Minutes 1/22/08 HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

MINUTES

HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

ADAMS BLDG, ROOM 264

Tuesday, January 22, 2008

ATTENDANCE:

Dempsey Benton, Dr. David Rubinow, Mike Pednau, Dr. Stephen Oxley, Cliff Hood, Peter Mumma, Iris Rubin, Rickye Collie, Mike Hennike, Dr. Jim Osberg, Laura White, Dr. Jack St. Clair, Debbie Dihoff, Ranota Hall, Dr. Tony Lindsey, David Womble, Art Robarge, Laura Thomas, Carmen Vincent, Dr. Donald Baucom, Pamela Graham, Kathryn Davis, Walker Wilson, Dr. Ranota Hall

ITEM	RECOMMENDATIONS/ CONCLUSIONS/ACTION	FOLLOW-UP
Welcome and Introductions	The DHHS Secretary, Demsey Benton, welcomed everyone and introductions were made. Those in attendance for this meeting are listed above.	N/A
Housekeeping	A contact list was passed around for additions/corrections. Travel reimbursement was mentioned and Mr. Womble will send out information to committee members regarding the process. Mike Pednau is assigned as the Chair of the workgroup by the Secretary. The Secretary provided a memorandum dated January 17, 2008 regarding the workgroup and background information. Mike Hennike provided one page fact sheets on each of the facilities that included operating budgets, authorized positions, census, admissions and cost per patient per day. Laura White indicated there will be data updates on the facility web sites that will include survey review reports, weekly admission and discharge data, number of patients and days the hospitals have been delayed (to be updated monthly). Significant incidents will also be available with information that does not breach HIPAA confidentiality. Other information will be added as necessary or requested by the workgroup or DHHS.	N/A
Issues to be Divided into Subcommittees	Mike Pedneau brought up for discussion how many subcommittees there need to be to work on major tasks. Tasks include: Standardization of policies, deaths, use of fiscal budget, chemical restraints, forced medications, consistent access and bed availability, uniform standards for requirements of primary treatment positions, quality assurance for standards of accreditation, and corrections of deficiencies. In addition, review of patient safety, assessing long-term mission and role of facilities and populations to be served, hospital and community interface, admissions/discharge planning parameters, continuity of care, staff recruitment, turnover, and maintenance were mentioned as issues. Dr. Jack St. Clair suggested grouping issues to reduce the number of subgroups needed to brainstorm and strategize. It was suggested that separating out issues by short and long term objectives might be helpful.	Subcommittees to be determined.
Centralized and Standardized Policies	Dr. David Rubinow requested information about centralized policies/standards and data actuaries. Jim Osberg explained the JCAHO and CMS standards and the need for each hospital to be a stand alone facility. He also mentioned that corporate policies have been developed, but they allow for a wide degree of local autonomy. Dr. Jack St. Clair indicated there are quarterly governing body reports that are submitted to the Division of Mental Health, Developmental Disabilities, and Substance Abuses Services (DMH/DD/SAS). Samples can be provided to the group if interested. The Department of Justice (DOJ) has been an impetus for driving standardization of the hospitals. Each State psychiatric hospital must respond to its region independently due to demographics and community needs. Carmen Vincent suggested using the regulatory requirements (JCAHO, CMS, CRIPA) as the minimum of quality of care objectives.	State Operated Services to provide the workgroup with a list of corporate policies that are being developed or revised.
State Psychiatric Hospital(s) Mission	A question about the mission of the State psychiatric hospitals due to the status of community gaps, leaving the hospitals as the “safety net” for communities was raised. It was agreed that there are not enough resources in the communities and for the facilities, specifically related to special populations that have led to overpopulation and increases in volume of admissions. The MR/MI population which requires specific resources that are not always available and require additional services due to the risks associated with the needs of these individuals is an example. Factors mentioned: population growth in the state and growth of the populations in need, milieu of community based services, downsizing of State psychiatric hospital beds, loss of services due to privatization of community services, and loss of community psychiatric hospital unit beds. Some beds have been added to the Developmental Centers to handle people with MR and behavioral health needs, but they are limited. Lengths of stay affect census at all facilities. There is a huge need for respite beds to alleviate hospital census volume.	The mission of the State psychiatric hospitals to be discussed further.
Staffing Issues Discussion	Adequate staffing was mentioned as directly influencing standardization of practices. It was asked if any wasted funds could be redirected, and what would need to take place in the communities quickly to slow down admissions to state hospitals? Dr. St. Clair indicated that there are not enough qualified staff for patient care. Lapsed salary latitude allows for hiring temp agency nurses to fill staffing gaps. Positions have had to be cut due to legislation which has cut into lapsed salary latitude. Dr. Oxley indicated it is a complex issue and although John Umstead Hospital does not have as much of a psychiatrist shortage as Cherry Hospital, nursing staff fill the gaps. With lengths of stay being shorter, the first few days are more work and staff intensive, and with challenging patients with violent tendencies there are not enough staff to handle these patients. The State psychiatric hospitals do not enough staff to have one-to-one and two-to-one and must force staff to work overtime, creating burn-out and low morale. This can lead to poor customer service and reduced quality of care. Dr. Ranota Hall asked Dr. Oxley to discuss the issues of staff qualifications and the need for intensive care. Dr. Oxley indicated that Health Care Technicians (HTCs) often do not have the expertise and education to handle the most intensive need patients. Nursing staff must mentor HTCs and with their load of paperwork/documentation, supervision and mentoring come last. Dr. Rubinow asked if documentation requirements could be reduced. This probably has not been reviewed closely as far as what is actually required. The electronic medical record (EMR) can alleviate the documentation needs. EMR has been discussed as a need, but DHHS has a shortage of IT staff to make this happen. Other obstacles for this technology are challenging and slowing down progress. Dr. Oxley indicated that Central Regional Hospital (CRH) is about a year away from having this in place. Carmen indicated you cannot throw EMR technology at a broken process and there should still be review of where there are inefficiencies.	Staffing and career ladders to be discussed further in a staffing issues subcommittee.
	It was indicated there is high variability of survey/regulatory teams in requiring new or changed documentation and it is different among all the hospitals. This adds to the lack of standardization among the State psychiatric hospitals with documentation and quality. Carmen suggested developing an internal process to centralize recertification capability. Art Robarge indicated that reviewing other facility processes has facilitated streamlining problem areas at Broughton. It was asked if there are meetings already in place that can meet the needs of these identified objectives. Can these meetings be more proactive rather than reactive? Dr. Osberg indicated there are monthly State psychiatric hospital directors meetings and this would be a place to start. It was indicated that community relationship efforts with local hospitals, regional crisis systems and between Local Management Entities (LMEs) and the State psychiatric hospitals are important to include in discussions and that standardized staff competencies would be helpful to utilize for improving quality and practices. Rickye Collie indicated that salary ranges are not necessarily the issue because they are competitive in NC, but there are not enough FTEs to handle the population to be served. Dr. Oxley stated that it would be helpful to have a better pool of entry level staff. Staff are often assaulted, and at risk by patients. This can create a sense of lack of appreciation, and the pay scale does not compensate for the impact of the assaultive environment of the State psychiatric hospitals. Dr. Hall stated that continued training for maintaining competencies and enforcing it among HTCs and nurses is important to prevent turnover. HTCs have not had a significant career ladder, and this is something that should be studied.
Budget for Salaries	It was indicated that budget issues and flexibility of funds would be an important subject to resolve by this workgroup. Dr. Oxley mentioned the limits of raising salaries and that it actually requires an act of Congress to pass it as a law.	To be discussed further.
Other Items	A question was asked about what is used to measure success. Dr. St. Clair indicated Cherry Hospital uses a strategic plan for that hospital. Although there is some lack of control with outcomes of patients once they are discharged, there is more work that can be done while patients are in the hospital. It was asked if there were other states NC could emulate regarding practices and Iris Rubin indicated some states are doing well, but most do not take direct admissions. NC State psychiatric hospitals have a higher rate of acute admissions than most other states. Cliff Hood indicated there is difficulty in attracting male HCTs and should be considering in discussions. Mike Hennike suggested that SOS create a list of corporate policies already in place for the group. He also suggested that the group review the key positions that are in the DRH plan. Need to determine main issues to focus on and hone down groups needed to work on the issues. Jim Osberg suggested the compliance issues document that SOS has been working on should be shared with the group for consideration—which is focused on expansion. The group indicated they would like the summary of compliance issues and what has been accomplished thus far. Other data/information requested: Length of stay, admissions, discharges, and recidivism. SOS to provide to Mike Hennike and Mike Pedneau.	Along with determining mission, specific objectives for the State psychiatric hospitals to be determined regarding patient outcomes and measuring success. SOS to provide requested data to Mike Hennike and Mike Pedneau.
Next Steps	Mike Hennike indicated that the group may have to shore up and meet in small groups more often.	Mike Hennike and Mike Pedneau to determine specific subcommittees for the Workgroup to focus on.
Next Meeting	February 5, 2008 at 1:00 p.m. Subsequent meeting: February 19, 2008, same time

There being no further business, the meeting was adjourned at 3:05 p.m.