Liberty Report on OSH – Attachments A through F

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

Attachment A. Organizational Structure of Current QM/Leadership Bodies at OSH

Superintendent’s Cabinet (Institutional Review Board) I. Clinical Executive II. Nursing Executive Council III. Medical & Allied Health Professional Staff (MAHPS) Bylaws Credentialing Ethics Medical Dept. CQI Medical Records Morbidity and Mortality Pharmacy and Therapeutics Utilization Review Infection Control/Employee Health IV. Quality Council Research Committee Consumer Council Education & Development Advisory Committee Patient Rights Patient Grievance Environment of Care Emergency Preparedness Hospital Safety Care of Patients Evidence-Based Practice *Patient Care consults Treatment Care Planning Advisory Group Treatment Mall Planning Core Curriculum Recovery Workgroup Valuing Diversity Metabolic Syndrome START BSP Patient Safety Critical Incident Review Panel (recommended by DOJ & CIP) Falls Committee (required by Joint Commission) *Highly Aggressive Patients (PI team) *Self-harm (PI team) Seclusion/Restraint *Working Well


by Anthony T. Cimino, Liberty Healthcare Corporation Solutions

Environmental Issues

1. Spatial intrusion.

High density of population leads to lack of privacy and intensified environmental (e.g., noise) and social friction, which can lead to violence. Security is focused on maintaining a highly secure perimeter, allowing treatment to occur in the interior. Easy-to-understand behavior modification system consisting of levels requiring increasing levels of clearly defined appropriate behavior and active participation in treatment. Compliance at each level is rewarded with greater variety of activities, chances for more privacy, and chances to contract for individual privileges. Noncompliance results in loss of gained privileges. Sufficient and appropriate space to run a varied activity program and allow for controlled stimulation. Sufficient space for smaller groups and some individual privacy. Patients gain some control over environment by having ability to earn privileges and greater mobility. Patients have real input into program planning and problem resolution via Community Meeting and natural daily interactions with staff. Behavior modification program provides structure, stability and predictability.

Problems and Barriers

2. Monotony and boredom.

Drab and low levels of stimulus change combined with high absolute levels of stimulation cause boredom that can lead to violence and disruptive behavior.

3. Lack of control and predictability.

Individual cannot control environmental changes and changes are unpredictable, resulting in behavior breakdown.

Staffing and Organizational Issues

4. Differing goals of security and treatment staff.

Security and treatment staff are separate with differing goals. Security usually has greatest influence. Security staff focused on perimeter security and has minimal responsibility for interior. When they do respond to interior emergency, they are under direction of clinical staff. Interior security is responsibility of all treatment staff. All treatment staff are expected to respond in an emergency situation. Practiced teamwork facilitates rapid staff notification and arrival in emergency situations. Policies and procedures are simplified and call for close patient supervision (frequent patient counts, control of contraband). All staff, without exception, must clear metal detector and submit to package inspections. Reduce security/treatment split by making both staffs accountable to same administrator who is a clinician versed in both. Administrator must take broad view of both to integrate them as one seamless program, which leads to more creativity. Establish clear admission policy to reduce inappropriate referrals from jails and mental health departments. When case is discharged for being inappropriate, program gives clear rationale and realistic recommendations for follow-up care.

5. Non-cooperation between security & mental health personnel.

Usually a poor to nonexistent level of cooperation between security and mental health departments, preventing them from working together effectively.

6. Managing violent patients.

It is difficult to manage violent and aggressive patients with effective therapeutic means that do not rely on coercive force.

All treatment staff trained in same techniques of non-aggressive behavior management and physical management of violent patients. Team approach is emphasized and bolstered with training and frequent relationship-building interactions/communication.

Attachment C. Summary of On-Site Meetings and Review Activities

Date 7/12/2010

Meeting / Committee / Unit Tour / Interviews

Meeting with OSH expert consultants Opening Conference with OSH Cabinet Meeting Clinical Services Leadership (3 clinicians) Meeting with Strategic Planning Dir., QI Dir., QI Assoc Dir. & Asst. Risk Manager Meeting with Chief Nursing Officer/Director of Nursing Meeting with Superintendant Meeting with CFO Meeting with 5 Program Nurse Managers from Forensics, Gero & Portland Meeting with Interim Superintendent Meeting with 20 Supervisory Nurse Managers Meeting with Director of Social Work/Discharge Planner Meeting with Director of Security Meeting with Director of PAR Meeting with Consumer Group Nurse Executive and Leadership Council (18 people) Meeting with Electronic Med Record (5 staff) Meeting with PSRB liaison Meeting with Friends of Forensics (family members) Meeting with Unit Director of Gero Services Meeting with Interim Director/ Recovery Services Attended Quality Council meeting Attended Medical Staff Meeting (30 physicians) Meeting with Clinical Disciplines: Directors of Social Work, Psychology, Rehab, Vocational Rehab & Clinical Director Meeting with Unit Program Directors Attended Critical Incident Review Panel meeting Meeting with QI Director and Assoc QI Director Tour of 34D with MHT1and Internist Tour of 40 Treatment Mall and meeting with Program Director and RN Interview with patient on 40-Mall who lives in the Cottages Interview with Supervising RN in Cottage Tour of 50E unit with Supervising RN Tour of 35A unit & Transitional Treatment Mall, interviewed staff & patients Tour of Geriatric Units 34C and 34D, interviewed RNs & MHTs Tour of Medium Security Units 50J & 50I, interviewed unit staff and patients Tour of Geriatric Learning Center, interviewed staff and patient Tour of Forensic Treatment Mall (Bldg 50), interviewed staff Night shift surprise tour of two units, meeting with nurses & MHTs Tour of Unit 50H, meeting with 11 clinicians Portland – Tour Unit P6A, meeting with Unit Nurse Mgr, MD & interviewed 2 patients Portland – Tour Unit P1A, meeting with Unit Nurse Mgr & interviewed patient Portland – Tour Unit P5A, meeting with 1 MD, 3 MHTs & interviewed 2 patients Portland – Tour Unit P1B, meeting with 1 nurse, 2 MHTs


Tour of Maximum Security Units 48B & 48C, interviewed unit staff Tour 50C, meeting with 3 clinical staff & interviewed patient Tour 34A, meeting with 5 clinical staff & interviewed 2 patients Tour 50H, meeting with 6 unit staff Tour 35B, meeting with 3 unit staff Meeting with Chief Medical Officer and President of Medical Staff Tour of 50G unit Meeting with HR Director Tour of 50D unit with RN and Psychiatrist Meeting with Exec Director of NAMI Oregon Tour of 50F unit and meeting with 6 employees

Totals: 4 days on-site; toured 26 units; met with and interviewed over 300 people

Attachment D. List of Documents Reviewed

Organizational documents: Hospital Mission Statement Organizational Charts Program Descriptions Description of Strategic Planning Departments Committee Resource Handbook list/description Job descriptions of front-line supervisors Job description of TCPS List of Cabinet members List of key Medical and Clinical staff Quality Improvement Plan Continuous Improvement Plan Continuous Improvement Plan Priorities MAHPS Bylaws PAR data reports Instructions and audit tool for 10 day comprehensive chart reviews Union Contract Reports: Un-redacted Perez Investigation Report by OIT Oregon OIT Report Hospital Plan in response to OIT Report OSH Annual Budget Annual/Monthly Budgets and Financial Reports Quarterly Governing Body Reports USDOJ reports (11/06 & 1/8/08) USDOJ letter to State Attorney General in request for documents Training curriculum/competency assessments Special Master’s Final Report Joint Commission Survey Report (2/09) Most recent CMS Report (2/08) Monitoring logs: Abuse/Neglect/Exploitation cases (past 3 months) Deaths in hospital or within 14 days of discharge (past 12 months) Incident log for the last 30 days (by patient) Seclusion/Restraint log (last 30 days) by patient Key forms: Incident Report Grid Patient Satisfaction Questionnaire QI Dept Orientation Checklist Policies: Abuse/Neglect/Exploitation reporting and investigation Abuse/Neglect/Exploitation documentation (draft policy) Assessment Timeline Guide Behavioral Precautions Constant Behavior Precautions Policy Consumer Council Policy Documentation Emergency Alarm System Employee Response to Violent Situations Falls Prevention Incident Reporting Sentinel Event Medication Administration Medical Emergency Response Mortality Review Nursing Assessment Pain Management Patient Assignments Patient Education Patient Grievance Physical care (intake & output, vital signs, weights, wounds) Physician Notification Parameters Positive behavior support principles & positive interventions to prevent/deescalate crises Provision of a therapeutic milieu PSRB Guidelines Seclusion/Restraint Security Dept. General Work Expectations Special Precautions (Suicide, Assault, Elopement, etc) Special Observations (1:1, 2:1, 3:1) START Training in Preventing/Managing Aggression Time and Attendance Unauthorized Leave Policy Verbal Orders

Committee Minutes: Care of Patients Committee minutes o Critical Incident Review Panel Minutes o Committee Fact Sheets Clinical Executive Committee minutes Superintendent’s Cabinet meeting minutes (past 12 months) Death Review Committee (past 12 months) P&T Committee (last 3 months) Quality Council minutes (last 12 months) EOC Committee (last 6 months) Medical Staff Committee minutes Patient Safety Committee minutes (last 6 months) Seclusion Restraint subcommittee minutes TPAG Committee (last 6 months) Nurse Executive &Leadership Council

Nursing specific documentation: Shift reports (past month) Staffing by ward/shift (past 2 weeks) Current vacancies Turnover data Staffing ratios, Medical Treatment Plans, QI plan, data and reports, Nursing competencies specific to particular populations. Staffing Proposal Nursing hours per patient day Nursing Leadership Management Series Staffing Patterns by unit and shift Curriculum for medication administration Role comparisons for new Unit structure

Attachment E. Organization Chart – Recommended Committee Restructuring

Executive Committee
Research Committee
MAHP Committee
Nursing Executive Committee
Clinical Executive Committee
Patient Council
Patient Grievance Committee
Quality Council Superintendent, Chairs
EDD Advisory

COMMITTEES: – Bylaws – Credentialing – Ethics – MD CQI – Medical Records – Mortality & Morbidity – Pharmacy & Therapeutics – Utilization Review – Infection Control
Clinical Services Committee
Chief Medical Officer, Chief Nursing Officer & Clinical Director, Chairs
Care of Patients Committee
Patient Safety Committee
EOC/Safety Committee
Critical Incident Review Panel

Functions rather than committees (?): – TCP Advisory – Treatment Mall Planning – Core Curriculum – Recovery Workgroup
PITs(?): – BSP – Diversity – Metabolic Syndrome – START
PITs(?): – Falls – HAP – Self-harm – Restraint/Seclusion
PIT (?) – Emerg Prep

Attachment F. Health Information Group (HIG) – Organization Chart Recommended Revision

Director of Quality Management
Medical Records Director
Technology Services Director
Quality Improvement Director
Risk Management Director
Asst. Director Information Services Spec. Coder Analyst Correspondence Specialist File Coordinator
Support Services Supervisor 1 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2 Medical Trans. 2
Operations & Policy Analyst 3 Operations & Policy Analyst 3 Operations & Policy Analyst 2 Operations & Policy Analyst 2 Info Systems Specialist 3 Admin. Spec. 1
Asst. QI Director QI Supervisor QI Supervisor QA Coordinator Medical Records Specialist Executive Support Specialist 1 Convert 1 QI position to Accreditation Mgr
Executive Support Specialist 1 Strategic Planning Unit (5 staff)
Reassign SPU staff to QI and RM Depts
Reassign 6-7 PAR staff to QI & RM Depts.
Planning, Analysis & Research (9 staff)
Reassign 2-3 PAR staff to Clinical Depts.