Commitment to Care: CPI and China

By Daniel Gugala | Posted on 05.07.2014 | 0 comments
CPI’s Daniel Gugala, vice president and general counsel, was interviewed by CN-Healthcare, a leading Chinese medical journal. Following is a transcription of the interview.
CN-Healthcare: Would you share with us a bit of your background?
Daniel Gugala: I am the Vice President and General Counsel of Crisis Prevention Institute, Inc. (CPI), responsible for corporate business operations, international market development, and legal affairs. I also have the good fortune to oversee CPI’s product and program development group, ensuring world class design and delivery for CPI’s internationally recognized program offerings.
I received my bachelor’s degree from the University of Wisconsin-Madison and Juris Doctorate from Marquette University. Prior to CPI, I worked in a product management role leading cross-functional teams in large-scale integration projects for Fortune 500 companies.
CN: How long have you been with CPI?
DG: I joined CPI in 2004 and I have been with the company for the past nine years. 
CN: What is your current role in relation to CPI China development?
DG: I lead CPI’s international expansion effort focused on the Asian market. Our goal is to help create safe environments for healthcare and human services professionals throughout Asia. 
About CPI 
CN: Who is CPI?
DG: CPI is an international training organization committed to best practices and safe behavior management methods that focus on prevention. Through a variety of specialized offerings and innovative resources, CPI educates and empowers professionals to create safe and respectful work environments. This enables professionals to enrich not only their own lives, but also the lives of the individuals they serve.
The cornerstone of CPI is the Nonviolent Crisis Intervention® program, which is considered the worldwide standard for crisis prevention and intervention training and is the program we are bringing to the China market. With a core philosophy of providing for the Care, Welfare, Safety, and Security℠ of everyone involved in a crisis situation, the program’s proven strategies give healthcare service providers the skills to safely and effectively respond to anxious, hostile, or violent behavior while balancing the responsibilities of care.
CN: What has CPI accomplished in healthcare settings since the company was established in 1980? (#of health professionals trained, #of hospital clients, examples of renowned hospitals, etc.)
DG: CPI was established in 1980. In the 80s, there were a lot of misperceptions regarding the best methods to respond to challenging and aggressive/violent behavior exhibited by patients in healthcare and mental health settings in the US, which are just like those happening recently in China. Organizations and staff members were in need of a training program to equip themselves with safe, respectful, noninvasive methods for managing disruptive and assaultive behavior in a way that was compatible with staff's duty to provide the best possible care. Additionally, they wanted to feel safe at work and gain confidence and competence when facing challenging individuals. The Nonviolent Crisis Intervention® program, which is designed and taught exclusively by CPI, was brought to the market to meet these needs.
Nowadays, this program has become the worldwide standard for crisis prevention and intervention training. More than 8 million human service professionals around the globe have participated in CPI’s training program and 35% of them are from the healthcare industry. Thousands of US hospitals use this program throughout their system and some of our renowned customers include Hospital Corporation of America (HCA), Universal Healthcare System (UHS), Ascension Health System, Dignity Health (formerly Catholic Health West), Banner Health, and Mayo Clinic.
CN: Does CPI training have any alignment with US federal and state government agencies, professional healthcare associations, and/or healthcare institutions?
DG: Yes. CPI’s Nonviolent Crisis Intervention® training program helps facilities meet a range of requirements set by federal, state, and local legislation and regulation as well as requirements set by accrediting bodies across a broad range of disciplines.
In addition, several agencies, including the Center for Medicare and Medicaid Services (CMS), require that healthcare facilities looking for federal funding receive crisis prevention training. The Individuals with Disabilities Education Act (IDEA) provides funding for such training in some settings.
Some other examples of agencies that recognize the need for training consistent with CPI’s core programs include:
  • Joint Commission;
  • CARF (Commission on Accreditation of Rehabilitation Facilities);
  • COA (The Council on Accreditation for Children and Family Services);
  • National Health and Education Associations; as well as
  • Numerous state and local governments.
About CPI Training Programs
CN: Would you briefly introduce CPI's training program in healthcare?
DG: The program we offer to the Chinese healthcare market is CPI’s cornerstone program: Nonviolent Crisis Intervention® training. The Nonviolent Crisis Intervention® training program, developed by CPI, is embraced worldwide as a highly effective behavior management system for organizations committed to providing quality care and services in a respectful, safe environment. Nonviolent Crisis Intervention® training offers a solid foundation to structure prevention and intervention approaches based on a philosophy of providing the best possible Care, Welfare, Safety, and Security℠ for staff and patients—even during crisis situations.

The strategies and techniques taught in the Nonviolent Crisis Intervention® training program provide staff with a proven framework for decision making and problem solving to prevent, de-escalate, and safely respond to disruptive or assaultive behavior. The program focuses on prevention, recognizing crisis at its early stage and verbal de-escalation. But it also realistically addresses the serious issue of physical intervention through careful assessment of risks and an evaluation of what may be considered “last resort.” CPI’s Principles of Personal Safety and Nonviolent Physical Crisis InterventionSM principles and dynamics are taught, recognizing the critical importance of staff confidence and ability to safely respond to physical assault. CPI’s Postvention model assists staff teams in managing the opportunities to rebuild communication and relationships with patients in the aftermath of a crisis and to prevent incidents from happening in the future.

CN: According to your observations, under what kind of circumstances has violence occurred in US healthcare? What are the reasons?
DG: Violent incidents in US healthcare settings have typically impacted nurses, as opposed to doctors, like we see in China. According to the US Bureau of Labor Statistics in 2011, 46% of all violent acts in the workplace that necessitated time off were against registered nurses. Some statistics from the Journal of Nursing Administration are:
  • 20% of nurses were verbally abused more than 200 times.
  • 25% of nurses said they had been physically attacked by patients more than 20 times.
  • Many nurses reported that they did not report incidents of verbal and physical abuse out of fear of retaliation and lack of support.
Source: Boyett, L., Gacki-Smith, J., Homeyer, C., Juarez, A. M., MacLean, S. L., & Robinson, L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration, 39, 340–349. doi: 10.1097/NNA.0b013e3181ae97db
Usually, patients feel anxious and frustrated in the following circumstances:
  • Long waits to see a healthcare professional
  • Individual needs not met by healthcare professional
  • Lack of information or frustration regarding their health condition
  • Being unprepared to receive a negative health report
  • Dissatisfaction of service, etc.
I believe there is uniqueness of medical tension in China, but many of the reasons are similar as the patient expectations are similar.
CN: How do healthcare professionals view the importance of CPI's training? Would you tell some successful stories?
DG: Most of our customers think the Nonviolent Crisis Intervention® program can greatly reduce the risk of injury by using verbal de-escalation and decreasing the number of physical interventions, improving communication among staff by establishing a common language, and boosting staff confidence to intervene in a crisis situation. The program aims to alleviate the stress and anxiety associated with confusion or uncertainty in difficult times and to help people feel safe and respected at work again.
CPI has thousands of references who will tell you about the change CPI has made for them, for their facilities, and for the patients in their care. I have successful stories to share.

CN: How many countries does CPI conduct business with? What are their features? Based on your knowledge, what are the trends of healthcare violence globally? What are the differences of the healthcare violence among different counties and regions?

DG: CPI has operations in the UK, Ireland, Australia, and hopefully soon in Japan and China. We have 28,000 active Instructors in over 17 countries. The basis of our training program is consistent across our markets, but we do have some variation on the program to meet existing local rules and regulations. For example, in the UK many Instructors (and their staff) are required to attend refresher training more frequently to meet the needs of the British Institute of Learning Disabilities.   
About CPI China
CN: What brought CPI to the decision to expand the program in China?
DG: CPI’s commitment to the international market has never been stronger and we have been successful in North America, Europe, Australia, and New Zealand. We have made a commitment as a management team to expanding our mission even further internationally. Asia, and particularly China, is a key focus area for CPI.
Certainly the medical tension issue has had an impact on our decision, but in reality the issues that China is facing in terms of responding to challenging behavior are very similar to what the US faced in the 1980s. It took the US 33 years to accomplish the level of training effectiveness for such situations that we have now. I believe that China will be able to achieve that same result in five to seven years because the country has been so adept at adjusting to the changing needs of the people. CPI wants to be the front runner in assisting medical professionals during this transition. 
CN: How did you learn about the violence in China hospitals? What is your comment on violence in China hospitals?
DG: Tension between doctors and patients in China has been well documented. The tension appears to be the result of a combination of factors. Some of these factors include:

  • Hospital policy concerning response to tension including mediation expectations and process;
  • Number of patients whom doctors are required to see each day and the quality of service they received during the short amount of time;
  • Patient expectations regarding the care they receive and the way they are to be treated;
  • Inefficient communication and lack of staff effort to build/rebuild trust;
  • As well as other factors that can vary by location.
There are many other issues in the Chinese healthcare industry which stem from its unique healthcare system, so we expect that it will take time and effort to significantly reduce or even eliminate medical tension. But we are confident it can be done through the support of health administrators who place a premium on staff safety. China is going through a nationwide healthcare reform so we expect changes regarding workplace safety to take place soon. CPI brings the world-leading training content, method, and delivery which have been proven effective across cultures and regions. We hope to be an important part of China’s healthcare reform and provide inspiration to professionals who are suffering from fears and anxieties due to the medical tension.  
CN: In your opinion, what can CPI's Nonviolent Crisis Intervention® training bring to China hospitals? How effective will it be? How is CPI’s solution different from/compatible with the current solutions conducted by other parties?
DG: CPI believes that positive change is possible by improving staff responses to patient behavior and implementing proactive policies that the hospital administration supports. The process of change will take time and there will be challenges, but real results (reduction in incidents, injuries, and costs) can be achieved.
CN: Acknowledging the Relationship Between Staff and Patient Behaviors
DG: There are factors that impact the behavior of both staff and patients who utilize any healthcare provider. CPI refers to this as the Integrated Experience. The policies and procedures of the hospital impact behavior of the hospital staff whose behavior further impacts the hospital’s patients. This interconnectivity works in reverse as well, where patient behavior impacts staff response and, with enough of the same type of interactions, impacts hospital policies and procedures.
In many instances these interactions result in tension because the focus for the hospital and staff is on how to mediate the tense incident instead of how to eliminate the tension in the first place. Staff expect there to be tension so they act in a manner that portrays tension, the patient notes that tension, and in turn they become tense. (Policies supporting the increase in the number of security guards, training doctors in Kung Fu, and having nurses wear helmets are examples of this.) 
CN: Enhancing Existing Policies and Procedures
DG: The challenge to implementing any change that is intended to proactively address behavior is that it requires commitment at the highest levels of an organization. It must also be fully supported in existing policies and procedures. The current policy of many health organizations in China appears to be solely focused on mitigating the hospital’s liability in the event of an incident. This is a very legitimate and necessary element of any hospital policy. However, it should not be the only policy.
Proactive policies designed to respond to behaviors at the earliest signs of tension could reduce the number of incidents. This would also increase staff safety and improve their confidence when dealing with challenging individuals. CPI’s program emphasizes team intervention. By working as a team, all of the intervention concepts are best utilized and staff feel supported. Good teamwork is a product of communication and experience. It takes time and effort, but CPI believes, as we keep learning and practicing, every organization will have well trained team(s) to best intervene during crisis moments. In addition, as hospitals improve their method of responding to various patient behaviors, the reputation of the hospital and of its staff improves.
CN: Staff Can (and Must) Be the Difference
DG: CPI believes the skills necessary to implement these types of proactive policies and procedures can only be achieved through staff training. The training must provide staff with the skills necessary to identify escalating behaviors and the proper approach to responding to those behaviors. The implementation of such policies and procedures requires the commitment of the hospital administration to change the mindset of the organization from thinking mediation to thinking prevention.
In any organization, regardless of country, this change in philosophy takes time and effort. But as we have seen throughout many other regions, a commitment by organization leadership can create this change. CPI is committed to our mission to provide for the best Care, Welfare, Safety, and Security℠ for staff and patients involved in tense situations for the long-term, and we are prepared to support Chinese healthcare organizations on this journey. 
CN: What's CPI's near-term plan for the China healthcare market? What is your vision of CPI in China five years from now?
DG: CPI has the resources and commitment to begin providing training in China immediately.  Our short-term vision is to find a progressive health organization willing to help us prove the effectiveness of our techniques in the Chinese market. In the next five years, CPI expects to fully establish a Chinese operation capable of supporting the professionals trained in China with the same level of services we have become known for throughout the rest of the world.  
CN: What are the challenges you think CPI might face in China?
DG: There are few difficulties for implementing the Nonviolent Crisis Intervention® program in China.
  1. The managerial level has not yet realized the importance of managing the crisis moment as opposed to responding afterward.
  2. Both administrative-level and frontline staff‘s mindset on crisis management is to focus on post-intervention rather than prevention. The damages of an incident are not only monetary loss but also losses on reputation, staff morale, trust, etc.
  3. Lack of proactive attitude toward challenging behavior management and long-term commitment to workplace safety.
  4. Lack of practical/implementable policy and procedure in workplace safety and lack of regular training to educate staff with skills and techniques to better respond at crisis moments.
  5. Intellectual property and quality of training: CPI values the ownership of the Nonviolent Crisis Intervention® program and believes the authenticity of the training helps guarantee the quality and effectiveness of the program. So we move cautiously in any new market to ensure the highest quality training delivery.
See photos from Daniel’s 2012 trip to China.

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