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Oregon State Hospital: Significant Actions Taken to Improve Safety and Promote Patient Recovery, but Further Improvements are Possible

Executive Summary


The Oregon State Hospital has undergone enormous change. To better promote patient recovery, management has taken significant action to improve safety and patient care. The hospital offers more treatment options and strategies to create a safer environment. It has also undertaken efforts to reduce overtime, and implement an electronic health record system. However, more action is needed in these areas to further improve safety and promote patient recovery.

 

Read full report here.

Oregon Moves Towards Recovery- Oriented Mental Health Care

The first treatment mall opened at the hospital in 2006, marking a shift from decades of unit-based treatment. The hospital operates much like a college campus. Patients reside on the living units, attend class-like treatment groups on the treatment malls separate from their living space, and eat in cafeteria-style dining rooms. Treatment groups help patients learn skills like handling difficult emotions, developing healthy relationships, managing medication, and understanding the legal process.

OSH pics 1New Salem campus facilities were completed in 2011 to further create a sense of well-being. Architectural features incorporate design elements intended to minimize physical safety risks while promoting patient recovery. The buildings look and feel similar to a college campus with plenty of green space. Holding an average of about 600 patients, the facility offers them opportunities to interact with their peers and simulate community experiences such as visiting a coffee shop or a salon.

The adoption of treatment malls is part of Oregon’s larger move towards recovery-oriented mental health care. This approach takes the view that individuals with mental illness can improve their health and wellness, live a self-directed life, and strive to reach their full potential through the recovery process. The recovery focus guides mental health services in Oregon, including the Oregon State Hospital.

Improving Treatment Plans and Groups Could Help Patient Recovery

OSH pics 2.1Hospital staff work with patients to develop treatment goals to address challenges that stand in the way of patient recovery. Patients attend treatment groups directed toward their treatment goals and group leaders evaluate their progress.

Case formulation is an important tool to help clinicians create effective treatment care plans that guide patient treatment. Formulations identify the signs and symptoms of mental illness, motivations behind patient behaviors, and patient strengths and skill deficits at a particular point in time. The process distills critical elements from the huge amount of information available and places them into a narrative context. It can be used to help develop treatment goals and guide patients to the treatment groups most likely to benefit them. We found that the hospital provides very little guidance and training on how case formulations are developed. As a result, case formulations are not consistent.

Treatment groups should be aligned with patients’ treatment goals given their importance in addressing patient challenges and evaluating patient progress. However, it is unclear whether hospital staff designed therapy groups to help patients address these goals. Hospital staff did not use patients’ treatment goals when selecting classes to offer on the treatment malls.

Also, the hospital does not have policies and procedures to ensure patients schedule classes that address their treatment goals and hospital staff do not use treatment goals to evaluate class effectiveness.

OSH pics 3The hospital initiated improved treatment by first implementing strategies to improve patient safety and adopting a new culture centered on patient recovery. Management is committed to further treatment improvements. However, the hospital has not yet developed a formal plan for implementing additional treatment improvements.

We recommend Oregon State Hospital management develop a formal plan for implementing treatment improvements to ensure the consistency of case formulations and integrate treatment goals with the treatment mall groups offered. The plan should include steps for communicating the needs for continual improvement, strategies, and timelines for implementation, milestones to monitor progress, and measures designed to evaluate the plan’s success.

We also recommend Oregon State Hospital management develop policies and procedures for developing and documenting case formulations; and designing, selecting, and scheduling treatment mall classes that consider treatment goals.

Fewer Incidents of Seclusion and Restraint Improved Patient and Staff Safety

Patients need to feel safe in order to make progress towards recovery. Hospital staff also need to feel safe to form therapeutic relationships with patients that support their recovery. Reducing patient aggression can reduce the safety risks their behavior can pose, and so reduce the need for staff to place patients in either seclusion or restraint.

OSH pic 4The hospital adopted the National Association of State Mental Health Program Directors’ (NASMHPD) strategies for safely reducing seclusion and restraint (S/R) use. These strategies address underlying reasons for patient aggression and, if implemented, can help organizations reduce the need to use seclusion or restraint. Management has made progress in implementing each of the six strategies, and their continued efforts can further reduce the use of S/R, and improve safety.

To improve safety at the hospital, we recommend Oregon State Hospital management:

  • continue to address organizational culture, training needs, and attitudes;
  • continue to use data to inform decision-making and practice in S/R reduction efforts;
  • continue Collaborative Problem Solving and Safe Containment implementation to ensure staff competency;
  • update policies and procedures that guide the on-the-job training of nursing staff to ensure consistency among the programs;
  • consider reestablishing the nursing staff mentoring program;
  • continue efforts to integrate S/R reduction tools and assessments into individual patient treatment;
  • provide adequate resources to the Peer Recovery Services Director to help ensure the department’s success;
  • continue to ensure stakeholders and consumers have a role in S/R reduction efforts;
  • continue to work with the Governor and legislature to fill vacant seats on the Oregon State Hospital Advisory Board; and
  • continue efforts to finalize the hospital’s debriefing policy.

Overtime Has Been Reduced— Fatigue Concerns Remain

OSH pic 5Excessive overtime can lead to fatigue, affecting nursing staff’s ability to deliver good patient care, make good clinical decisions, and communicate effectively. Nursing staff provide the bulk of direct-patient care at the hospital, comprising registered nurses (RNs), licensed practical nurses (LPNs), mental health therapists (MHTs) who are licensed certified nursing assistants, and habilitative therapy technicians (HTTs).

The hospital has worked to reduce overtime by hiring nursing staff to fill vacancies, using ratios to ensure appropriate staffing levels, creating a float pool of nursing staff to cover unscheduled absences, revising weekend shift times and hours, and addressing patient aggression to reduce the need for additional staff. Additional actions could further reduce overtime and its effects on patient care.

We identified several staff whose overtime hours indicate they may be at risk for fatigue and its effects. There are no policies that limit overtime hours or consecutive days staff can work. Nor does the hospital offer training on fatigue and its effects, recognizing fatigue, or on employee obligation to ensure they can provide safe patient care.

To reduce overtime and its adverse effects on patient care, we recommend Oregon State Hospital management develop strategies to limit unscheduled absences and manage individual staff’s overtime. Management should also provide training to staff on fatigue and its effects on patient care.

We further recommend Oregon State Hospital management consider the analytical framework used in our 2012 audit of the Department of Corrections to explore other strategies to further manage personnel costs while meeting patient treatment needs and maintaining a high level of patient and staff safety.

Automation Can Improve Patient Care

The hospital is implementing an electronic health record system, but parts of the system remain incomplete. The incomplete system adversely affects organizational efficiency and potentially, the quality and cost of patient care.

OSH pic 6Completing the system would help automate several key manual processes. For example, the hospital could replace its manual process for dispensing patient medication with an automated system it purchased several years ago. The automated system would provide safeguards designed to prevent medication dispensing errors.

The hospital is working to convert patient records from paper to electronic records but critical medical records such as patient prescriptions, allergy information, and “do not resuscitate” and “advanced directive” documents are still maintained as paper. Hard copy record systems can lead to additional costs, lost productivity, and limited accessibility.

We recommend Oregon State Hospital management complete implementation of its electronic health record system, prioritizing automation of processes that significantly impact patient care and conversion of critical patient information to electronic format.

Agency Response

The agency generally agrees with our findings and recommendations.  The full agency response can be found at the end of the report.

 

All Audits Featured Noteworthy Performance Audit Public Health
Lottery1

Oregon State Lottery: Unclear Laws May Let Prohibited Casinos Operate in Oregon

Executive Summary


The Oregon Constitution prohibits casinos, but enforcement is difficult because “casino” has not been clearly defined. The Oregon State Lottery’s current rules and practices may not be detecting retailers that receive most of their income from video gambling machines. We recommend Lottery seek legislation to define “casino” and take several steps to improve compliance.

 

The Oregon State Lottery offers a variety of gambling options including Powerball, Mega Millions, and Oregon games: Megabucks, Raffle, Keno, Lucky Lines, Win for Life, Pick 4, Scratch Its, and video gambling machines.

Machines are the largest annual revenue source with average net receipts of $727 million over the last five state fiscal years. Net receipts as used in this report are dollars deposited in machines minus dollars won. During fiscal year 2014, machines generated net receipts of $743 million, of which $178 million was paid in commissions to retailers and the remaining $565 million was used for state purposes. As of December 2014, there were about 2,300 retailers operating nearly 12,000 machines.

Lottery3The Oregon Constitution prohibits the operation of casinos in the State of Oregon, but does not provide a definition for a casino. In 1994, the Oregon Supreme Court concluded that “voters intended to prohibit the operation of establishments whose dominant use or dominant purpose, or both, is for gambling.” Neither the court nor the legislature has defined the terms “casino,” “dominant use,” or “dominant purpose.”
Lottery has established administrative rules to enforce casino prohibition. Under its current rule, retailers are not casinos if their non-lottery sales are at least 50% of their total income. For retailers whose non-lottery income may be less than 50%, the rule allows the Lottery to consider additional factors such as a visual inspection to determine if a retailer is operating as a casino.

In practice, Lottery is satisfied if a retailer’s facility does not look like a casino, so they perform no review of retailer income.

Lottery has identified Limited Menu Retailers as Lottery1 posing a higher risk of operating as a casino because they tend to have limited sales of non-lottery products, thus, relying more on Lottery income for their business. In 2014, 234 Limited Menu Retailers operated 1,305 or 11% of the nearly 12,000 machines in use and generated about 21% or $158 million in machines net receipts.

We focused our procedures on the higher risk Limited Menu Retailers and found that Lottery’s enforcement practices may not adequately address the Oregon Constitution’s casino prohibition. We followed the procedures prescribed by Lottery’s current enforcement program and found the program does not detect all retailers whose dominant income is gambling.
While most of the Limited Menu Retailers we reviewed did not have the appearance of a casino, over half of these retailers derived more than 50% of their income from machine commissions. Many of these Limited Menu Retailers had difficulty generating non-lottery sales sufficient to comply with the income threshold.

Recommendations

To help Lottery strengthen existing controls and to facilitate compliance with casino prohibition, we recommend Lottery management work with the legislature and other stakeholders to develop a clear and enforceable definition of a casino that aligns with the 1994 supreme court ruling of dominant use/dominant purpose. Lottery should verify gross sales reports when using them to perform an income analysis. For retailers challenged with meeting the 50% non-lottery income threshold, Lottery should evaluate whether removing a machine would enable the retailer to comply with the dominant use/dominant purpose court ruling.

Agency Response

The agency response is attached at the end of the report.

Read the full report

All Audits Compliance Audit Featured Performance Audit
Maze

The Evolution of New Auditor Training at OAD

How does training impact the work of new auditors?

We provide training to our newly hired auditors because government auditing is very different than business auditing. Unfortunately, no universities specialize in this field, and even a single class is rare. We try to update and improve our training each time, but what we’ve learned in the last year about our instructional design approach has given us new insights.

First, what we taught was not specifically designed to help new performance auditors conduct their day-to-day work. We explained about preparing a good workpaper, or using our software, Teammate. But there were gaps in the framework and perspective of auditing. To address those gaps, we began to develop trainings that complemented our practical nuts and bolts offerings with courses focusing on soft skills development and leadership.

Auditing has a maze-like feeling for the new hire but we sometimes forget that there are two perspectives of a maze – the bird’s eye view, and the view from inside. From above, our eye can trace the shortest route. But inside, there are no direction markers.  Success must come by assembling a clear memory of the layout of the maze through arduous trial and error.

Inside Hampton Court Maze

Inside Hampton Court Maze

Some people enjoy the puzzle of a maze and pay to wander through corn mazes. Some have no patience for mazes. The image to the right makes some folks feel like a lab rat. And not a very smart one, since I hear that lab rats are quite capable of negotiating mazes.

But even as we think about this frustration, we also need to ’embrace the maze’. Every new audit is an agency maze. We try to understand how all the program and financial pieces fit together, and build up the picture through interviews, data analysis, and observation.

On the financial side we have workpapers and team member continuity to guide us through the maze of risks each year. On the performance side, we are often entering new agency mazes and our initial, scoping phase produces a rough drawing of the maze to help us narrow down to an issue that we should audit.

Above Hampton Court

Above Hampton Court

The other maze is our audit process.  We want newly hired auditors to be able to negotiate their way through the agency maze without also getting lost in the auditing maze. The better we can prepare new auditors in our methods and procedures, how to audit, the more they can focus on what they are auditing.

Our instructional design efforts are laying out the tasks more clearly for new hires with 11 classes so far. For example, we have training on audit documentation, interviewing, elements of a finding, sufficiency of evidence, and report writing. This knowledge and skill set are spread out, presented when a new hire will encounter them, then reinforced as they do their work.

Nonetheless, we recognize that many aspects of auditing are affected by circumstances and context that can’t be set in procedure. Strategies, priorities, principles, and standards provide general guidance in these situations. Leadership is also important and we want to help our newly promoted team leads understand the new responsibilities and situations they must take on, and perform them with competence and confidence.

We are developing that team leader training in our next phase, and some intermediate auditor training, and some technical training on specific software or analytical tools.

This seems like a lot of work but we are asking our auditors to develop and offer the classes, which involves us all in the responsibility of defining expectations, developing the content, and presenting the instruction.

We want to shorten the learning curves of our auditors because that translates into highly professional work from everybody. Staff members that have had the opportunity to take part in thorough and holistic training are a key element of a learning organization.

Auditors at Work Featured Financial Audit Performance Audit
Sheronne2

GED Audit wins national award

Audit Manager Sheronne Blasi

Audit Manager Sheronne Blasi

We are very pleased to learn that our

Education Featured Noteworthy Performance Audit
OADsign1

In the News: Community Colleges Audit

A recently released audit by the Secretary of State Oregon Audits Division caught the attention of legislators and the general public. The audit (read the executive summary and the full report) showed that, while Oregon’s community college completion rate was lower than it needed to be to meet Oregon’s 40-40-20 initiative by 2025, the use of targeted investments could help put the state back on track for reaching that goal.

Read the Oregonian and Statesman Journal articles here.

In addition to sparking a discussion around Oregon’s community college completion rate (as well as high school and four year college completion rates), the audit has been referenced by community college leaders and legislators in regard to SB 81, a bill that would provide a tuition waiver to community college students that meet certain eligibility requirements.

Keep tuning in for further updates on the impacts of our audits on Oregon governance.

All Audits Education Performance Audit
NSAAwinners

TANF Audit Wins National Award

Congratulations to our very own Jamie Ralls, Sandy Hilton, Ian Green and Scott Learn!

An audit released last April on Oregon’s Temporary Assistance for Needy Families, better known as TANF, was selected as this year’s winner for a national award on excellence in accountability.

You can read the complete audit here!

The Excellence in Accountability Awards are distributed annually by the National State Auditors Association. This year, from a pool of 34 entries across four categories, the Oregon Audits Division took home the prize in large performance audits.

After interviews, extensive data analysis and reviewing more than 80 cases in-depth, the audit found that, despite budget cuts and increased workload, Oregon’s TANF program continued to successfully help dozens of clients across the state.

However, the audit also found that the program was making little to no progress in moving its clients toward self-sufficiency. Auditors identified opportunities for improvement that would help keep Oregon’s TANF program on steady ground.

The award will be presented at the 2015 NSAA Annual Conference in Little Rock, Arkansas in June.

This marks the first time the Oregon Audits Division has won this award.

Congratulations to the team and to the other winners!

Families and Children Featured Noteworthy Performance Audit