to assess risk using available risk assessment tools that are unlikely to ever predict future violence with 100% accuracy, and thereby, potentially, restrict patients on false grounds.

This noted, the focus of risk assessment has moved from prediction to prevention. This allows consideration of vital aspects of risk: nature, likelihood, severity, imminence and frequency.¹⁰ The task therefore becomes one of risk management, i.e. risk mitigation and minimisation, rather than probabilistic prediction.

The problem, however, is that there is a paucity of research and practical guidelines describing how to make sure that risk assessments directly inform risk management. While there are papers on the implementation of risk assessments^11–13 these documents fail to give a clear, detailed account of how this was achieved in terms of process and organizational procedures employed. Perhaps this is not surprising when one considers the fact that changes in health-care organizations are often viewed as the most difficult and complex ones to achieve¹⁴ as diverse perspectives and interests of various stakeholders (patients and the government) and professions (clinicians and allied health professionals) need to be fused.

Despite the documented reality of such problems, most implementation models advocate a linear and logical connection between continuing education, audit and research.¹⁵ Kitson et al.,¹⁶ however, argue that successful implementation of research into practice is dependent on the interplay between the nature of the evidence, the context in which the proposed change is to be implemented and the mechanisms by which this change is facilitated. Likewise, Ambrose's¹⁷ framework for managing complex change highlights the interconnectivity between implementation phases and stages. In a similar fashion, Golden¹⁸ describes a four-stage model of health-care organizational change. This model outlines stages based on: (1) identification of a performance gap, (2) determining the desired end state, (3) assessing readiness for change, (4) broadening support and organizational redesign and (5) reinforcing and sustaining change. All stages are described by using practical examples from an implementation effort in a multisite hospital in Canada.

The purpose of this paper is to describe the dynamic process and procedures employed to implement violence risk assessment and management measures across the high secure psychiatric hospital for Scotland and Northern Ireland, the State Hospital.

Aim

This paper describes the process and problems experienced when implementing violence risk assessment measures and management plans into everyday clinical practice. The aim of this implementation was to ensure that each patient had:

A structured risk assessment using an evidence-based SPJ tool leading to a tailored risk management package included as part of the care and treatment planning paperwork;

To formally review the risk assessment and management plans on (at least) an annual basis.

Description of the setting and context of the implementation

Setting

The State Hospital is the high secure psychiatric hospital for Scotland and Northern Ireland. Patients are admitted because of a major mental disorder, and the link between their mental health needs and the serious risk of harm posed to others. Patients are transferred to lower secure settings by a process of clinical team decisions and ministerial agreement for those on restriction orders. At the time of implementation (2005/2006), the hospital consisted of 11 wards including one female, one learning disability, one admission ward, two rehabilitation wards and six continuing care wards.

Patient population

There were approximately 240 patients resident at the State Hospital at the time of implementation. Of these, the majority were male (95%). The average age was 40 years. Over 70% of patients had been convicted of offences prior to admission, and over 73% had reported adverse childhood experiences such as physical and/or sexual abuse (The State Hospitals Board for Scotland¹⁹). Schizophrenia was the primary diagnosis for most patients (70%).²⁰

Legislative context of implementation

Golden¹⁸ views the organization's vision as the identification of a performance gap and determining the desired end state in an organization. In other words, a potential gap between current practice and desired or expected aspirations needs to be acknowledged. In terms of violence risk assessments, the MacLean report advocated a systematic and transparent process in the assessment and management of violent and sexually violent offenders.²¹ This is further reflected in amended legislation^1,22,23 and governance guidelines and arrangements^24,25 in Scotland. Practitioners and clinicians alike agree that SPJ tools such as the HCR-20 are ideally suited for this process as SPJ tools are transparent, systematic and can be employed in a dynamic manner.²⁶ Due to the likely impact of ongoing changes in legislation, i.e. the Mental Health (Care & Treatment) (Scotland) Act (2003)¹ and the development of services, it was expected that a large number of patients would be transferred from the State Hospital to less secure environments. This required the systematic and structured sharing of information on risk factors, risk strategies and management plans across various service providers to ensure continuity of care and thus reduce the likelihood of recidivism and aggressive behaviour.

Multidisciplinary risk assessment and management in clinical practice

The shift of focus from risk prediction to risk prevention emphasizes the need for care to be proactive rather than reactive.²⁷ In practice, this means that all risk management information, such as treatment planning, formulation and review documents, needs to be transparently clear to all staff involved in the treatment of patients.²⁸ At the State Hospital, risk assessment and management were completed and discussed by the multidisciplinary teams within a care and treatment planning approach thereby allowing the team to provide realistic and collaborative care.²⁹ In addition, completion of risk assessments in a team setting discourages clinicians from viewing the risk assessment as a complete process, but instead as part of a dynamic concept of management. Not only does this ensure that risk is considered within a wide holistic framework it also enables a collaborative relationship between communication and working practices within an organizational system.²⁹

At the State Hospital, different clinical teams developed their preferred approach to this collaborative process. However, the key features of the care and treatment planning framework were (see Figure 1):

Team identify appropriately qualified person to complete a review of collateral information in a format that can be used in the future;

Team identify an appropriately qualified person to complete a SPJ risk assessment including identification of risk factors, offence formulation and scenario planning using an agreed template and format;

Draft risk assessment is brought to the clinical team for discussion by all team members;

Team agree on the risk factors, offence formulation and scenario plans and design risk management plans as part of the care and treatment planning process;

Each key risk issue is linked to a risk management objective;

Risk management objectives are conceptualized in terms of interventions and treatment, monitoring, supervision and victim safety planning;

All objectives for the management of risk have a responsible person(s) linked to them.

This process can be tailored to individual working practice, in particular in relation to how risk assessments are completed and discussed. For example, at the State Hospital, the ward psychologist on the admission ward completed the historical scale using file information. The clinical and risk scales were completed jointly by the clinical team based on their knowledge and experience of the patient. In contrast, other wards preferred a qualified risk assessor, either a member of the clinical team or an ‘expert’ outsider (for instance, when assessing sexual violence risk) to draft the entire risk assessment based on file information and then consider each item through clinical team discussion.

Figure 1

Outline of risk assessment and management process. SPJ, structured professional judgement; CPA, Care Programme Approach

Description of the implementation process: organizational redesign

1. Setting the scene

Leadership

Leadership has been repeatedly found to be a key factor in organizational change.^30,31 The change leader is responsible for highlighting the benefits of the proposed change to all stakeholders and maintaining interest throughout the implementation. Golden¹⁸ summarizes the ideal leader as a person with specific characteristics such as being influential, well respected and connected throughout the organization, as well as being considered to have expertise, confidence and appear motivated and empathic towards others.

At the State Hospital, the change leader (MS) was a Consultant Forensic Clinical Psychologist, was a Board Member of the Risk Management Authority and had been involved in implementation projects in the Scottish Prison Service. In this way, the change leader had accrued internal as well as external respect, had direct access to governance and future planning in services, was knowledgeable and confident in terms of wider research evidence and provided opportunities for staff to give feedback on the process.

Challenges. Although mandatory, staff did not always follow the suggested guidelines for implementing the violence risk assessment and management plans. It appeared that the ability to create relationships with key staff and thereby connect with the organizational culture was vital to successful implementation. While this is reflected in previous research,³² in practical terms this means that the leader has to develop strategies to make staff feel valued and consulted, i.e. find the resources, choose key staff and spend time with staff outside the implementation context.

Change team

Golden¹⁸ points out that while research links certain qualities in the change leader with successful implementation, the literature does not indicate that there should be only one leader. Instead, he suggests that a steering committee consisting of respected members of staff should be set up, whose role it is to maintain credibility and influence throughout the implementation.

At the State Hospital, a clinical risk assessment and management strategy group was set up by inviting specific interested parties to assist and share their professional opinion on the implementation process. In line with practical guidelines, the strategy group consisted of highly regarded and skilled clinical staff from diverse backgrounds (psychiatry, psychology, nursing, occupational therapy, clinical effectiveness and information technology [IT] staff). The remit of this group was to push the change forward and to offer constructive advice. The change leader consulted the change team on any procedure and new care and treatment documentation suggested.

Challenges. Some members of the original strategy group at the State Hospital were openly advocating against the use of standardized risk assessment measures, and did not appear to be in favour of the introduced risk management documentation. As Golden¹⁸ argues, any organizational change is likely to meet opponents. He recommends that, if necessary, ‘formal powers’ should be employed to deal with these. As a result, the change leader took a more proactive approach to the selection of the change team and chose specific and dedicated individuals who were able to promote the implementation effectively.

Senior organizational support

The literature cites resources such as funding, manpower and appropriate IT and administrative support as key components of successful change; the lack of these has been associated with implementation failure cross-culturally.³³ In order to ensure the availability of resources, as well as widening organizational support, it is imperative to secure senior organizational assistance.

For the implementation project in this paper, the Chief Executive and the State Hospitals Board signed up to the implementation from the beginning. This was part of the strategic plan and intended to emphasize the future vision for the organization. By doing so, the change leader (MS) succeeded in securing funding and resources. This enabled the change leader to use project management time flexibly, to pilot various models of training and manners of risk assessment completion and to assess which one of these was most effective in assisting in the completion of risk assessment and management plans.

Pilot project

In research, the purpose of pilot studies is to identify barriers and potential problems in the applicability of research instruments or protocols.³⁴ The usefulness of a pilot also applies to implementation projects with the added advantage that conducting a pilot study can be used to demonstrate that the implementation is worth supporting.

Prior to implementing the risk strategy across the hospital, a stakeholder analysis was conducted to identify all staff groups and departments most likely to be affected by the implementation. A pilot group was established, which piloted the implementation on 3 out of the 11 wards before the risk assessment and management changes were funded to be set in place across the entire organization. This allowed the strategy group to assess barriers and incentives for uptake on wards and staff to familiarize themselves with the change. Based on the needs and problems staff identified, the implementation process was accordingly revised where appropriate (Box 1). Box 1

Implementation process: organizational redesign summary

Context

Identify gap in practice and conduct organizational needs assessment

Leadership

Identify key change leaders in each area, ensure their co-operation

Change team

Get a group of like-minded people who can advise and champion the process

Senior organizational support

Get senior management support

Secure funding for pilot and for full strategy

Regularly report back on progress

Pilot project

Proposal for a pilot

Report back on pilot to all concerned

Make changes following pilot

2. Lights. Camera. Action: running the implementation

Adapt existing protocols

Past research and papers on practical implementation issues state that one of the essential strategies to ensure staff support is to build on existing practice and protocols.²⁸ In line with this, changes were kept at an absolute minimum at the State Hospital.

Challenges. Some clinical teams consistently failed to adhere to the changes in the new documentation. This was evident at an administrative level (e.g. documents were not filed correctly and thus appeared to be missing) and at a clinical level (e.g. clinical teams used outdated protocols and templates) despite the communicated need for attention to be paid to all aspects of the risk assessment process. In other words, some clinical teams did not recognize the importance of the changes and in particular the need to translate risk issues into risk management plans. This situation was resolved when the medical director encouraged staff members to adhere to the newly introduced care and treatment documents. This was further facilitated when the organization formally commissioned the change leader to write a detailed violence risk assessment and management policy which was approved and published.

Another noteworthy obstacle experienced was the extent to which staff were able to embrace the concept of risk formulation as part of risk assessment and management. In terms of risk, the aim of formulation is to provide a holistic, psychological framework to understand the interaction between various factors, and identify underlying causal mechanisms.³⁵ The Royal College of Psychiatrists³⁶ stressed the importance of formulation in identifying the specific factors likely to increase and decrease risk, yet there appear to be no specific learning modules on how to achieve this.

Training

The literature on training in violence risk assessment tools repeatedly highlights its benefits and its impact on the quality and accuracy of risk assessments conducted.^14,37 However, training on the risk assessment tool alone is not sufficient to enable optimal care and treatment. Indeed, there is a need for training on how to translate the information collected in risk assessments into effective risk management plans for their clients. The care and treatment process involved five essential stages to enable clinicians to produce defensible and appropriate risk assessments leading to a coherent risk management plan that would outline the key risk management activities of: intervention, treatment, supervision, monitoring and victim safety planning³⁸:

Review of all file information in order to obtain a thorough understanding of the person's background and past history;

Identification of risk factors relevant to SPJ tools used;

Understanding of the person's pattern of offending behaviour (formulation of offending or offence analysis);

Scenario planning on the nature (imminence, severity and likely victims) and likelihood of future violence in various settings (secure hospitals, low secure settings, community);

Risk management plans linked to risk factors, offence analysis and scenario plans.

In line with research on successful implementation strategies, training was delivered through various means and learning activities to increase applicability to clinical practice.³¹ At the State Hospital, training packages were developed at two levels:

One day awareness training. This training session was open to all qualified staff and aimed to establish an understanding of the principles and processes involved in violence risk assessment and management planning, so that staff could effectively contribute to the management of patients at risk;

Two full days. Key members of the clinical teams on each ward were encouraged to attend the full two-day training on the HCR-20, risk management and the whole care and treatment planning paperwork (e.g. file review, identification of risk factors, formulation, scenario planning and risk management planning). The aim of this training was to introduce the use of the HCR-20 system of risk assessment and management as part of the patient's annual review.

Training outcome. The effectiveness of training was assessed in two separate evaluations. Results indicated that there was a statistically significant increase in trainees' knowledge post HCR-20 training.³⁹ These findings were replicated in a recent evaluation of risk assessment and management training at the State Hospital underlining the potentially positive impact of the training model used.⁴⁰ However, the pre-training scores were relatively high suggesting that attendees already had a degree of knowledge or awareness of the violence risk assessment and management process.

External validation

According to Kitson et al. ¹⁶ successful implementation occurs when research evidence is high, the context receptive to change, and where facilitation to change uses both external and internal sources.

The implementation, in particular the training on the procedures and process, was externally validated. Both the risk assessment and management system and the manner of training delivery, ‘train the trainers’, was approved by the Risk Management Authority in Scotland, and the training is now offered to external organizations by the Forensic Network in Scotland. This training approach has been reported as effective in other papers.⁴¹ Additional training sessions were provided at a later date to enable assessors to rate patients on the Psychopathy Checklist Revised⁴² and International Personality Disorder Examination,⁴³ both being relevant to the completion of the HCR-20.

Communication, listening and valuing contributions

The most challenging aspects of organizational redesign is the dissemination strategy used, as changing the organizational culture means changing the individual within.⁴⁴ Communication appears to be vital as in those organizations where change is most effective, educational and communication strategies are central aspects.⁴⁵

Throughout the implementation at the State Hospital, the change leader (MS) provided guidance protocols on relevant procedures, gave support to all wards and encouraged all staff to discuss and share the problems they experienced. The change leader and other members of the implementation team also attended the clinical team and multidisciplinary meetings on each ward in person to receive feedback, to assess progress and problems outlined. In addition, question and answer sessions were set in place to assist clinical staff to adjust to the implementation. Consultants were invited to discuss their concerns and raise any issues. For instance, some consultants thought that the new documentation was too time consuming which impacted on the clinical time available to spend with patients and clinical teams. As a result, the change leader invited all clinical teams and consultants to provide alternative solutions, and where possible these led to revised protocols (Box 2). Box 2

Active implementation summary

Adapting existing protocols

Get clear paperwork and try and fit changes into systems that already exist

Training

Train all staff – do not just offer drive-by training but follow-up, try several models of training as part of the pilot

External validation

Secure external validation and acknowledgement on the methods of your approach

Communication

Invite feedback, criticism and suggestions for change; make suggested changes where possible. Do not accept criticism without suggestions for change

3. Maintaining the change

Project management and action plan

The crucial part of any implementation effort is to ensure the sustainability of the implementation.⁴⁶ In order to achieve this, effective project management and action planning should go hand in hand. Both involve mapping out the likely sequencing of events, and attempting to stick to a set timeline. However, project management refers to the tasks required to be completed within this timeline, whereas an action plan focuses on the process. While Ambrose¹⁷ postulates that an action plan is essential to organizational change, Golden¹⁸ argues that the most effective change leaders acknowledge the dynamic nature of organizational change and deal with events as they occur. This requires a very specific set of skills as the project manager needs to be able to review the process on a regular basis and apply changes to the project plan.

At the State Hospital, for instance, the change leader reviewed implementation plans and modified these to meet organizational needs. This was particularly evident when implementation plans were changed according to the training model piloted.

Governance systems

Audits were conducted to act as incentives for adhering to the new risk assessment and management process.⁴⁷ According to Sederer⁴¹ ‘what gets measured gets managed’ (p. 715), especially when measures are developed collaboratively and are seen as relevant. As part of the overall governance strategy, performance monitoring allows the organization to make technical adjustments to the system and also to identify where additional organizational realignment is necessary.

At the State Hospital audits were conducted on annual care and treatment plans throughout the implementation. The first audit was conducted by the psychology department who attempted to assess all care and treatment plans completed in the hospital to get a well grounded understanding of the extent to which clinical teams followed the new process. The audits conducted in years two and three, however, were conducted by the clinical effectiveness department and were restricted to a specific time period, and are hence lower in numbers. Table 1 outlines the results of these three audits.

Table 1

Audit of risk assessment and management strategy (example: HCR-20)

				Scenario plans
Year	No. of care and treatment plans audited	No of HCR-20s completed	Formulation of offending behaviour	Hospital	Other	Warning signs
1. April 2007–March 2008	84	35 (41.7%)	24 (28.6%)	61 (72.6%)	35 (41.7%)	27 (32.1%)
2. Nov 2008–Jan 2009	30	19 (63.3%)	18 (60.0%)	18 (60.0%)	25 (83.3%)	25 (83.3%)
3. Dec 2009–Feb 2010	21	19 (90.5%)	16 (76.2%)	19 (90.5%)	19 (90.5%)	19 (90.5%)

Challenges. The findings in Table 1 clearly indicate that staff did not immediately comply with the newly introduced guidelines and suggested processes. It is thought that this lack of adherence to the new process may have been partly due to staff's perception that the audits were not official measurements even though outcomes were reported to the senior management team. This situation changed dramatically as soon as governance targets were set as part of the local delivery plan, i.e. as part of the controlled systems, e.g. the integrated care pathways process and key performance indicators.

Research

In addition to monitoring, research is used to evaluate the implementation process and its outcome.⁴⁶ At the State Hospital, a research study was commissioned with the aim of investigating the predictive validity of SPJ tools, when implemented into clinical practice, in mentally disordered offenders in Scotland. While the predictive validity of the HCR-20 has been well established in studies on mentally disordered offenders,^6,48,49 the majority of research is based on retrospective studies, with risk assessments often conducted by researchers rather than clinicians.

The process of the research study lent further support to the results identified in the audit as the research assistant reported considerable problems receiving and locating completed risk assessments. The results of the study provide important information on the efficacy of the implemented risk strategy (Vojt et al., in preparation) (Box 3). Box 3

Maintenance of change summary

Governance

Set key performance targets that all will be measured against; set-up organizational governance targets to be reported on at board level

Make sure these are reported on a regular basis

Set clear time scales to avoid project drift

Regular reports to senior management team

Provide clear policy papers for all staff

Audit

Not just quantitatively but also qualitatively – mapping of risk factors to risk management planning

Need to be seen as official measurement of key performance indicators

Research

Evaluate your strategy through research projects

Recommendations

Clinicians routinely assess violence potential and make related management decisions in psychiatric emergency services, civil psychiatric hospitals, forensic settings and outpatient practice.¹¹ While different risk settings will require different guidelines, the overarching principle is the same: there is a need to balance the risk to the public with the human rights of the forensic patient. This can only be achieved if risk is appropriately identified and risk management plans are put in place. Ideally, in this way, the patient is given the opportunity to address his difficulties while staff are able to develop logical and coherent strategies to manage the risk presented. The following is a short guideline that may help future implementation efforts in introducing a risk strategy at service level (Box 4). Box 4

Risk assessment and management implementation – a recipe for success?

Develop a clear statement of the change to be implemented

Carry out a needs analysis of the requirements to implement the change

Ensure sufficient funding, e.g. for administrative and IT support, materials required, dissemination means and extra manpower where required

Conduct a pilot study to identify procedural problems

Identification of change leader with sufficient influence and respect within the organization and one or more spokesperson(s) best suited for targeting specific staff groups

Consistent communication to staff to identify reasons for resistance and to acknowledge good practice and the sacrifices made by staff

Expect opponents to the change and design an action plan on how to deal with these

Training

Training of all clinical team members in appropriate risk measures

Awareness training for all staff

Adapt existing protocols to include

Standardized evidence document outlining the evidence gathered in the risk assessment

Standardized care and treatment plan using the information gathered in the risk measure

Standardized file review protocol as the background catalogue for completing the risk measure

Monitor the implementation through official governance systems, audits and research efforts

Reservations

Maden⁵⁰ elaborates that the completion of risk assessment instruments, and thus any implementation effort associated with these, may be seen as irritating and time- and resource-consuming. He notes that documentation may include irrelevant material due to the fear that important information may be left out. These concerns reflect the challenges experienced during the implementation at the State Hospital. The question is whether completing these care documentation forms impacts significantly on the clinical time and opportunity available to professionals to spend time with patients and ward staff. While this has not been researched as yet, it is important to note that a good risk management plan, i.e. care and treatment plan, would provide a useful focus of clinical time, and thus is more likely to be a benefit rather than a cost to patients.

Future research

Assessing the impact of completing risk assessment and management documentation may be suitably assessed in a longitudinal study following successful implementation, with areas of interest being, for example, the therapeutic alliance, staff empathy and long-term detention statistics. Future implementation efforts may wish to include measures to control the quality of change. For instance, audits should be conducted detailing the quality with which violence risk factors are addressed in risk management plans. The overarching question, however, is what exactly is ‘good’, i.e. effective, risk management, and how can it and its key elements be reliably assessed? Qualitative research may be the step forward in this respect. For example, a qualitative study looking at patients' experience of risk management, thereby identifying barriers and incentives to service uptake and continuity of care, is currently being conducted in Scotland.

Conclusion

Changes at an organizational level are notoriously difficult to achieve;⁵¹ the State Hospital proved to be no exception to this. Due to the nature of the implementation, i.e. complete risk assessments as part of the risk management process, and within a multidisciplinary team approach, the entire organization was required to change. This paper outlined the steps taken to ensure the success of the implementation as well as the difficulties experienced in the process and how these were overcome. The results of the most recent audit confirm that a hospital-wide risk assessment and management strategy is possible to achieve. This said, it is unclear to what extent the guidelines used in this implementation are applicable to services where risk assessment measures and treatment plans are completed by one individual alone, i.e. outside the multidisciplinary context. However, in line with Kitson et al.'s¹⁶ understanding of change and implementation as dynamic, guidelines to organizational change may be best seen as potential ‘recipes for success’¹⁸ rather than clearly mapped-out models.

Declarations of interest: None.

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