New Hampshire Hospital (NHH) is a 210-bed subspecialty hospital that accepts patient referrals from surrounding mental health community programs and professionals. The referred individuals have been assessed in the community and found to pose a danger to themselves or others as a result of mental illness. NHH's yearly admission rate has steadily increased, from 850 patients in 1990 to 2,380 patients in 2008. Many factors contribute to this trend, one being the number of individuals sent to NHH from local jails and from the secure psychiatric unit (part of the Department of Corrections) at the New Hampshire state prison. NHH essentially serves as a step-down facility for patients who have faced legal charges and are deemed to need further evaluation and treatment before being discharged to the community. The increasing number of patients at high risk of violence complicates their discharge to the community (1,2,3,4,5).

Clinicians are frequently asked to determine a patient's potential risk for future violence, an assessment that is fraught with difficulty (6,7). Actuarial models have been developed to assist clinicians in predicting future violence in the community for patients recently discharged from psychiatric inpatient units (8,9). This report describes the development of the NNH Administrative Review Committee (ARC), which the hospital initiated to mitigate the risk associated with the overall management and disposition of high-profile patients. This best-practice model may be useful to other inpatient psychiatric facilities caring for high-profile patients.

The NHH administration oversaw the development of the ARC policy, structure, and process. To gather the data necessary to develop and implement the committee, NHH psychiatrists, the chief medical officer, the chief executive officer, NHH legal counsel, the administrator of community integration, and the administrator of patient care services were interviewed. The National Association of State Mental Health Program Directors (NASMHPD) was queried to determine whether similar committees were functioning in other institutions. In addition, various risk assessment instruments were reviewed. [A list of these instruments is available as an online supplement to this column at ps.psychiatryonline.org.]

The results of the data gathering helped outline the potential duties of the ARC. This led to the development of the ARC policy, which defined the role and responsibility of the ARC and the procedures for its use as a risk management tool. The survey of NASMHPD medical directors found no similar procedure in use at other institutions.

The hospital administration determined that the ARC would be a critical component in the management of high-profile patients and that the work of the committee must be considered in the context of an attorney-client privileged communication. The ARC policy would need to be clear, brief, and concise, and the committee would be limited to reviewing the highest-risk patients with very clear criteria for referral. ARC review would be mandatory for patients who meet criteria for referral. The policy would allow the attending physician discretion to refer patients not meeting ARC review criteria and allow the chief medical officer the discretion to require a patient to be reviewed by the ARC who otherwise does not meet ARC criteria. The ARC policy was developed to include criteria for removing a patient from oversight, and all ARC decisions would need final written approval from the NHH chief executive officer.

All ARC communications are considered attorney-client privileged communication. This provides a risk management process designed to mitigate potential liability resulting from the acts or actions of patients with mental illness who are at risk of violent or aggressive behaviors.

The members of the ARC are the chief operating officer, the administrator of patient care services, the administrator of the community integration department, the chief medical officer, and the NHH legal counsel or their respective designees. The presence of the NHH legal counsel or a counsel designee is required for the meeting to be held. This requirement maintains the goal of attorney-client privileged communication.

The ARC policy delineates high-risk patients requiring ARC review. A patient meeting one or more of the following criteria is referred to the ARC:

• Found not guilty by reason of insanity

• Transferred from the secure psychiatric unit of the Department of Corrections

• Admitted with outstanding criminal charges or past convictions or found not competent to stand trial for the following reasons: aggravated felonious sexual assault, felonious sexual assault, aggravated assault, murder or attempted murder, kidnapping, arson or attempted arson, and criminal threatening

• Admitted after inflicting a serious bodily injury to another person (requiring medical care), even if no criminal charges were filed

• Admitted after a serious suicide attempt of clearly lethal intent and method: hanging, use of firearms, jumping, drowning, or carbon monoxide poisoning.

The chief medical officer may, at his or her discretion, refer to the ARC for review a patient not meeting the above criteria. The attending clinician may present a patient not meeting ARC criteria to the chief medical officer to assess whether management of the patient's risk would benefit from review by the ARC.

A patient meeting criteria for review is referred to the ARC when the clinician completes an ARC data sheet. The clinician is expected to present any pertinent information about the patient's status to the ARC. On review of all information provided, the committee considers the potential risk a patient poses to him- or herself or others and then makes a determination regarding the patient's privilege status, visits outside of the hospital, discharge, and disposition. Final written determination, approved by the NHH chief executive officer, is forwarded to the attending clinician within three days of the close of the ARC meeting. The attending clinician must implement the ARC recommendations on receipt of the written determination.

After an extensive review of the ARC policy by the NHH medical staff, Department of Health and Human Services administrators, and the attorney general's lawyers, NHH set a date for implementation, and administrators held a series of regularly scheduled meetings with clinical and support staff to provide education about the policy's provisions. A data collection process was developed, based on the criteria for ARC review, to gather information about diagnostic categories, legal issues, and risk factors leading to ARC referral. This data collection, currently under way, will help determine whether specific risk management themes emerge that need further investigation.

Mr. A, a 40-year-old man with a diagnosis of schizophrenia, was charged with first-degree assault and attempted murder after he attacked a family member with a baseball bat. He was psychotic when the event occurred and was found competent to stand trial. The superior court judge accepted a plea of not guilty by reason of insanity and committed him for five years to the secure psychiatric unit of the Department of Corrections. He accepted treatment and was stabilized on a second-generation antipsychotic medication. Five years later, he received another five-year commitment to the secure psychiatric unit, was determined to be psychiatrically stable, and was transferred to an NHH inpatient unit. Upon transfer, he was not psychotic and was adherent to medication treatment. The superior court judge ordered that any change in supervision status needed his approval.

Mr. A continued to follow his treatment regimen. His mental status was assessed regularly. The treating psychiatrist presented Mr. A's case for ARC review whenever a request for a change in supervision (such as privileges to go on community trips, to go independently off the inpatient unit without supervision, and to go on grounds without supervision) was deemed to be clinically appropriate. ARC meetings focused on risk management (for example, given his current clinical status, was Mr. A capable of dealing with a change in supervision? Was there any recent evidence of increasing hostility or belligerence that heightened his potential for violence?). Discussion about the psychiatric treatment he was receiving focused on his medication adherence and participation in therapy groups and how his compliance and participation affected his overall risk of violence. ARC approval allowed the psychiatrist to petition the superior court judge for hearings to review and possibly change Mr. A's supervision status. Mr. A used his independent supervision privileges appropriately.

Three years after Mr. A's admission to NHH, the treating psychiatrist presented Mr. A's case to the ARC to allow his discharge to an outpatient program in the community. The ARC approved this request, as did the superior court judge. Mr. A was discharged to that program and continues to follow his treatment regimen.

The implementation of the ARC policy led to a clear description of patients whose cases need review before the patients can be discharged from NHH. Concrete delineation of these high-profile patients minimized potential inconsistency across treatment teams referring patients to the ARC. Treating clinicians have reported that the guidance provided by the ARC is helpful given the increasing number of dangerous patients in their care. They appreciate the ARC's role in sharing the burden of decision making for these high-profile patients and its ability to provide guidance on difficult discharge issues. Reviewing the more difficult cases allows the ARC to apply appropriate risk management principles and ensures due diligence and oversight to protect the patient, staff, community, and hospital. The policy's approval by the attorney general's office confers legal credibility, and clinicians appreciate the attorney-client privileged setting that allows for open, productive discussions.

The ARC is viewed by treating clinicians as a committee that focuses on risk management, not on clinical care or treatment plans. This important distinction helps diminish resistance to the operation of this committee, because clinicians do not perceive the ARC as a group of administrators making clinical decisions, even when the occasional disagreement occurs between the treating clinician and the ARC. The process allows for further discussion, which has generally fostered resolution of the issues. This distinction has led to the ARC's acceptance as an invaluable asset rather than an administrative burden.

We have no indication that other state hospital facilities have implemented a similar mechanism to address the increasing number of dangerous patients treated in state systems. The development of this best practice has focused discussions and provided guidance to clinicians caring for high-risk patients at our treatment facility.

Thus far, we have no data addressing the effectiveness of ARC review. This limitation will be addressed by future research.

NHH has successfully implemented a committee that provides a risk management process to mitigate potential liability to the hospital and to treating clinicians. The ARC provides a mechanism to monitor patients who are at high risk of violent or aggressive behaviors. Supervision, discharge, and dispositions are thoughtfully addressed through presentation to and review by ARC. This best practice is seen as positive and productive by our clinicians. Other state facilities may benefit from the development of a similar committee and risk management process.