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 7. Improving Personnel Management – Perception that management cannot dismiss poor performers

Summary: 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. The common perception is that the HR process is too cumbersome to manage and remove “bad” employees and that it cannot recruit, hire and train new staff quickly enough to ameliorate the chronic desperate need for direct care staff that has been continually strained by the high rates of mandatory overtime.

Although the hospital is striving to hire more RNs and direct care staff as quickly as possible, some units remain understaffed with just one RN and 2-5 MHTs being assigned to serve 40-44 forensic patients. This is creating a “perfect storm” for negative outcomes. It would be extremely difficult, if not impossible, for the RN to supervise the MHTs to ensure compliance with policies and standards of care and to be responsible for the assessment and care of so many patients.

Recommendations:

HR 7.1. – Selecting for compassionate attitudes: The hiring and retention process must include an appreciation for identifying candidates who demonstrate the inherent qualities of compassion, tolerance, patience, respect and empathy. Although training can increase awareness and skills, some personality traits and attitudes/values such as these are not skills to be taught.

HR 7.2. – Career development program for MHTs: Given the fact that direct care staff (MHTs) comprises the largest contingent of employees at OSH, it might be wise to develop a special subprogram within HR that could focus on hiring. This could include targeting recruiting and incentives; better presentation of MHT jobs as genuine careers with an emphasis on expanding competencies and career advancement; better training programs to provide the initial skill sets; formalized mentoring program to support new staff; employee recognition programs; and streamlining operational procedures for accelerating recruiting, interviewing, credentialing, hiring, orienting, mentoring and evaluating new employees.

HR 7.3. – Mentoring for new staff: Hospital needs to implement a mentoring model wherein new staff are paired with a seasoned competent staff member for one to two months (or more if needed) for role modeling, skills development, confidence, etc. This is also described in Recommendation OT6.1.c with respect to new direct care staff.

HR 7.4. – Employee recognition program: OSH has many dedicated, committed staff; yet they have been beaten down by all the negative exposure. There should be employee recognition programming in which the hospital can recognize and celebrate successes. Staff needs to hear praise for good performance and learn to take pride in their important work.

HR 7.5. – Forums that value feedback from staff and patients: Feedback from staff and patients is often ignored or discounted at OSH. The hospital should have forums where patients and line staff can provide input to leadership and be engaged in policy discussions. They currently feel unvalued and unheard. One possible forum is described in Recommendation L2.5. “Mechanism for Superintendent engagement.”

HR 7.6. – Pressing need to fill Social Work vacancies: The Social Work Department has primary responsibility for discharge planning, which is vitally important to a recovery oriented public psychiatric hospital. With 15 reported vacancies, this function is being under-served, which has the potential for increasing the rate of hospital readmissions and other negative outcomes, including mortality. There is a critical need to bolster recruiting for Social Workers at OSH.

8. Additional Observations – This section consists of additional observations that may be of use to Oregon State Hospital.

Recommendations:

QUESTIONS ABOUT THE ADEQUACY OF CARE

X 1.1 – MISC: Although OSH has a medical clinic, there are limited medical services provided on the units. There is no medical OD on-site after hours to respond to medical issues. The unit staff calls the psychiatrist OD who triages and calls the medical OD for guidance. Evaluate adequacy of medical coverage on all units.

X 1.2 – MISC: The Review Team had questions as to the adequacy of OT and PT services. Evaluate OT or PT services at hospital.

X 1.3 – MISC: Reportedly, on certain units, durable medical equipment is outdated. Evaluate adequacy of the same.

THERAPEUTIC ENVIRONMENT

X 1.4 – MISC: There are limited, if any, planned structured leisure or recreational activities offered to patients on evenings and weekends on any of the units at the Salem campus. We recommend an evaluation of whether these activities should be increased.

X 1.5 – MISC: There are numerous hanging hazards on the units (ex: grab bars in bathrooms, plumbing fixtures exposed, etc.) and no supervision or routine checks of these areas by staff to monitor patient safety. We recommend a review of this observation.

X 1.6 – MISC: Staff reported that most patients on 50G and 50F are not attending the treatment mall. Review and address treatment mall attendance and effectiveness for all units.

X 1.7 – MISC: Develop specific ISP objectives for individuals returned to OSH after a failed community placement that focus on providing supports for the specific problem/issue the individual experienced while in the community setting.

X 1.8 – MISC: After traumatic event on unit (medical emergency, physical restraint, etc.) staff often debrief. Patients say they need the same opportunity, since the situation is very upsetting for them and the milieu.