Quality and Compliance External Review Report for the Oregon State Hospital and Oregon Department of Human Services
Produced by:
Liberty Healthcare Corporation
401 E. City Avenue, Suite 820 Bala Cynwyd, PA 19004
Ken Carabello, M.S.W. Director of Regional Operations 800-331-7122
DRAFT REPORT – FOR INTERNAL DISCUSSION ONLY
I. Executive Summary
1. Overview
Background: Oregon State Hospital has invested great energy and vigor in striving to improve, but the results to date have been disappointing. It is paradoxical that the very efforts to improve the hospital have contributed to the current confusion because changes have been implemented on so many fronts and with such rapidity. The sheer volume of change at OSH would overwhelm any organization, but we believe that the essential problem has been the lack of adequate planning and coordination of these improvement efforts.
To date, the hospital has received many ideas and recommendations for improvement from entities such as the DOJ, the Governor’s Special Master, the Geller/McLaughlin consultants, the Department of Human Services, the Hospital Advisory Board, the OIT and more, and the State has directed generous resources to achieve a lasting solution at OSH. Many of the best recommendations have already been implemented, or are under development (e.g., electronic medical record, treatment mall) and other ideas are worthwhile. A framework for organized change: Having completed our on-site review and analysis, the Liberty Review Team believes that the challenge at OSH is how to prioritize and organize the planned changes and how to establish clear authority and accountability in the leadership entities that will marshal the needed resources and actively direct and monitor the implementation. Many of our recommendations will echo those of other experts, but we hope to contribute a fresh and practical framework for better organizing the change process.
We will present many recommendations, both detailed and general, but we also hope to provide a structure that can help prioritize and organize the recommended changes and, ultimately, guide the establishment of an enduring and effective hospital organization that delivers high quality care to the people of Oregon. Convergence of change factors: Historically, the current level of disorganization and frustration at OSH has resulted from a complex convergence of factors and changes. One major factor has been the monumental strain of building and moving into the new hospital. Another has been the scrutiny of the US DOJ. The recent changeover from a Unit Director model to a Unit Nurse Manager model presents another profound and fundamental change at OSH. The hospital has historically operated as independent units with the Unit Director functioning somewhat differently unit to unit. Another problem has been the dilution of authority and decision-making caused by a proliferation of committees that perform uncoordinated and sometimes redundant functions. An ineffectual system for performance monitoring and disciplinary action has hindered the hospital’s ability to remove poor performing personnel. Moreover, the crucial function of Quality Improvement (QI) in daily operations has been rendered impotent through a combination of factors.
2. Summary of Key Findings
Key domains for improvement: In light of these and other complex challenges at OSH, the Liberty Review Team has endeavored to formulate and simplify its recommendations for improvement at OSH by presenting them within each of the following seven domains:
1) Staff Compliance vs. Quality Improvement: Historically, each of the 22 treatment units at OSH had functioned as an independent operation with distinct variations in roles and practices. Despite the recent change from a Unit Director to a Unit Nurse Manager model, however, the hospital units continue to struggle to establish standardization of best practices. The Liberty Review team believes that this struggle is rooted in a fundamental confusion between staff compliance and quality improvement. Stated most simply, the hospital is attempting to use QI to enforce compliance. But the current departmental and committee structures under the Quality Council are so disorganized and diffuse that neither compliance nor quality improvement is being served effectively. Quality Improvement activities cannot take the place of an effective performance management system. Without a functioning supervisory structure that holds staff accountable and a meaningful process to appraise employee performance, compliance will not improve at OSH. By adding new committees and task forces and increasing quality monitoring activities within each of them, the hospital has endeavored to establish compliance and accountability. But leadership by multiple committees is diffuse and ineffective and supervisors need both performance data and clear lines of authority to manage personnel. Compliance is a supervisor’s responsibility not the QI Department’s responsibility.
2) Need for stronger front-line engagement by Cabinet and leadership: The Hospital’s leadership team – specifically the Cabinet, Clinical Discipline Chiefs and Nurse Program Managers – need to establish a much stronger presence inside the treatment units by making daily engagement with the clinical and direct care staff. Specifically, the clinical leadership needs to regularly visit the units to directly observe operations in order to effectively monitor and reinforce standardized roles and procedures across units. In turn, unit staff needs to see the visible presence of clinical leadership to be assured of their concern and oversight. In particular, the Unit Nurse Managers currently feel unsupported and overwhelmed in their new expanded role in which they are assuming some of the job responsibilities from the former Unit Director role. The Nurse Program Managers should be frequently interacting with the Unit Nurse Managers and clinical personnel on every unit. The use of email as the primary mode of communication and policy enforcement exacerbates the perceived disconnection between hospital leadership and unit staff. The absence of visible leadership has created the perception that unit-based staff must be self-sufficient in managing operations and delivering patient care within their own units. This perceived leadership vacuum fuels the tendency for each unit to “do things its own way” and resist efforts to standardize practices.
3) Need for clear and decisive authority: Combined with the actual and perceived absence of hospital leadership on the units, the lines of authority for decision-making are confused and unclear. Staff at all levels are hampered by uncertainty about who is in charge and who is making decisions with regard to different functions. Accountability is vague. For example, clinical supervisors have looked to HR to manage underperforming clinicians, while HR accurately regards such supervisory intervention to be beyond their scope of practice. Although recent directives have established the mechanism of having clinicians supervise clinicians within their own discipline, there is still need to clarify mechanisms for cross-disciplinary supervision and lines of authority. For example, security personnel are given primary authority to manage volatile situations within the units, which reflects a correctional/control approach rather than a hospital/therapeutic response to challenging behavior. This model for handling disruptive behavior greatly raises the liability and risk of injury. There should be no question that OSH is a treatment facility. It is imperative that a lead clinician must guide the decision-making in managing aggression and conflict on the units. Security staff should not take any independent action in the resolution of behavior problems within the therapeutic interior of the program. They should be working under the direction of senior clinical staff at the scene of the incident.
4) Proliferation of committees and diffusion of leadership authority: In its earnest initiatives to correct problems and improve health delivery as quickly as possible, the hospital has initiated multiple committees and workgroups to take action. Unfortunately, the proliferation of committees at OSH has contributed to the disorganization. With approximately 28 standing committees, nine MAHPS committees and eight transition workgroups, it is nearly impossible to communicate and coordinate efforts. Committees and teams are working in isolation and ignorance of each other’s goals and interventions and there is serious confusion about which entities hold the authority to resolve issues and are accountable for results. Hospital managers and professionals at OSH universally complain about having to attend too many meetings, which translates into a massive drain on clinical staff resources and detracts from the primary mission of patient care. The excessive reliance on committees gives the appearance of greater inclusion of input from all participants, but has paralyzed decision-making and action. There is a need to greatly simplify and streamline the committees and workgroups, such as consolidating clinically-focused committees, disbanding committees performing duplicate functions and time-limiting the work of performance improvement teams and working groups. Some functions do not require their own Committee and can be consolidated.
5) Health Information Group and Quality Management is disorganized and ineffective: Unlike any other hospital of its kind, OSH has four major departments that are primarily carrying out the functions of a hospital quality management department – Strategic Planning, Quality Improvement, Risk Management and Planning Analysis and Research. Compared to most public sector psychiatric hospitals, OSH would be considered richly staffed in terms of quality management resources. But the Quality Management function is disorganized and has been marginalized at OSH. There are no hospital-wide QI performance measures that reflect the mission and priorities of the organization. Extensive data is collected at the unit level, but it is not applied in a meaningful way. Staff are not taught to appreciate the purpose and value of QI and are ignorant of, and largely excluded from, participating in current QI activities. QI has been cut from orientation training. The HIG departments, particularly the Strategic Planning Unit, QI Department and Planning Analysis and Research (PAR), are disconnected from each other and the hospital as a whole. The PAR Department operates in a silo, often taking on projects that are driven by individual requests instead of those generated by clinical leadership.
6) Rectify causes of excessive 1:1 which drives excessive overtime: The ordering of 1:1, 2:1 and 3:1 observation has been the primary cause of costly mandatory overtime at OSH. Intensive observations are too frequently ordered because staff are afraid to manage aggressive patients rather than for reasonable clinical/treatment purposes. Unit staff request 1:1 because they do not feel safe with certain patients. Or, they will request a 2:1 because they fear that doing a 1:1 could result in an investigation or reprimand if the patient makes an unsubstantiated complaint against the staff. The multiple factors leading to this pervasive apprehension need to be addressed. The policy and practice of heightened observation must be critically examined to bring more order to the units, decrease the demand for mandatory overtime and free up the Unit Nurse Managers to more adequately address patient care issues. The excessive demand for overtime has had profound consequences for staff morale at OSH and has led to abuse of the overtime system.
7) Perception that management cannot dismiss poor performers: There is prevalent thinking that managers can do little to discipline or remove problem employees. Clinical managers have looked to HR to handle personnel issues, while HR declines such responsibility because it is a management issue. At the same time, undue fear of union issues and the lack of management knowledge concerning the personnel system have reinforced the conviction that it is exceedingly difficult to remove problematic employees. Reluctant to act, managers retreat into helplessness and tolerate continued poor performance from problem employees whose behavior hurts team cohesion and morale.
III. Recommendations by Key Domains – See links below for all text for this report
Liberty Healthcare report on the Oregon State Hospital – DRAFT, September 2010 (Full Text PDF)
Introduction & Summary
Review Team & Methodology
Part 1, Staff Compliance vs. Quality Management
Part 2, Leadership
Part 3, Decisive Authority
Part 4, Diffusion
Part 5, HIG and the Role of Quality Management
Part 6, Prime Causes of Overtime
Part 7, Improving Personnel Management
Report Attachments A through F