Lakewood, Washington

  • In a State psychiatric hospital of 825 beds, CSM has been assisting the State and hospital leadership in their efforts to correct deficiencies leading to a Federal Systems Improvement Agreement and decertification. 
  • We have currently engaged in a facility-wide initiative to create functional work groups aimed at addressing all aspects of CMS Conditions of Participation and enable the facility to both reaccredit with the Joint Commission as well as reapply for CMS Certification.
  • Worked with the senior management group to develop leadership skills, strategic planning and fostering organizational culture change.
  • Performed ongoing clinical and operational tracers related to documentation and record keeping, providing on the spot staff training and monthly summary reports to guide senior staff in decision-making.
  • Assisted in the hospital’s efforts at creating a performance improvement plan around enhancing patient and staff safety through improved programming, staff skill development and a commensurate reduction in violent episodes. 
  • Provided an in-depth analysis of restraint and seclusion use at the hospital with the goal of significant reductions in utilization and ensuring all standards of safety and quality are utilized.
  • Assisted hospital leadership on various Quality Improvement initiatives:
    • Development and facilitation of a strategic planning retreat incorporating operational and clinical leadership in a comprehensive violence reduction planning effort
    • Facilitating a follow-up Physician Summit to effectively engage medical staff in the violence reduction efforts
    • Developed and facilitated the planning effort behind the establishment of a Specialized Treatment, Assessment and Rehabilitation (STAR) ward for the most behaviorally challenging patients
    • Performed a comprehensive review of the hospital’s utilization of restraint and seclusion with recommendations aimed at reducing utilization, ensuring effective training, implementation and compliance with regulatory standards/best practices