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 5. HIG and the Role of Quality Management – Quality Management is disorganized and ineffective

Summary: The Liberty Review Team has organized its observations and recommendations for this domain into two major categories: restructuring the Health Information Group and developing a more meaningful Quality Improvement plan. Recognizing the importance of the Electronic Medical Record (EMR) project on the future of the Quality Management Program, our team met with individuals with key roles in the development, training and implementation of the EMR product. Despite the magnitude of this project, occurring in concert with construction of a new facility, it is evident that a great deal of very thoughtful and methodical planning has gone into the project. While the true effectiveness of the transition to an EMR will become evident post-implementation, we were quite impressed with the attention to detail in all aspects of the project. It is our expectation that the move to the EMR will not only support, but enhance, the quality management effort at OSH.

1) Restructuring the HIG [Health Information Group] Departments at OSH to regain effectiveness: 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 functions are not organized to best serve the organization or to support the hospital’s QI and Risk Management functions. The HIG departments are disconnected from each other and the hospital as a whole. Similarly, the Planning, Analysis and Research Department operates in a silo, often taking on projects that are driven by individual requests instead of those generated by hospital or clinical leadership. Strong QI and RM Departments play an essential role in a public psychiatric hospital, particularly at facilities that have been involved with US DOJ and are addressing CRIPA compliance issues.

We believe that the first step in restoring QM to its appropriate position at OSH should be a major consolidation and simplification of its multiple QM-related departments and entities within the Health Information Group (HIG). We will begin with a functional analysis of the current QM operations as follows: Currently, the Health Information Group is organized into six departments under the oversight of the Director of Strategic Planning. These are the Strategic Planning Unit, Medical Records, Technology Services Management, Planning, Analysis and Research (PAR), Quality Improvement (QI) and Risk management (RM).

Four of the six perform QM functions. The role of the PAR Department is to assist OSH administrative and clinical leadership with improved decision making that is clinically-led and data-informed. In practice, however, the PAR Department operates independently, making unilateral decisions on what quality projects to pursue rather than working in collaboration with hospital leadership in setting priorities for analysis and research.

The hospital also has a separate Strategic Planning Unit. Strategic planning is a hospital leadership function and it is unusual to have a separate department with resources under one Cabinet member. A Quality Management Director in a public psychiatric hospital often facilitates and assists leadership with strategic planning activities, however, strategic planning is the responsibility of the Superintendent and his/her Cabinet. The actual role of the QI Department, meanwhile, has been diminished to an administrative support role, focusing on tasks such as developing agendas, scheduling rooms for meetings, tracking committee minutes, and sitting on multiple hospital committees.

Traditionally, QI should be actively auditing and monitoring key processes that maintain patient safety and quality of care and is a position to alert the leadership of incidents and negative trends at the earliest point of identification so that the leadership can evaluate and implement corrective actions or improvement as needed. QI‘s role appears to have migrated to the PAR Department and its marginalized role is reflected in its relocation to a “marginalized” location over the State Vehicle Maintenance Shop, cut off from the administrative and clinical leadership. Finally, there is additional confusion regarding the role of the CRIPA Manager and nine positions that were funded to OSH as part of Special Session HB 5556 in February 2008 for “developing a mechanism for organized, strategic data collection and analysis” evolved into the current HIG structure. The relationship between this entity and the other QM functions is ill-defined, which translates into more confusion about who is truly in authority and directing the QM process, who is accountable to whom and for what processes. Thus, as it currently stands, the QM departments at OSH are not organized to best serve the hospital.

Although there may have been good reasons for creating and structuring the various quality-related departments and committees over the years, there is no reason to retain the current structure today.

The Liberty Review Team recommends a major consolidation and simplification of the QM organizational structure. We recommend disbanding the Strategic Planning Unit and PAR as separate departments in the HIG structure and realigning these resources under the existing QI and Risk Management Departments.

Recommendations for restructuring HIG:

QM 5.1. – More appropriate job title: We recommend changing the title of Director of Strategic Planning to a title that highlights the QI and RM roles that are essential components of a public psychiatric hospital. Consider the title Director of Quality Management.

QM 5.2. – Realign the resources of the HIG Departments Our specific recommendation would be to realign resources in the Health Information Group to establish cohesive, integrated QM departments and operations. See Organization chart in Attachment F for recommended restructuring of HIG.***

QM 5.2a – Shift resources in the HIG to cover staff vacancies. There are three vacancies in the QI Department and the Director of Strategic Planning has asked for two additional positions for Risk Management. The HIG is well staffed and additional positions are not required if current resources are redeployed to assist with performing important QI and RM functions.

QM 5.2b – Redeploy PAR staff: Re-assign some PAR positions (6-7) under the QI or RM departments and/or reassign some PAR positions (2-3) to Clinical Leadership (CMO, CNO, Clinical Director) to help develop strong peer review systems and provide support for Clinical QI initiatives. Incumbents in the current PAR positions would be evaluated for appropriateness, as positions are re-assigned.

QM 5.3. – Create Joint Commission PPR Position: OSH should create a new Accreditation Manager position in the QI Department who will be responsible for the annual Joint Commission Periodic Performance Review (PPR). Currently, the QI Director is spending nearly one third of his time completing this function, which undercuts time needed for planning and managing the immediate day-to-day quality process at OSH.

QM 5.4. – Reduce committee administrative duties performed by QI staff: Streamlining the number of committees will eliminate labor intensive and ineffective infrastructure, which is administratively supported by QI staff who now coordinate (scheduling rooms) and track committee activities (fact sheets, committee minutes, etc).

QM 5.5. – Relocate the QI Department closer to hospital administration: To be successful, the QI department must work closely and be well aligned with hospital and clinical leadership. Close physical proximity to each other on campus (in the same building) will help to strengthen and facilitate these collaborative working relationships. Counteract the perception that QI is not really important by physically relocating the QI Department from its current location (over the garage) to administration.

QM 5.6 – Clarify Role of the CRIPA Manager with QI & RM Departments: Recognizing that OSH cannot dictate the role and purpose of the CRIPA Manager, it remains vitally important that restructuring of QM is completed with participation and input from staff who have been coordinating CIP activities so that there is full agreement and understanding of how the new streamlined function will continue to cover all required areas of responsibility.

QM 5.7. – Training on CRIPA: Include an overview of the CRIPA Statute and how it is applied and evaluated in a state psychiatric hospital in the orientation for new employees in the Quality Improvement and Risk Management departments

2) Developing a more meaningful QI plan for OSH: Any public sector psychiatric hospital should have a Quality Improvement (QI) Plan that is based on hospital-wide goals and specifies the performance measures that will be evaluating the most important processes over the year. The OSH QI Plan is silent about who and how the facility will implement its QI priorities and initiatives in 2010. Currently, OSH has no hospital-wide goals for quality nor is there a comprehensive list of QI performance measures to help prioritize the organization’s activities and guide the use of staff resources for these activities. At the same time, OSH has a Continuous Improvement Plan (CIP) that appears to command greater attention and help determine the quality improvement priorities for the hospital. Moreover, the various committees have their own “internal” QI goals that may or may not coincide with CIP priorities.

There also seems to be no designated authority responsible for tracking the implementation of the CIP priorities. During multiple interviews with a variety of clinical and direct care staff on the units and in the treatment malls, no one could answer the question, “What are the two most important hospital goals or quality improvement initiatives that OSH is working on this year?” Many staff said they didn’t know, some cited the DMH core values, some flipped their ID badge over and recited the National Patient Safety Goals, and others made a guess that it was “ensuring the safety and security of the patients?”

In short, OSH has no overarching “quality plan” that guides staff and no clear mechanisms to ensure that goals/priorities are being met or achieved. The call for greater accountability was a predominant theme at OSH. “We don’t hold each other accountable for getting things done. “ We believe that it has not been possible to establish true accountability at OSH because of the disorganized structure and diffusion of authority. There are too many qualityrelated processes under too many entities without clear lines of command and without a systematic hospital-wide plan that prioritizes goals and activities. Recommendations for improving the QI Plan:

QM 5.8 – Hospital-wide quality goals: The Quality Council, chaired by the Superintendent, must establish hospital-wide quality goals that are prioritized by OSH Leadership. Once goals are established, the QI Plan should be revised and revitalized and made to complement the Continuous Improvement Plan (CIP).

QM 5.9 – Better use of QM data at unit level: Quality data are collected at the unit level (e.g., falls, assaults, seclusion/restraint, staff/patient injuries, medication variances, etc.) but the unit staff does not see this coming back in any meaningful way that could alter outcomes of care. The complex committee structure does not make for timely responses to aggregated data. For instance, falls data is collected at the unit level, then sent to PAR who aggregates the data for the Falls Committee and the Patient Safety Committee, both of which then report to the Quality Council with their recommendations. In addition to the delay and inefficiencies of this multi-step process, it is questionable that the Quality Council can realistically share the results and recommendations in a meaningful way with the unit staff at the unit level. Certain recommendations and data, such as Highly Aggressive Patient (HAP) data, must be timely and delivered to staff at the unit level so that they can fully “own” the process and be able to effectively monitor their progress (or lack of) on their unit.

QM 5.10. – Improve the current Risk Management – Incident Response system: process for managing incidents could be strengthened in three ways: The

QM 5.10.a. – Maintain the CIRP: The Level 3 incident investigations are well done. There is a good representation of hospital and clinical leadership on the Critical Incident Review Panel (CIRP) who ask thoughtful questions and request follow-up and closure on corrective actions taken in response to the investigative findings. CIRP is chaired by the Superintendent and is a very worthwhile committee that should be maintained in any restructuring of OSH committees.

QM 5.10.b. – Clarify Level 2 incidents for investigation: OSH has a good electronic incident reporting system, and the RM Department staff is diligent in reviewing shift reports and other information sources to ensure incidents are being reported. But the RM incident report grid needs to be revised to clarify what incidents are categorized as Level 2 incidents and require an investigation at the unit level. Previously, Level 2 investigations were performed by Unit Directors. With the change to Unit Nurse Managers, it is important to clarify who will now conduct the investigations.

QM 5.10.c. – Thorough reviews of Level 4 incidents and staff accountability: Although the QI staff leads the Root Cause Analysis (RCA) process in addressing Level 4 Sentinel events, there is little collaboration between QI and hospital leadership to conduct a thorough, comprehensive RCA or to enforce and hold staff accountable for implementing action plans. It is important to conduct a thorough comprehensive RCA that drills down to credibly identify areas in need of improvement. There must be collaboration between QI and clinical and hospital leadership in asking tough questions about what went wrong and making sure that appropriate corrections are implemented. With the general diffusion of authority at OSH and the marginalization of the QI Department, the Department has become weak and unassertive in determining that corrective actions have been implemented by other hospital staff in timely fashion to address problems revealed in the RCA process.

QM 5.11 – Restructure the comprehensive audit process and increase quantity of audits: Due to vacancies in the QI Department, managers from across the facility have been enlisted or “volunteered” to assist with the 10 day comprehensive audits. The audit tool is lengthy, very time consuming to complete and tries to capture staff’s compliance with policies (documentation) and evaluate compliance with Joint Commission standards and CMS regulations. The audit tool needs to be down-sized with practitioner compliance indicators separated from deficiency driven standards indicators (verbal orders). A new, more manageable compliance tool could be developed and used by clinical leadership to evaluate practitioner specific performance (See also Recommendation C 1.8- Improving audits of clinician’s performance). The numbers of QI audits being conducted are too few to obtain a reliable picture of whether standards are being met to address deficiencies cited by accreditation agencies. The numbers of QI audits need to be increased to collect meaningful data. OSH should consider the sampling guidelines provided by the Joint Commission to assist with determining adequate numbers of audits to reliably measure compliance with standards. If HIG resources are re-aligned as suggested in recommendations QM 5.2, the QI Department would be able to increase the number of audits and expand the indicators that should be monitored to evaluate compliance with JC, CMS and CRIPA requirements.

QM 5.12 – Reinstitute QM training: The QI module has been removed from the 40 hours of hospital orientation for new employees. This is particularly unfortunate as OSH is moving toward implementing more sophisticated quality improvement approaches (LEAN & RPI) and staff has not even been introduced to the most basic concepts of quality improvement and how quality improvement activities are structured and occur at the hospital. Reinstitute the QI training module in hospital orientation for all employees. Moreover, it should be bolstered by explicitly demonstrating that the leadership is fully behind the revitalized quality initiatives.

QM 5.13. – Improve the patient grievance process: Dissatisfaction with the current grievance system is widespread at OSH. Patients have little to no faith in the grievance process. Staff has been lax in reviewing, investigating and providing a reply to patients about complaints within the set time requirements. All too often complaints simply “drop into a black hole” by being lost, destroyed or ignored entirely. There have also been complaints that individuals have suffered retaliation for filing complaints. The grievance process needs to be carefully reviewed and overhauled.

In addition to reorganizing committees per recommendation D 4.3.a. Eliminate the Patient Rights Committee, there is a need for systematic training, accountability and communication. First, many employees do not understand the grievance process and need specific training. Second, response times must be enforced and a system that ensures 100% of grievances receives an adequate response. To hear nothing is very demoralizing and devaluing for patients.

The grievance policy and procedure should be reviewed and revised for maximal efficiency and accountability and should report directly to the Superintendent. Hospital leadership must clearly designate staff to maintain a grievance log to track the type of grievances, the timeliness of response, etc. and once a reliable system is in place, leadership can more easily identify trends that reflect underlying unit issues. At that point, emphasis should be on addressing milieu issues in an effort to improve the patient treatment experience, rather than solely responding to grievances.