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.
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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.