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 2. Leadership – Need for strong front-line engagement by Cabinet and clinical leadership
Summary: The Hospital’s leadership team – specifically the Cabinet, Clinical Discipline Chiefs and Nurse Program Managers – need to establish a much stronger presence inside the treatment units and treatment malls by making daily engagement with the clinical and direct care staff. Specifically, members of the clinical leadership need to regularly visit the units to directly observe operations in order to effectively monitor and reinforce standardized roles and procedures across units. In turn, unit staff needs to see the visible presence of clinical leadership to be assured of their concern and oversight. In particular, as stated before, Unit Nurse Managers currently feel unsupported and overwhelmed in their new expanded role in which they are assuming some of the job responsibilities from the former Unit Director role. The Nurse Program Managers should be frequently interacting with the Unit Nurse Managers and clinical personnel on every unit. The use of email as the primary mode of communication and policy enforcement exacerbates the perceived disconnection between hospital leadership and unit staff. The absence of visible leadership has created the perception that unit-based staff must be self-sufficient in managing operations and delivering patient care within their own units. This perceived leadership vacuum fuels the tendency for each unit to “do things its own way” and resist efforts to standardize practices. Additionally, leadership needs to examine issues/problems and make a decision. An example is the issue of census on the geriatric units. The geriatric units run at two thirds capacity. While hospital leadership has discussed the low census, and various options for remedy; no decision has been made.
L 2.1. – Strong presence of leadership on units: All Cabinet members and/or Clinical Chiefs should visit all hospital units and treatment areas on a regular (weekly) basis with an eye on strengthening standardized practices. Engagement and interaction with clinical staff, direct care staff and consumers is vital and their input needs to be welcomed. Leadership needs to do direct observation of unit activities and staff performing usual duties to identify salient challenges or problems and to be in touch unit life and progress. Leadership needs to be highly visible to staff and patients alike in order to demonstrate concern and active oversight by the leadership.
L 2.2. – Cabinet should conduct visits all shifts on all units: The Review Team recommends that each member of the Cabinet should personally conduct “rounds” on all off-shifts and weekends. During this critical time of transition at OSH, each Cabinet member should “round” once a month either on the swing shift after 5PM, night shift or weekends. This can be accomplished by creating a quarterly schedule and adding a clerical monitoring function to confirm that all shifts on all units are being visited. The purpose of the rounding is to talk with the staff, listen to their concerns, observe the delivery of patient care and formally report back to the Cabinet at the next meeting. This will not only provide valuable information to the Cabinet regarding the “pulse of the organization,” but will also help staff feel more involved and connected. It is also an opportunity for top leadership to dispel rumors, discuss policies/practice and answer questions.
L 2.3. – Strong presence of Nurse Program Managers on units: Nurse Program Managers should be present on their assigned units a minimum of twice a week. This presence should be for a substantial amount of time (1-2 hours) and should not be used for regularly scheduled meetings. Rather the purpose of unit visits is to directly interact with staff, ascertain that staff has what is needed to take care of patients in a safe and therapeutic manner, talk with patients about their care, randomly review nursing progress notes, assist the Unit Nurse Manager in his/her job as needed and provide consultation/education. Being on the units with some degree of frequency will also allow the Nurse Program Managers to observe the interaction between patients and staff and potentially role model such behaviors as de-escalating patient conflicts, engaging a withdrawn patient in conversation, etc. These expectations should be included in the Nurse Program Manager’s Performance Evaluation Plan. This expectation should be tempered by the fact that there are presently 3 RN Program Managers for 14 forensic units.
L 2.4. – Importance of face-to-face rather than e-mail communication: It is important to stop the over-reliance on E-mail as the primary means of communication between leadership and unit managers and for the dissemination of important policy changes. Nor is it effective to provide hard copies of policies for those who do not use the computer. Important policy changes naturally elicit questions and concerns. There needs to be face-to-face time between leadership and unit-level supervisors and between supervisors and line staff for discussion, questions, clarification and follow-up reinforcement for compliance, all of which helps to build teamwork.
L 2.5. – Mechanism for Superintendent engagement: It will be crucial for the Superintendent to be a highly visible leader with a first-hand awareness of facility operations and issues throughout the hospital. The Liberty Review Team recommends that the new Superintendent establish times when he/she can meet with Direct Care and Support Staff. The HR Department could randomly select a group of 10-12 employees (e.g., nursing, physicians, dietary, housekeeping, physical plant, etc) to meet monthly (or more often) with the Superintendent. The purpose is to enable staff to candidly discuss what they think is working well at the hospital and what is not working. It is important that the Superintendent is alone with staff and is not accompanied by other hospital executives. His/her commitment to taking time out of a busy schedule to meet with staff in a small group will give the clear message that their ideas and input are valuable. The small group meetings also generate very good ideas for improvement. HR will need to be careful to avoid mixing employees who supervise others with those who do not. The supervisory group can also be randomly chosen and the groups can alternate from meeting to meeting. The use of personal invitation cards adds to the perception that the staff person is important and valued by the hospital.