Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Invisalert Solutions, LLC

Name of Innovative Program: 
15-minute Observation Check Compliance For The Inpatient Setting.
Sponsoring Organization
Invisalert Solutions, LLC
Name of Innovative Program Lead: 
Peter Nagy
E-mail Address of Innovative Program Lead: 
pnagy@invisalertsolutions.com
Project Description: 
The 15-minute observation check is the standard of care used on inpatient behavioral health units to support patient safety.   Unfortunately, for a variety of reasons, these critical observation checks can be missed, which may have adverse and sometimes tragic consequences for consumers receiving care.  InvisAlert’s simple system replaces the paper clipboard with a mini-iPad, essentially a digital clipboard, which, using HIPAA-compliant software, displays unique information about each consumer and their respective observation schedules.  The system uses audio and visual cues to assist the staff observer but will not allow a 15-minute observation check to be recorded unless the staff observer and consumer are within close, line-of-sight proximity which is adjustable from 1-20 feet.    The consumer wears an unobtrusive, tamper-proof wristband that sends a signal to the iPad authorizing an observation record once the pre-set proximity between staff observer and consumer has been reached.  If an observation is missed, a tiered series of alerts can be sent to the nurse’s station, charge nurse or supervisor to intervene as necessary.
Creativity and Innovation: 
The genesis for InvisAlert's solution was repeated negative events at multiple acute inpatient psychiatric facilities where the root cause consistently pointed to the traditional pen-and-paper clipboard system for two reasons:  First, the paper clipboard system has no means to measure or enforce observation compliance.  Second, the actual workflow of staff and consumers is not supported by the paper clipboard system.   When an initial market search failed to identify pre-existing products that could solve the drawbacks of the clipboard, InvisAlert was the result:  a simple, cost effective and unique (patent pending) system that supports consumers in their recovery and provides unit staff with the tools necessary to ensure safety on the unit.  The InvisAlert team, led by an inpatient veteran, developed a simple solution that measures and enforces compliance even within the busy and sometimes confusing workflow of inpatient settings including 1:1’s, shift change, off-unit, outdoor therapy and discharge status.  
Leadership: 
The InvisAlert system will provide unit staff with the tools to be successful in keeping all consumers on the unit safe while their needs are met quickly and attentively.  InvisAlert was designed after extensive input from administrators, nurses, health techs, and inpatient consumers at a wide range of facilities.  By designing a product specifically for inpatient workflows with inputs from the entire treatment team, InvisAlert’s system will engender better teamwork while empowering consumers to focus on their recovery knowing their safety is paramount.  The response from all of the discussion participants was overwhelmingly positive with respondents expressing strong convictions that the InvisAlert system would positively benefit their consumers and those of the behavioral health community at large.  This convincing response suggests that we have a great opportunity to create the standard of care for patient safety and thereby benefit the largest number of consumers.    
Sustainability: 
The founders of InvisAlert have self-funded the development of the working prototype.  Two hospitals in the survey were asked to participate in user evaluations and both have accepted.  Based on the convincing endorsement of all of the survey participants, InvisAlert has attracted investment interest and commitments from a variety of investors including the Ben Franklin Technology Partners Life Science Division.  In addition to the support of the survey participants, a large public hospital corporation has expressed interest in the system for an enterprise-wide roll-out.  
Replicability: 
Observation checks and 1:1s are the standard of care on acute inpatient units in the United States and many other countries throughout the world.  The InvisAlert system is a simple, user-friendly system, which does not need a high level of computer literacy.  The system was designed with input from non-profit, for-profit and state facilities, which are reflected in the wide array of features a staff supervisor may choose from to customize the care needed to support each individual on their unique path to recovery.  The InvisAlert system has been designed for stand-alone operation or easy integration into an EHR. 
Results/Outcomes: 
The current pen-and-paper clipboard system has no means of insuring or verifying compliance of the 15-minute observation check.  Furthermore, the traditional clipboard is not designed to accommodate the complex workflows present on a busy acute inpatient unit.  The InvisAlert system overcomes these drawbacks and insures and documents observation compliance regardless of circumstance.  Tragically, sentinel events occur 5 times per day across the United States in inpatient settings but agitation, violence, injury and other adverse outcomes can be daily occurrences in every facility.  By making the observation check system more effective, InvisAlert will keep consumers safer and speed their respective recoveries.     
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