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 6. Prime Causes of Overtime – Rectify causes of excessive 1:1 which drives excessive overtime

Summary: 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 simply want more staff on the unit. 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.

Noise, confusion and congestion also increase when multiple patients have additional staff assigned to them. The combined chaos and intensity of activity directly undercuts the maintenance of a calm, orderly, and respectful therapeutic environment and paradoxically leads to increased agitation and aggression and the potential for increased use of seclusion/restraint, PRN medications, and intensive observations. Four main factors appear to drive the pervasive sense of staff apprehension and disorder:

(1) Teamwork is weak at the unit level. Direct care staff is not fully integrated into the treatment teams and therefore have little opportunity to give input into day-to-day assessment of patient functioning, treatment plans, behavior management issues, unit operations, safety and security, scheduling and much more. There should be strong opportunities for staff development for the direct care staff so that they can continue to strengthen and expand their skills and competencies and gain pride from their increased effectiveness. At the same time, cooperation between and among disciplines is variable. The Treatment Care Planning process is emblematic of the lack of coordination and/or communication within the hospital units. There are disconnects between the hospital leadership, clinical leadership, treatment teams, direct care and security. There is only a weak sense of a unified team that shares responsibility for unit security, therapeutic environment, behavior management and responding to challenging behavior.

(2) 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 demands for overtime have had profound consequences for staff morale at OSH and have led to abuse of the overtime system. It has also exacerbated conflicts between the Unit Nurse Managers and the MHTs especially on those units where clinical leadership is weak and the direct care staff is more accustomed to directing patient interventions.

(3) The methodology for preventing, managing and responding to aggression, self-injury, and other challenging behavior at OSH, especially on the forensic units, is variable, under-resourced and ineffective. There are far too many “take downs” and the staff are more aggressive than is necessary in applying restraints. The hospital must commit to a single approach that supports its goal of reducing seclusion/restraint and injuries to nil level. There needs to be a very strong leadership from psychology staff with expertise in positive behavior management techniques, including an increase in the number of behavior specialists throughout the hospital for designing individualized behavior plans, training staff, monitoring implementation and training and directly supporting staff across disciplines. Above all, the methodology should be team-based, with all unit staff involved in managing difficult behavior and directed by clinical personnel, not abdicated to security and/or direct care paraprofessionals.

(4) HR must continue to rapidly fill new positions and existing vacancies. Although additional staff will not solve the issue of placing large numbers of patients on heightened observations, it will reduce the number of times any one person is required to work overtime.

Recommendations:

OT 6.1. – Strengthen the team-based application of positive behavior management: The proactive use of positive behavioral management by a coordinated team must be accentuated, strengthened and unified at OSH. Clinicians must be more involved in decision-making, implementation, monitoring and follow-up of behavioral interventions. Successful prevention and management of aggression requires an approach that is fundamentally team-based in its values and application. There are several ways to bolster this crucial function:

OT 6.1.b. – Improve behavior management training for MHTs: Improved training, and on-going refresher training for direct care staff. Provide greater investment in staff development by strengthening and expanding skills and competencies so they are more confident (less afraid) in preventing and deescalating difficult behavior.

OT 6.1.c. – Mentoring new direct care staff: Mentoring for new line staff to reinforce and role-model procedures and methods. Although overtime does not significantly impact the RN staff, mentoring of new RNs is certainly critical, especially at this time when more RNs are being hired. There is the feeling among at least some of the current new RNs that the orientation process is lacking in skill development needed to feel comfortable in working with an aggressive population. Feedback from new RNs and MHTs to Nursing Education is critical to reassessing the orientation period.

OT 6.1.d. – Bolster teamwork and methodology for handling aggression: OSH needs to bolster both its teamwork and methodology for managing aggressive/disruptive patients so that staff has the appropriate skills and confidence and team support to deescalate and handle conflictive situations. This is crucial so that it will not be necessary to order so many 1:1, 2:1 and 3:1 intensive observations and should greatly reduce the frequency of restraint/seclusion intervention. This is especially important because large numbers of new MHTs are currently being hired. This is the prime time to provide them with the skills needed to prevent and deescalate aggressive patient behavior. If the practice of freely placing patients on 1:1, 2:1 and 3:1 is not adequately addressed, the new direct care staff will think that this is always needed for safety, thereby making them feel unsafe when this practice is more thoughtfully and clinically followed. OSH needs to forestall new staff becoming acclimated to the status quo.

OT 6.1.e. – Direct care belongs on treatment teams: Direct care supervisory personnel should be included in treatment team meetings and QI activities. They are crucial members of the team, who provide the eyes and ears on the units and have the most involvement with the patients, and their “buy-in” is essential. It is unclear to what degree MHTs and MHT supervisors are involved in treatment planning in general, and behavioral planning in particular.

OT 6.2. – Revise policy for use of intensive observations: The policy and practice of placing a patient on heightened observation should be critically examined in order to bring more order to the unit, decrease the mandatory overtime and potentially free up the Unit Nurse Manager to more adequately address patient care issues. In order to make an impact in this problem area, it will require the buy-in of physicians, RNs and MHTs (and potentially other direct care staff). Moreover, psychology should have a much stronger role (see below).

OT 6.3. – Strengthen role of psychology in guiding behavior management: Teamwork is absolutely crucial to prevention, de-escalation and management of aggressive and challenging behavior and psychology is crucial to behavior management methods. This will require a lot of focused attention and training with much stronger participation of psychology in managing challenging behavior. Presently the minimum core “treatment team” appears to require only a psychiatrist and a nurse. While other disciplines are encouraged to participate, actual level of involvement varies by unit. Treatment planning meetings need to emphasize a fully integrated interdisciplinary team approach that includes active involvement of interdisciplinary clinicians and direct care personnel.

The Liberty Review Team recommends a much strong role for psychology staff to support the comprehensive application of positive behavior management across the units. This calls for a reexamination of how psychology staff is being utilized at OSH. Under the previous Unit Director model, psychologists were assigned to separate units. Currently, OSH is trying a new centralized model in which psychology staff are assigned to any unit as need arises. A priority for OSH is to develop a means to ensure the comprehensive application of a solid behavior support plan. We feel this is integral to addressing the issues necessitating excessive use of 1:1 coverage, and milieu management issues.

OT 6.4. – Remove incentives for abuse of overtime: If the MHTs do not sign up for voluntary overtime, they are able to volunteer the day of the overtime and have it count as mandatory overtime. This actually was part of an agreement between the Union and administration. The advantage is that their name goes to the bottom of the mandatory list, which makes it likely that they can stay on their usual unit. Those who voluntarily sign up ahead of time for overtime are likely to be assigned to another unit. Although the facility may be unable to modify this agreement, attention should be given to collecting data on mandatory overtime.

Since there is currently a disincentive to voluntarily sign up for overtime, more MHTs are waiting until the day the overtime in needed, volunteering for the mandatory overtime, having their name go to the bottom of the mandatory list and being allowed to stay on their home unit. The facility should consider counting this time as voluntary instead of mandatory when reporting out the data. During the Liberty review, some staff voiced that it was demoralizing to see other staff “gaming” the system to get overtime, holiday pay, etc.

OT 6.5. – Balancing security and treatment: The relationship between security and clinical and nursing needs to be improved with greater cooperation and communication. Given the failure of clinical leadership to take charge and direct the response to emergency situations and challenging behavior, security has been given control and tends to utilize a heavy handed approach.

It is not enough to provide some training on behavior management. First there needs to be a clearly conceptualized approach that balances treatment and security and is applied the same way across all hospital and forensic units alike. (A sample model is presented in Attachment B). Second, mechanisms must be put into place for continuous refresher training – with security and direct care and treatment personnel together – and meetings where all three can interact and develop teamwork.