Liberty Report on OSH – Pt. 1, Staff Compliance vs. Quality Management

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

Part 1. Staff Compliance vs. Quality Management

Summary: Historically, each of the 22 treatment units at OSH had functioned as an independent operation with distinct variations in roles and practices. The recent change from a Unit Director model to a Unit Nurse Manager model, the introduction of a new role at the Unit level (Treatment Care Plan Specialist), and the proposed addition of a Unit Shift Supervisor on each unit makes it an especially important time to move
toward greater standardization, beginning with a clear, shared mission, values and philosophy of care.

Nevertheless, although OSH fully recognizes the crucial importance of establishing standardized best practices, it continues to struggle with this overarching goal. There are several factors that hinder progress, but the Review Team believes the most important factor may be a fundamental confusion between 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. While both current organizational and committee structure is less disorganized and diffuse than before; nonetheless; neither Staff Compliance, nor Quality Management are being served well under the present system.

At present, OSH managers have little understanding or appreciation of the deficiencies in their current supervisory structures and performance management systems. Consequently, there is a tendency to blame an ineffective QI program as the major factor contributing to the staff’s poor compliance with policies and procedures. Compliance is a supervisor’s responsibility not the QI Department’s responsibility.

As a case in point, OSH is implementing a comprehensive auditing process that is designed to capture discipline specific documentation (MD, Nurse, Social Worker, Psychology) and compliance with standards (S&R documentation, TO/VO Authentication within 48 hours. etc.). But the process does not require the auditor to list the specific practitioners who are involved in the patient’s care, so there is no way that clinical supervisors can follow up to address performance problems. Additionally, the numbers of audits being conducted to address compliance with standards are too few in number to obtain an accurate picture of whether standards are being met. The auditing process by itself cannot achieve compliance. Presently, OSH is also floundering under capable, yet reluctant and disorganized leadership. The Liberty Review Team believes that the expected hiring of a high energy, competent superintendent will provide much more stability and direction to the organization. The new Superintendent will be the final authority for enforcing compliance through standardized operations across units. This will entail revision of the organizational structure to simplify lines of command and communication and strengthening the executive leadership team for greater accountability for improvement.


Clarify OSH mission and values: The new OSH Superintendent with a smaller Executive Team reconstituted from the current Cabinet should clarify and define a new Mission, Vision and Values for the hospital and then communicate them to the staff.

Focus on key standardized policies: There is need for a systematic and prioritized plan for revisiting particular crucial policies/practices to support standardization of best practices and compliance across the multiple units. At a minimum, the Liberty Review Team recommends the following policies/practices be reviewed. Given the volume of aggressive episodes (patient to patient and patient to staff) at OSH, most facilities that employ psychologists would place strong emphasis on team-based, positive behavioral management methods to prevent disruptions and aggression and maintain safe, therapeutic environments for the patients and staff. We recommend that OSH move in that direction as quickly as possible. Revise policies and practice so that clinicians always supervise security personnel when responding to disruptive and aggressive behavior episodes and that interdisciplinary team-work is involved in planning, responding to and evaluating behavior incidents. Each episode involving the direct participation of security personnel should be reviewed by Risk Management. Revise all applicable policies and practice (i.e., nursing, clinical, security, behavior, etc.) to remedy competing or conflicting policies. Review/revise the Seclusion/Restraint policy and practice in order to protect patient rights and to be current with standard practice. The current policy allows for a stepdown from restraints to seclusion. A patient who is calm and can be removed from restraints cannot then be placed in seclusion unless the behavior warrants. Review/revise the Behavior Precautions policy. This policy requires that a staff member could be responsible for maintaining visual contact with up to 4 patients on “Visual Precautions.” Since it would be impossible to keep tract of multiple patients unless everyone moved as a group, the assigned staff member could not be compliant with this policy. The Liberty Review Team also recommends that consideration be given to reviewing the policy and practice of rotating staff on an hourly basis when they are assigned a 1 to 1 patient. This is not the common practice in other facilities (staff are relieved, but not on an hourly rotating basis) and could actually be counter-therapeutic for patients who are already destabilized and must now adjust to multiple staff changes during a shift. Given the current number of patients on 1:1, the current practice of moving staff from one 1:1 assignment to another fails to accomplish the rest break that the policy is intended to provide.

Identify current and potential areas of variance: The Nurse Program Managers, especially on the Forensic Units, must become more involved in the day-to-day operations of the units they supervise. If this scope of supervision is too great, then additional Nurse Program Managers should be hired. Without this type of oversight, there is little chance that standardization across units can be accomplished at OSH. Given the implementation of the new Unit Nurse Manager role, the upcoming Unit Shift Supervisor role and the unfolding of the Treatment Care Plan Specialist role, it is critical that each position understands the functions of the others within the milieu setting. In view of the long-standing tradition of semi-autonomous units at OSH, we believe that the goal of standardization of best practices across unit will not occur without intensive, first-hand, continuous intervention and education of staff.

Clarification of lines of command within new unit leadership structure: The Unit Nurse Managers, primarily on the Forensic Units, are experiencing a high level of frustration and anxiety regarding their new roles. At the time of the review, they were uncertain which duties, previously within the Unit Director’s job description, would be added to the Unit Nurse Manager job description. The job description of the Treatment Care Plan Specialist states that this person will “lead Quality Assurance projects related to the IDT (Interdisciplinary Team) as delegated by the nurse manager or Associate Director of Clinical Services.” There is no direct reporting line from the nurse manager to the TCP Specialist so delegation of work from the Unit Nurse Manager could create conflicts. In addition, the Unit Shift Supervisors are not in place, leaving months when the Unit Nurse Manager will be expected to assume the duties previously done by the Unit Director (except for those dealing with treatment planning and patient grievances). This is a critical time when many Unit Nurse Managers are voicing being overwhelmed and fearful of negative patient outcomes and must be given face-to-face supervisory support. With the implementation of the full model (Unit Nurse Manager and Unit Shift Supervisor), it is critical that both job descriptions are operationalized the same unit to unit. The presence of the Program Nurse Managers at the unit level will allow them to identify variances from standardized procedure, provide consultation and problem-solving with unit leadership, develop a plan to bring practice within policy, and deliver targeted training to staff as needed to address variances.

Temporary expert support for Superintendent: Given the magnitude and complexity of work to be accomplished, it could be very helpful to provide a time-limited support executive (or two) to directly assist the Superintendent on a daily basis during this critical period of reorganization and consolidation. The executive support executive would be an objective party without operational demands or responsibilities, who would be ready to advise and guide on the many demands immediately facing the new Superintendent.

Facilitate “buy-in”: Once an important and fundamental policy decision has been made, it is crucial to communicate the change to everyone –at all levels of the organization and in all capacities – by gaining their “buy-in” as the foundation for subsequent implementation and operations decisions. The leadership needs to publicize the top hospital-wide quality goals for OSH (such as decreasing seclusion/restraint, assaults; serious injuries from falls) so that staff at every level, from management to direct care, are fully informed, involved and gain buy–in. This should be followed up with continuing efforts that publicize progress being made toward the goal, including employee recognition and rewards, so that staff can take pride in progress and gain confidence in their leaders.

Streamline credentialing process: The credentialing process for the MAPHS Bylaws should be streamlined. In most hospitals, the bylaws only require medical staff to credential physicians and physician extenders. But OSH has developed an almost unworkable system for credentialing all clinicians that renders the credentialing system too big to function efficiently or effectively. Instead it is strongly recommended that the Chiefs of the other Clinical Department take responsibility for conducting primary source verification (PSV) of their respective staffs. The Clinical Chiefs should then be held accountable for licensure, training and performance of their staff rather than shifting this function to another committee under the medical staff structure.

Redeploy administrative support for credentialing: Given the time-consuming and detail-driven work involved in primary source credentialing, it is possible to utilize welltrained clerical personnel to perform many “paperwork” functions for the credentialing clinicians. The Chief Medical Officer reported that he has four administrative staff, but has requested an additional position to perform credentialing duties, however, this position has been frozen. The complement of four staff assigned to the CMO’s would seem to be more than adequate resources and OSH should consider redeploying one or more of the current administrative staff to perform credentialing activities.

Clinical chiefs should revamp job descriptions: The hospital has moved in the right direction by now having clinical chiefs (rather than Unit Directors) perform performance appraisals of clinical staff by respective disciplines. This helps to clarify reporting lines to hold staff accountable for their performance, but job descriptions for staff with supervisory responsibility have not been updated to include their role and responsibility for supervising staff. Developing and rewriting job descriptions is the responsibility of department heads and the clinical chiefs within them. The HR Department should only function as technical advisors to staff in crafting the job descriptions. C 1.8. – Improve auditing of clinicians performance: The comprehensive “10-day” auditing process that is being implemented at OSH is trying to meet the needs of both QI and Staff Compliance, but is failing to satisfy either. The auditing tool is designed to capture both discipline-specific documentation (MD, Nurse, Social Worker, Psychology) and compliance with standards (S&R documentation, TO/VO Authentication within 48 hours). But the process fails to identify the specific practitioners so that clinical supervisors can follow up to address performance problems and the sample size is too small to collect reliable data. We recommend creating a separate audit form that focuses on indicators that address practitioner performance and identifies the individual practitioner so that clinical supervisors can follow up with specific individuals to address performance issues.

C 1.9. – Direct audit results to Clinical Chiefs: At present, the results of the 10-day audits are not being used to evaluate staff performance. The results are submitted to the Medical Records Committee, but no action is taken and compliance rates are poor with no measurable improvement over time. We recommend changing the audit methodology to identify specific practitioners with poor performance and giving those results to the designated clinical chiefs (instead of or in addition to the MR Committee) so that the data can be used to measure and monitor performance improvement. If indicated, the data adds objectivity to personnel decisions to remove poor performers.

C 1.10. – Performance management/appraisals: OSH needs to develop a strong peer review process in each clinical department that reinforces that clinical performance is the responsibility of the clinical discipline chiefs and that compliance with policies and practices are addressed through the clinical supervisory chain of command. A qualified expert should be used to provide training to all clinical chiefs on establishing strong peer review systems, understanding the distinction between peer review and quality improvement, and using data to assist staff to improve their job performance.