New risk assessment tool at MDHHS state psychiatric hospitals reduces incidents and injuries to patients and staff

First psychiatric hospitals in the state to implement innovative process

LANSING, Mich. – As part of ongoing efforts to improve care and reduce incidents of aggression and injuries to patients and staff at Michigan’s four state psychiatric hospitals, the Michigan Department of Health and Human Services (MDHHS) has implemented daily risk assessments and care planning. This new process has resulted in a 47% reduction in patient injuries and a 27% decrease in serious patient-related staff injuries.

“We take the health and safety of our staff and patients seriously and continually strive to improve the care our patients receive as well as working conditions for our staff,” said Elizabeth Hertel, MDHHS director. “Patient-to-staff aggression is the leading cause of workplace injury among our staff. Implementing this risk assessment tool has helped us make great strides in reducing incidents and injuries as well as improving staff retention.”

The Dynamic Appraisal of Situational Aggression (DASA) is a seven-item risk assessment rating used to evaluate the likelihood of aggression in behavioral health inpatients within 24 hours. Patients are rated daily by direct care nursing staff on the following categories:

•          Irritability.
•          Impulsivity.
•          Unwillingness to follow directions.
•          Sensitive to perceived provocation.
•          Negative attitudes.
•          Verbal threats.

Staff completing the DASA consider whether each of the seven behaviors are present and then determine a rating of low, moderate or high risk of aggression. Based on their DASA score, the Aggression Prevention Protocol is used to develop individualized intervention strategies that are implemented to prevent aggressive behavior before it begins. Strategies can include reassurance and distraction techniques, one-to-one nursing, medication or setting limits and establishing boundaries of acceptable behavior, as well as increased observation.

“Patients in our state hospitals are dealing with some of the most serious behavioral health illnesses and sometimes these conditions prompt them to act out, causing injury to themselves, staff or other patients,” said Dr. George Mellos, MDHHS State Hospital Administration senior deputy director. “This tool helps our staff stop these incidents of aggression before they start and puts the management of patients where it belongs, in the hands of the direct care staff who know them best.”

In addition to the reduction in staff injuries, staff retention has increased. Since February 2024, state hospitals have experienced a 43% reduction in staff turnover.

“Early outcomes [at MDHHS facilities] are already highly impressive, including significant reductions in staff injuries and turnover,” said Dr. Roland Jones, scientist with the Institute for Mental Health Policy Research and forensic psychiatrist at the Centre for Addiction and Mental Health. “This initiative highlights the value of coordinated, evidence-based practices in promoting safety, reducing risk and enhancing quality of care across psychiatric services, leading to safer environments for both patients and staff.”

DASA and the Aggression Prevention Protocol was developed by the Centre for Forensic Behavioural Science at the Swinburne University of Technology in Melbourne, Australia. MDHHS’ state psychiatric hospitals are the first psychiatric facilities in Michigan to implement the survey and protocol. State psychiatric hospitals in Virginia are using the tool as well as The Johns Hopkins Hospital in Baltimore and UCLA Medical Center, which implemented it in its emergency department.

“The outcomes from Michigan's Department of Health and Human Services’ implementation of the DASA and Aggression Prevention Protocol are already reaping benefits with reduced staff injuries and staff retention,” said Dr Michael Daffern, director of the Centre for Forensic Behavioural Science at Swinburne University of Technology and author of the DASA. “This is an excellent example of world class implementation and evaluation using novel best practice in mental health.”

MDHHS operates four in-patient psychiatric hospitals serving about 600 patients, Caro Psychiatric Hospital, Kalamazoo Psychiatric Hospital (KPH), Walter Reuther Psychiatric Hospital and the Center for Forensic Psychiatry (CFP). DASA was implemented at KPH in March 2024, Caro and Walter Reuther for adult patients in July 2024 and CFP and Walter Reuther for youth patients in September and August 2025, respectively.

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