Crisis of Cost, Day 1: State hospital’s mandatory overtime soars in past year

From the Salem Statesman Journal, May 23, 2010

‘An insane replacement for actual staffing’

Oregon State Hospital employee Calvin Patterson sits outside the hospital's transitional cottages, where he works.

Oregon State Hospital employee Calvin Patterson sits outside the hospital's transitional cottages, where he works.

Calvin Patterson is sick and tired of mandated double shifts for employees at the Oregon State Hospital.

“This is an insane replacement for actual staffing,” said Patterson, an eight-year employee.

During her first year of work at OSH, Sharon Mangan has become stressed out by mandated overtime and patient-caused violence.

Patients have assaulted her twice in recent weeks in the overcrowded and volatile forensic program, compounding her fear and anxiety. Mangan said one patient choked her and that another spit blood in her face and broke her glasses while being restrained by staffers.

“We’re not being protected. Nobody is protecting the line staff,” she said.

Leslie Ann Warren has worked at the hospital since 1987. She said employee morale has cratered.

“I’ve never seen it this bad,” she said. “It’s horrible. You look at the faces of the people working, and you know they aren’t happy.”

Employee anger about overtime, understaffing and violence is spilling out as the state is building a new $280 million replacement hospital on the OSH campus, and hospital managers are attempting to hire hundreds of new employees.

The partially built replacement facility, touted as “world class” by state leaders, will replace the existing 127-year-old complex — deemed obsolete and unsafe five years ago by state-hired consultants.

Here’s why some hospital workers are mad and demoralized:

    -Mandated double shifts have snowballed, leading to stress, frustration and fatigue.

From January through March of this year, workers logged 9,294 hours of mandated overtime in the forensic program, hospital data show. That’s a monthly average of 3,098 hours. By comparison, mandatory overtime in the same program didn’t crack 2,000 hours in any single month in 2009. The highest total was 1,761 hours in July 2009.

    -Hospital managers have plugged vacancies among the ranks of registered nurses and psychiatrists, but dozens of vacant front-line positions, known as mental health therapists and technicians, haven’t been filled.

    -Patient assaults on staff members have shot up on some treatment units, leaving workers feeling battered, unprotected and vulnerable.

In the first three months of this year, the hospital recorded 267 patient assaults on staff, 89 per month on average — a jump from 55 per month in 2009.

Violence takes toll

Mangan described patient attacks as horrifying. She has witnessed co-workers suffer injuries serious enough to require treatment at Salem Hospital’s emergency room.

Hospital training and orientation sessions failed to prepare her for such violence, she said.

The former painting contractor, hoping for stable employment amid the recession, became a certified nursing assistant and started working at OSH in April 2009.

“Before I took the job, I figured we were going to get some self-defense training because we are in there with crazy murderers, rapists, everything,” she said. “No, our training consisted of four hours in a little room with a couple of instructors. It was a joke.”

The forensic program houses patients who were judged guilty of crimes but insane at the time. They were sent to the hospital for treatment, not punishment.

Patient-caused violence in the program has long been a sore point for workers, challenging hospital administrators to devise new ways to curb it.

Last year, the hospital opened a maximum-security unit for a small number of violent female patients who had committed scores of assaults on fellow patients and staff members.

Creation of the new unit produced mixed results: assaults dropped on wards formerly terrorized by the highly aggressive patients, but staff became punching bags in the women’s unit.

The latest attempt to stop attacks committed by one notoriously violent patient requires her to be placed in wrist restraints prior to leaving her room. The hospital also has hired an outside specialist to devise a new behavior plan for the troublesome patient.

Meanwhile, the fear factor has become almost unbearable for Mangan, who has to steel herself to go back to work. She grimly predicts that staff safety won’t become a high priority until someone gets killed.

‘We are tired’

Patterson started working at the psychiatric facility when he was 19. The hospital’s growing reliance on mandated overtime has chipped away at his job satisfaction.

“It wouldn’t be a bad job if they got this squared away,” he said.

The mental health therapist has primary work duties at the hospital’s transitional cottages, which house minimum-security forensic patients. When tapped for mandated overtime, he puts in double-shift duty on medium-security and maximum-security forensic wards.

Patterson has vented his frustration about forced overtime in hospital-wide e-mails to employees. His first message was titled “WHAT IS WRONG WITH THIS PLACE?”

“I am being mandated tonight 8 days after my last mandate. Being that the swing shift mandate rotation list contains 146 names, I am extremely frustrated by this as should be every person who is having the same mandate experience.

“Where is management to help us with this obviously major dilemma? WHAT IS BEING DONE? These are not acceptable working parameters.

Patterson recently told the Statesman Journal that his first missive prompted a favorable reaction from many co-workers but drew fire from a manager, who deemed it “poisonous.”

Undeterred, Patterson fired off another e-mail: “The last time I spoke up and said something about the mandate situation, my words were described as ‘poisonous’ in a letter sent to all the nurse managers. You know what’s poisonous? Letters sent out from directors that attempt to blame staff as the cause of our mandate situation. We are not the cause. The poor management of our hiring and staffing levels are to blame.”

The first patient-occupied section of the new hospital is scheduled to open in November or December, and the entire facility is slated to become fully operational by late next year.

Like many front-line staffers, Patterson fears that mandated overtime will follow workers into the new hospital.

“How can you move forward if you can’t even fix the very basic operations that make this hospital run?” he asked in his second hospital-wide e-mail. “And again, I ask, what is being done to help us in this dire matter? The mandate problem has not changed at all. Change needs to happen soon. Very soon. WE ARE TIRED.”

Brant Johnson, a mental health therapist who serves on a state hospital advisory board, said the reliance on mandatory overtime hit a wall on recent weekends.

The supply of eligible workers ran out, requiring the hospital to operate at unsafe staffing levels, he said.

“It’s gotten to the point where prescribed safety levels of staff are being lowered because there’s nobody to work,” Johnson said. “It really puts the safety of patients and staff at risk.”

Lives disrupted

It’s not just tired and cranky workers saying that mandatory overtime causes havoc in their personal lives and creates fatigue that can hamper job performance. An independent fact-finder recently came to the same conclusions.

Arbitrator Nancy E. Brown was hired under terms of the collective bargaining agreement at OSH. Brown issued a final report, dated May 10, following meetings in March with hospital management and union leaders.

“To be unexpectedly mandated means canceling personal plans with family members and friends,” she wrote. “Child care, care for elderly parents and responsibilities for pets; these care arrangements must be changed or made.

“Family events are missed. Missed doctor appointments can result in the payment of ‘no show’ fees or co-payments and long waits for the rescheduled appointment. MHTs that are going to school are unable to attend class. …”

Lack of sleep, fatigue and illness are common problems for workers pulling frequent double shifts, Brown reported.

“There is also the concern that driving home so tired is dangerous for others as well as themselves,” she said.

Patient care can suffer, too.

“Frustrated staff are not so therapeutic as well-rested staff members,” Brown wrote, and fatigue may hamper an employee’s ability to perform detailed tasks such as dispensing medications.

Mental-health advocates and federal investigators have issued similar warnings in recent years. Now the state is facing a threatened federal lawsuit by the U.S. Department of Justice, and some people expect the feds to take action soon.

“I think the ball is going to shift over into the court of the Department of Justice,” said Bob Joondeph, executive director of Disability Rights Oregon, an advocacy group that filed a federal lawsuit in 2005 on behalf of patients alleging that hospital crowding and understaffing jeopardized the safety of residents and workers.

Joondeph said U.S. DOJ litigation has increased under the Obama administration, and the agency is well aware of the lingering problems at OSH.

“This stuff, in many ways, is putting more pressure on them to act,” he said.

Relief in sight?

To ease the burdens on staffers, the hospital is aiming to fill 60 front-line MHT positions, short for mental health therapists, said Richard Harris, director of the state Addictions and Mental Health Division.

Harris said he wants the positions filled within three months. He said the hospital will replicate a fast-track hiring process that proved effective in cutting the vacancy rate for registered nurses from 24 percent in mid-2008 to less than 5 percent by August 2009.

“We learned a lot by trying to cut out the number of steps that it takes to complete the hiring,” he said. “So I’ve asked staff to just use the lessons we learned from that hiring and apply it to the MHTs.”

Harris said he’s confident that the hospital will meet the goal of hiring 60 front-line staffers by late summer.

“I just think we have to be very aggressive about it,” he said. “I’ve been surprised at the difficulty of filling these positions. What’s important now is that we get people on board in this next three-month period.”

Harris recently assumed a more direct role in hospital management after the April 2 forced resignation of superintendent Roy Orr. Harris now has an office at OSH and estimated that he spends 10 to 12 hours per week at the facility.

Orr was forced out by Harris and Bruce Goldberg, director of the state Department of Human Services. They said new leadership was necessary to speed up the pace of change at OSH. A nationwide search is under way to find Orr’s replacement.

While Harris is determined to shore up front-line staffing, he said the hospital won’t slack off on planned hiring in other areas.

“It’s critical not to go backwards on our recruitment of nursing staff,” he said. “We made great progress in hiring nurses and filling up the open positions for psychiatrists, so we can’t let that slip.”

Harris was at a loss to say when, or if, mandatory overtime might be eliminated.

“Whether or not there’s a time when you won’t have mandatory overtime, I don’t know,” he said. “But certainly the way it is being used now is not satisfactory.”

There is no consensus among hospital managers and staff members about what has been driving up mandated overtime.

Cited reasons include staff turnover; an uptick in sick time taken by workers dealing with fatigue, stress and burnout; and elevated staffing required to intensively monitor patients who formerly were controlled with seclusion and restraints, a trend accelerated by federal pressure to curtail such practices.

The spike in mandatory overtime also has coincided with furlough days ordered by Gov. Ted Kulongoski for all state workers, including employees at OSH and other state institutions that stay open 24/7.

“I would suspect there’s a bump because of furloughs,” Harris said. “Don’t get me wrong, I don’t believe that’s the major cause. The major cause is not filling these (front-line) positions. We have 60 positions that need to be filled. If they are filled with qualified individuals, the use of mandatory overtime would go down.”

Prior to the 2009 legislative session, Orr shocked a legislative committee when he said the hospital needed $124 million to hire almost 1,000 new employees in 2009-11.

It didn’t happen.

Legislators green-lighted a scaled-down $36 million staffing package during a session dominated by fears about economic calamity and temporary bailouts for budget crises, primarily a flow of federal stimulus money.

As a cost-containment measure, the 527-employee OSH staffing expansion was set up to occur in waves of hiring, coinciding with phased opening of new hospital facilities.

Interviewed by the Statesman Journal two days before his tenure as hospital chief came to a jarring end, Orr said he didn’t regret making his initial pitch for nearly 1,000 new employees.

“I don’t make any apologies for putting that number out there, not when we’re talking about building almost 1,000 inpatient beds between two facilities, here and in Junction City,” he said.

Orr acknowledged that he was under the gun to bolster thin staffing with rapid hiring and ease employee frustration about the reliance on mandated overtime.

“They want to keep the heat on me, or us, and they are waiting to see if our efforts will bear fruit,” he said. “The message has been received, and we’re going to be as responsive as we can possibly be.”

Nearly two months after Orr was sacked, the hospital is scrambling to quickly hire 60 front-line workers, and hire a new superintendent.

Frustrated staffers, such as Patterson, hope that relief is coming soon but they remain skeptical.

“It would be great if that all came to fruition,” he said, “but I don’t know how many times we’ve heard that kind of promise.”

Chronic understaffing at Oregon’s main mental hospital stems from decades of inattention and neglect by state leaders. The deep-seated problem has continued to fester in recent years, despite repeated infusions of new employees. Here are the separate staffing increases:

    -In December 2005, the Oregon Advocacy Center (now called Disability Rights Oregon) filed a federal lawsuit on behalf of patients alleging that hospital crowding and inadequate staffing posed a threat to patients and workers. A month later, the Legislative Emergency Board approved spending $9.2 million to add 35 staff members and make other improvements to settle the suit.

    -Following stinging criticism of patient care and hospital conditions in 2008 by the U.S. Department of Justice, the Legislative Emergency Board authorized the hiring of 190 new staffers.

    -Last year, lawmakers boosted the hospital’s two-year budget for 2009-11 to $324 million, a 31 percent increase that provided funding to hire 540 new employees. Of the total, 527 were budgeted for OSH and 13 were appropriated for other state positions connected to hospital hiring. Those jobs are in payroll, human services and information systems.

    -Next year, hospital managers are likely to ask legislators to fund another staffing expansion. No specifics have emerged about the potential size or cost for another hiring boom that may be in the offing for 2011-13.