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.
New 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
Hospital 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.
The 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.
The 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
Excessive 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.
Completing 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.
The agency generally agrees with our findings and recommendations. The full agency response can be found at the end of the report.
Hello again, fellow data wonks and wonk wannabes!
Last time, we discussed random sampling in Excel and what factors you should consider when determining your sample size. (Hint: 30 is generally large enough, but not in all cases)
One of the downfalls of Excel is the lack of an audit trail. In these examples, we will provide a high-tech and low-tech way to document your sample selection process in detail. First up, ACL.
The High-Tech Method
I am working with fictional data below. As you can see, our population contains 36 counties. Make note of your population size when working in ACL as this will be important later on. You can count a table by using the shortcut “CRTL + 3”.
Next you select the “Sampling” menu and click on “Sample Records”. This also has a shortcut, which is “CTRL + 9”.
Change “Sample Type” from “MUS” to “Record”. Then click on “random” on the middle left of the interface. Enter in the “size” of the sample. I pulled a sample of 10. The “Seed” allows you to document and repeat a random sample. Any number will do – just pick the first one that comes to mind.
I know what you’re thinking. However, just because something is repeatable does not change the fact that it is random.
Enter in the “population” we recorded earlier, then define the table name you want the sample sent to.
There you have it; a random sample of 10 counties in Oregon, with a full log file and repeatable methodology in case you ever get questioned about how you pulled your sample.
The Low-Tech Method
If you are still hung up on what a seed has to do with random sampling, the low tech way will make it clear to you. Below we have a copy of a random number table. You can find these in the appendix of most statistics textbooks or via Google.
The “seed” tells you where to start on the table. If I have a seed of 1, we would start at the 1st number, which also happens to be a 1. A seed of “3” start at the 3rd number in which in this case is 4. This is what makes it repeatable. Our population was 36, so to pull a sample we will be looking at sequences of 2-digit numbers. I will use a seed of “3” and pull just three samples.
In the random number table to the right, I’ve crossed out the first two numbers since our seed was “3”. Starting with the 3rd number, I looked at each 2 digit sequence. If the number fell between 01 and 36, it was a valid random sample and highlighted in green. If the number was above 36, I moved to the next sequence. Also, if repeats are not allowed in your sample you would move to the next number as well (e.g. 11 would be my next sample, but it was already pulled so I would skip over the repeat). Keep moving right and down until you have pulled the full sample.
In this case, my sample was 01, 11, and 20 or Baker, Gilliam, and Lane (shown below). Functionally, this manual low-tech process is identical to what ACL does.
You can apply the Random Number table approach to extremely large files. If you had 1,000,000 records you would look at 7-digit sequences rather than 2-digit shown above.
And there we have it! Two useful methods for documenting sample selection.
If you are stuck on a project in ACL, Excel, or ArcGIS please submit your topic suggestions for a future blog post.
We here in the audits division are proud that the work we do makes a difference. Our work attracts the attention of the legislature, statewide news sources, and even local media outlets. Local media coverage of our audits is just another way we communicate with the people of Oregon about the work that we’re doing on their behalf to make government better. This is part of an ongoing series of posts rounding up recent instances in which the Oregon Audits Division makes a cameo in the local news.
KTVZ – What’s a casino? Oregon rules unclear, audit finds
“Video gambling machines are a major source of income for a number of retailers even though the Oregon Constitution prohibits ‘casinos.’ Trouble is, casinos are not defined in Oregon law, with the result that the prohibition is not currently subject to effective enforcement. Those are among the findings announced Tuesday of an audit of the Oregon State Lottery conducted by the Oregon Secretary of State’s Audits Division.”
The Oregonian/OregonLive.com – ‘Little casinos’? Cash-cow ‘delis’ flout Oregon Lottery rules, audit finds
“The Oregon Lottery has failed to flag cash-cow ‘delis’ that might be operating illegally as casinos, a state report has found — in part because regulators have increasingly shied away from basic financial checks. The audit from the Secretary of State’s Office, released Thursday, brings to light an open secret long lamented by reformers who worry that the lottery’s billion-dollar returns come at the expense of problem gamblers.”
The Register-Guard – Opinion: Curbing lottery creep
“The audit makes several recommendations. The first is that state lawmakers work with lottery officials to establish a “clear and enforceable definition” of a casino. The audit also recommends that lottery regulators analyze the financial records of food-light retailers to determine compliance with the 50 percent non-lottery income threshold. For retailers found in violation, the lottery should determine whether removal of some video machines could bring the business into compliance.”
The Oregonian/OregonLive.com – Lottery director answers criticism after audit questions casino rules
“The director of the Oregon Lottery responded to criticism in the wake of a state audit this week that called on officials to clarify the state’s ‘casino’ ban and raised questions about the lottery’s ability to enforce its gambling rules.”
GoLocalPDX.com – Oregon’s Data Center Has Major Weaknesses, Says Report from Atkins
“A new report from the Secretary of State Jeanne Atkins’ Office claims that the data center operated by the Department of Administration continues to have major weaknesses. The problems going back nine years continue to potentially expose the most confidential records and data of Oregonians.”
Statesman Journal – Audit criticizes security at Oregon’s state data center
“Oregon technology managers never resolved known security vulnerabilities at a state data warehouse that stores a trove of sensitive information about Oregonians, state auditors concluded in a report released Tuesday.”
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.
The 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 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.
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.
The agency response is attached at the end of the report.
Critical security issues were never resolved at the data center
Data center management and staff are meeting day-to-day computing needs of state agencies relying on its services. However, critical security issues identified throughout the past nine years were never resolved.
Security problems affect multiple components of the data center’s layered-defense strategy intended to make it more difficult for unauthorized users to compromise computer systems.
These weaknesses increase the risk that computer systems and data could be compromised, resulting in leaked confidential data such as social security numbers and medical records information.
Data center was never fully configured for security
Management got a good start on security planning, but during data center consolidation management abandoned the plan thinking they would complete some steps at a future time. Once the data center became operational, staff was overburdened and unable to make meaningful progress toward resolving critical security issues or implement security systems they purchased.
These adverse conditions continued because management did not assign overall responsibility or authority to plan, design, and manage security. In addition, they did not provide the necessary staffing to implement and operate security systems.
First steps have been taken to resolve longstanding data center problems
Two key steps that occurred were the state Chief Information Officer (CIO) became responsible for data center operations and the state Chief Information Security Officer was moved to the data center and tasked to oversee its overall security function.
These actions increased management’s focus on security at the data center. However, it will take additional time, perseverance, significant resources, and cooperation to resolve all known weaknesses.
Some computer operations were stable but disaster recovery was only partially tested
Apart from security, data center staff provides important operational support to agencies, including routine backups and monitoring computer processing. Data center staff made significant strides to resolve prior disaster recovery weaknesses identified by earlier audits. Their innovative approach was to partner with the Montana State Data Center to establish an alternate site to store and process data.
However, additional work needs to be done to ensure data at that site is secure, update recovery plans, and test the system.
We recommend agency management take steps to reconfigure data center security to provide the layered-defense strategy needed to protect state data systems. To accomplish this, management should clearly define security roles, responsibility and authority to carry out the plans and provide sufficient staff.
We also recommend management update and fully test disaster recovery plans and ensure data is secure at the remote site.
The agency agreed with all of the audit findings and recommendations. The response includes specific plans to correct longstanding security weaknesses and improve overall security organization, plans and staffing.
Their full response is attached at the end of the audit report.
As auditors, we strive to ensure that government functions fairly, efficiently, and effectively. Auditing has long been one of the methods used to ensure that government is performing to expectations, and is part of a broader system of accountability that minimizes incidences of corruption and the misuse of public funds.
Despite these measures, it is frequently reported that trust in government has dropped to historic lows. State and local governments have retained higher levels of public trust than the federal government, but they have also seen declines in reported public trust since hitting a peak in 2001.
But is reported public trust a true indicator that something has gone wrong, or right? Is it something that we as auditors need to keep in mind as we go about our work?
In the following video, Onora O’Neill discusses trust, and it’s often ignored cousin, trustworthiness.