Performance audit, Department of Health Services, Arizona State Hospital

              PERFORMANCE AUDIT
DEPARTMENT OF HEALTH SERVICES
ARIZONA STATE HOSPITAL
Report to the Arizona Legislature
By the Auditor General
October 1989
89- 9
DOUGLAS R. NORTON. CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
LINDA J. BLESSING, CPA
DEPUTY AUDITOR GENERAL
October 27, 1989
Members of the Arizona L e g i s l a t u r e
The Honorable Rose Mofford, Governor
Mr. Ted Williams, D i r e c t o r
Department of Health Services
Transmitted herewith i s a report of the Auditor General, A Performance
Audit of the Department of Health Services, Arizona State H o s p i t a l .
This report i s i n response to a June 2, 1987, r e s o l u t i o n o f the J o i n t
L e g i s l a t i v e Oversight Committee. The performance a u d i t was conducted
as a part of the Sunset Review set f o r t h i n Arizona Revised Statutes
$ 341 - 2351 through 41- 2379.
This i s the s i x t h i n a series o f reports to be issued on the Department
of Health Services. The report addresses the effectiveness and
e f f i c i e n c y of the Arizona S t a t e H o s p i t a l ( ASH) i n providing care and
treatment to i t s p a t i e n t s . S p e c i f i c a l l y , we found that because of
extreme s t a f f i n g problems, ASH has d i f f i c o l t y providing adequate s t a f f
on i t s treatment u n i t s . In a d d i t i o n , the report suggests that ASH
consiaer r e s t r u c t u r i n g i t s treatment program and u n i t posittons to
improve supervision and program management. Further, we found that ASH
rleeds to improve i t s d i e t a r y services to i t s p a t i e n t s . F i n a l l y , we
found that although ASH has improved the use of i t s t r a n s i t i o n a l l i v i n g
u n i t , other u n i t s w i t h i n the h o s p i t a l need to be made more aware of the
program's functions.
My s t a f f and I w i l l be pleased to discuss or c l a r i f y items i n the
report.
Sincerely,
Do' g 4as R . Norton
Aud~ or General
DRN : l mn
S t a f f : William Thomson
Deborah A . K l e i n
Lucinda A. Trimble
Lucy K. Bradley
David J. Vidoni
Jean Wood
2700 NORTH CENTRAL AVE 0 SUITE 700 PHOENIX, ARIZONA 85004 @ ( 602) 255- 4385
The O f f i c e of the Auditor General has conducted a performance audit of
the Arizona Department of Health Services, Arizona State H o s p i t a l , i n
response to a June 2, 1987, r e s o l u t i o n o f the J o i n t L e g i s l a t i v e Oversight
Committee. This performance a u d i t was conducted as part of the Sunset
Review set f o r t h i n Arizona Revised Statutes ( A. R. S. 5541- 2351 through
41 - 2379.
This i s the s i x t h i n a series of reports to be issued on the Arizona
Department of Health Services ( DHS). The report focuses on the functions
of the Arizona S t a t e H o s p i t a l under the D i v i s i o n of Behavioral Health.
Because o f Extreme S t a f f i n g Problems, ASH Has
D i f f i c u l t y Providing Adequate S t a f f on
I t s Treatment U n i t s ( see pages 5 through 17)
Arizona S t a t e H o s p i t a l ( ASH) has d i f f i c u l t y providing adequate s t a f f on
i t s treatment u n i t s . Because of the type of s e r i o u s l y i l l p a t i e n t s the
h o s p i t a l i s caring f o r , i t i s important t o have adequate s t a f f . However,
h o s p i t a l s t a f f believe the current l e v e l s are inadequate and unsafe. For
example, one supervisor noted that only 2 s t a f f are avai lable to awaken,
clean, diaper, and dress 31 c h r o n i c a l l y mentally and p h y s i c a l l y i l l
p a t i e n t s , w i t h i n the a l l o t t e d two hours. Another supervisor noted that
the two s t a f f assigned to her u n i t at n i g h t are not s u f f i c i e n t i f an
emergency should occur among the 25 p a t i e n t s . S t a f f i n g concerns were
also noted i n a recent survey by the Department of Health and Human
Services, Healthcare Financing A d m i n i s t r a t i o n ( HCFA). HCFA reported that
despite recent increases i n s t a f f , the h o s p i t a l s t i l l o n l y m a r g i n a l l y
meets s t a f f i n g standards for licensed nurses.
S t a f f shortages stem from the h o s p i t a l ' s high turnover and extended
vacancies. Not only does the h o s p i t a l have a turnover rate o f nearly 50
percent, but i t can take as long as 75 days to f i l l vacancies. Further,
ASH'S e f f o r t s to cover the shortages caused by the vacancies a c t u a l l y
increase the problem. To cover vacancies ASH frequently has to p u l l or
l l f l o a t " s t a f f from one u n i t t o another. I n order to avoid being f l o a t e d ,
s t a f f frequently c a l l i n s i c k , causing f u r t h e r shortages. Some s t a f f
become so d i s s a t i s f i e d w i t h f l o a t i n g that they q u i t , causing s t i l l more
vacancies.
Turnover i s f u r t h e r aggravated by s t a f f d i s s a t i s f a c t i o n w i t h the work
environment. S t a f f are d i s s a t i s f i e d w i t h supervision at ASH, as well as
w i t h s a l a r i e s and promotional o p p o r t u n i t i e s . P s y c h i a t r i c technicians,
the largest segment of the nursing s t a f f , are p a r t i c u l a r l y d i s s a t i s f i e d
w i t h the s a l a r i e s and promotional o p p o r t u n i t i e s because beginning
s a l a r i e s are only $ 13,660, and there are few o p p o r t u n i t i e s f o r promotions
or advancement.
ASH Needs t o Consider Restructuring I t s Treatment Program and Unit
P o s i t i o n s t o Improve Supervision and Program Management ( see pages 19
through 26)
ASH needs to consider r e s t r u c t u r i n g i t s treatment program and u n i t
management. Each u n i t i s s t a f f e d w i t h i n d i v i d u a l s from various
d i s c i p l i n e s such as n u r s i n g , s o c i a l work, and psychology. However, ASH'S
current s t r u c t u r e lacks an i n d i v i d u a l a t the u n i t or program l e v e l t h a t
has o v e r a l l r e s p o n s i b i l i t y for a l l d i s c i p l i n e s working on the u n i t s .
To improve u n i t and program supervision, ASH should evaluate the need for
program managers, head nurses, and lead p s y c h i a t r i c technicians. Program
management p o s i t i o n s could provide o v e r a l l a d m i n i s t r a t i o n f o r ASH'S
treatment by handling such r e s p o n s i b i l i t i e s as coordinating therapies for
p a t i e n t s , planning a c t i v i t i e s , budgeting, implementing program p o l i c i e s
and procedures, and p r o v i d i n g f o r the h i r i n g , o r i e n t a t i o n , and t r a i n i n g
of s t a f f . Establishment o f a head nurse p o s i t i o n would provide increased
c l i n i c a l supervision of nursing s t a f f , and the use of lead p s y c h i a t r i c
technicians on each u n i t could a s s i s t i n the supervision of technical
s t a f f .
ASH Needs t o lmprove the Food Se r v i ce For I t s Pat i en t s ( see pages 27
through 34)
ASH needs to improve the d i e t a r y services provided for i t s p a t i e n t s . We
analyzed both p a t i e n t menus and the meals served t o p a t i e n t s and found
that the foods are high i n c h o l e s t e r o l , f a t , and sodium. For example,
according to an analysis of ASH menus, meals planned for p a t i e n t s on
regular d i e t s had a c h o l e s t e r o l content as high as 203 percent above the
recommended l e v e l . Because n u t r i t i o u s meals are important for proper
p a t i e n t treatment, p a t i e n t care i s being compromised by inadequate food
service. ASH's f a i l u r e to provide n u t r i t i o u s meals i s due to inadequate
menus, lack of standard recipes, and poor purchasing planning.
ASH's method of serving foods i s also i n e f f i c i e n t and problematic.
Frequently, only one person serves p a t i e n t s coming through a serving
l i n e . This causes delays i n serving p a t i e n t s , and, i n a d d i t i o n , servers
don't always have time to ensure p a t i e n t s are g e t t i n g the foods
prescribed on t h e i r d i e t s . For example, we observed a server attempting
to serve hot dogs to p a t i e n t s on vegetarian d i e t s . F i n a l l y , the servers
do not always serve the c o r r e c t p o r t i o n s of food.
ASH Has Improved the Use o f I t s T r a n s i t i o n a l L i v i n g U n i t Program;
However, Other U n i t s Within the Hospital Need to Be Made More Aware of
the Program's Functions ( see pages 35 through 43)
ASH has improved the use of i t s t r a n s i t i o n a l l i v i n g u n i t ( TLU). However,
the functions of TLU have not been communicated to u n i t s outside of the
program. In 1984 the L e g i s l a t u r e , recognizing the need for a program to
provide graduated steps of care between the h o s p i t a l treatment u n i t and
the community l i v i n g s i t u a t i o n , establ ished a l i n e i tem designating
funding for a t r a n s i t i o n a l l i v i n g u n i t ( TLU). Although only 12 spaces
were a v a i l a b l e on the u n i t for the more than 550 discharges a year,
between September 1984 and October 1988, TLU had r a r e l y operated at
capacity. In a d d i t i o n , the average p a t i e n t length of stay was longer
than projected, and r e l a t i v e l y few p a t i e n t s were discharged from TLU. In
November 1988, ASH reorganized TLU. Since i t s reorganization, ASH has
been able to increase TLU's p a t i e n t census, reduce the average length of
stay i n the program, and discharge more p a t i e n t s .
TABLE OF CONTENTS
Page
INTRODUCTION AND BACKGROUND. . . . . . . . . . . . . . . . . . . . 1
FINDING I: BECAUSE OF EXTREME STAFFING PROBLEMS, ASH HAS
DIFFICULTY PROVIDING ADEQUATE STAFF ON
ITSTREATMENTUNITS . . . . . . . . . . . . . . . . . . . . . . 5
Staff Shortages Exist on Treatment Units . . . . . . . . . . . 5
Shortages Stem From Turnover and Vacancies . . . . . . . . . . 8
E f f o r t s to Ensure Sufficient Numbers of
Staff Contribute to Turnover . . . . . . . . . . . . . . . . . 8
Work Environment Leads to Staff Turnover . . . . . . . . . . . 11
ASH Needs to Take Actions to Address
StaffingProblems . . . . . . . . . . . . . . . . . . . . . . . 12
Recommendations. . . . . . . . . . . . . . . . . . . . . . . . 16
FINDING II: ASH NEEDS TO CONSIDER RESTRUCTURING ITS TREATMENT
PROGRAM AND UNIT POSITIONS TO IMPROVE SUPERVISION AND
PROGRAM MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . 19
Current Structure. . . . . . . . . . . . . . . . . . . . . . . 19
ASH Should Evaluate Current Structure and
Consider Changes . . . . . . . . . . . . . . . . . . . . . . . 20
Recomnendations. . . . . . . . . . . . . . . . . . . . . . . . 26
FINDING Ill: ASH NEEDS TO IMPROVE THE FOOD SERVICE
FOR ITS PATIENTS . . . . . . . . . . . . . . . . . . . . . . . 27
Foods Served to ASH Patients Are Not Nutritious. . . . . . . . 27
ASH'S Failure to Provide Nutritious Meals I s
DuetoPoorPlanning. . . . . . . . . . . . . . . . . . . . . 29
ASH Does Not Provide Adequate Service of Foods . . . . . . . . 31
Recommendations. . . . . . . . . . . . . . . . . . . . . . . . 33
TABLE OF CONTENTS Con't
Page
FINDING IV: ASH HAS IMPROVED THE USE OF ITS TRANSITIONAL
LIVING UNIT PROGRAM. HOWEVER, OTHER UNITS WITHIN THE
HOSPITAL NEED TO BE MADE MORE AWARE OF THE
PROGRAM'S FUNCTIONS. . . . . . . . . . . . . . . . . . . . .
TLU Has Been U n d e r u t i l i z e d . . . . . . . . . . . . . . . . . . 36
Use o f the TLU Has Been Improved . . . . . . . . . . . . . . . 39
ASH Needs t o Comnunicate TLU's Functions t o
I t s Other H o s p i t a l U n i t s . . . . . . . . . . . . . . . . . . . 42
Recomnendations . . . . . . . . . . . . . . . . . . . . . . . . 43
OTHER PERTINENT INFORMATION. . . . . . . . . . . . . . . . . . . . 45
Medicare C e r t i f i c a t i o n . . . . . . . . . . . . . . . . . . . . 45
A S H F a c i l i t i e s . . . . . . . . . . . . . . . . . . . . . . . . 47
AGENCY RESPONSE
APPEND l X
ASH EMPLOYEE SURVEY RESULTS
LlST OF TABLES
Page
TABLE 1 - Department of Health Services -
ASH Statement of FTEs and Actual
and Budgeted Expenditures,
Fiscal Years 1986- 87 through 1988- 89
( unaudited). . . . . . . . . . . . . . . . . . . . . . 4
TABLE 2 - Results of Analysis of Regular and Mechanical
Soft Diets Served to ASH Patients
During the Week of April 24- 28, 1989. . . . . . . . . . 28
TABLE 3 - Transitional Living Unit Length of Stay
Fiscal Years 1984- 85 through 1988- 89
( Based on Patients Dis charged from Hospi t a l ) . . . . . . 38
LlST OF FIGURES
FIGURE 1 - Interrelationship of Staffing Problems at ASH . . . . . 13
FIGURE 2 - Current Structure of ASH Treatment Programs and Units . 21
FIGURE 3 - Current Reporting Structure of ASH Treatment Units. . . 22
FIGURE 4 - Proposed Structure of ASH Treatment Programs. . . . . . 25
FIGURE 5 - Transitional Living Unit Average Monthly Census
September 1984 through October 1988 . . . . . . . . . . 37
FIGURE 6 - Transitional Living Unit Average Monthly Census
September 1984 through March 1989 . . . . . . . . . . . 41
INTRODUCTION AND BACKGROUND
The O f f i c e of the Auditor General has conducted a performance a u d i t of
the Department of H e a l t h S e r v i c e s , Arizona State Hospital ( ASH) i n
response to a June 2, 1987, r e s o l u t i o n of the J o i n t L e g i s l a t i v e Oversight
Committee. This performance a u d i t was conducted as a p a r t of the Sunset
Review set f o r t h i n Arizona Revised Statutes ( A. R. S.) 5541- 2351 through
41 - 2379.
Hospital Mission and
Programs
The Arizona S t a t e H o s p i t a l ( ASH), p u b l i c l y funded since 1887, serves as
the s o l e S t a t e operated mental h o s p i t a l i n Arizona. ASH'S treatment
f a c i l i t i e s are located i n Phoenix. A. R. S. 536- 202 requires ASH to
provide i n p a t i e n t care and treatment of i n d i v i d u a l s w i t h mental
disorders, p e r s o n a l i t y d i s o r d e r s , or emotional c o n d i t i o n s . ASH receives
p a t i e n t s on b o t h a voluntary and i n v o l u n t a r y b a s i s . Approximately 20
percent of the p a t i e n t s are v o l u n t a r i l y admitted. The remaining 80
percent are committed by courts t h a t have determined them to be a danger
to themselves or to others, or g r a v e l y d i s a b l e d , and who are u n w i l l i n g or
unable to undergo a v o l u n t a r y e v a l u a t i o n . During f i s c a l year 1987- 88,
ASH provided treatment to 1,242 p a t i e n t s , and had an average d a i l y census
of 528 p a t i e n t s .
ASH has developed separate care and treatment programs i n order to
accommodate varying p a t i e n t c l i n i c a l needs. Each treatment program i s
s t a f f e d by p s y c h i a t r i s t s , medical s p e c i a l i s t s , psychologists, nurses,
p s y c h i a t r i c technicians, s o c i a l workers, r e h a b i l i t a t i o n t h e r a p i s t s , and
a u x i l i a r y c l i n i c a l s t a f f . The treatment programs are as f o l l o w s :
a General Adult Program - Treats approximately 100 p a t i e n t s and
provides admission and diagnostic assessment s e r v i c e s . P a t i e n t s i n
t h i s program are expected to have lengths of stay of 90 days o r l e s s .
a Psycho- Social Rehabilitation Program - Provides care for
approximately 100 p a t i e n t s w i t h chronic, longer term mental
disorders. P a t i e n t s i n t h i s program tend to have longer periods of
h o s p i t a l i z a t i o n ( 90 to 365 days) and require more s t r u c t u r e d
a f t e r c a r e .
a Behavior Management Program - Serves approximately 75 p a t i e n t s w i t h
recent h i s t o r i e s o f dangerous behavior, those believed to be
dangerous w i t h a high- escape r i s k , and those p a t i e n t s committed by
the courts for observation and/ or treatment because they were
determined to be not g u i l t y by reason o f i n s a n i t y .
e Youth Services Program - Designed for c h i l d r e n and adolescents ages
6 to 17 who require intermediate term care as a r e s u l t of a
s u b s t a n t i a l mental d i s o r d e r . There are approximately 24 p a t i e n t s i n
t h i s program.
a Gero- Psychiatry Program - Provides treatment to meet the special
needs of approximately 125 e l d e r l y p a t i e n t s w i t h severely d i s a b l i n g
mental and physical d i s o r d e r s .
0 Extended Care Program - Provides care to approximately 100 patients
who require a lengthy h o s p i t a l i z a t i o n of 180 days or more. Emphasis
i s placed on d a i l y l i f e s k i l l s as many patients s u f f e r from
coexistent organic mental disturbances such as a head i n j u r y , mental
r e t a r d a t i o n , o r s t r o k e .
Progress i n recent years - During our a u d i t , we i d e n t i f i e d several
noteworthy improvements made at ASH over the past few years.
0 Establishment of a C h i l d r e n ' s Treatment u n i t i n 1987 provided beds
for 8 c h i l d r e n . P r e v i o u s l y , c h i l d r e n under the age of 12 could not
obtain i n p a t i e n t treatment at ASH.
0 I n i t i a t i o n o f a program for the d u a l l y diagnosed mentally
ill/ developmentally disabled p a t i e n t s i n January 1988. As a r e s u l t
of t h i s program, previously " undischargeable" p a t i e n t s have been
placed i n t ~ co mmunity s e t t i n g s .
a Expansion of the h o s p i t a l ' s Chemical Dependency I n p a t i e n t Program for
f i s c a l year 1987- 88. This program provides i n t e r v e n t i o n and
treatment for any i n d i v i d u a l i d e n t i f i e d as s u f f e r i n g from a substance
abuse problem as well as a mental d i s o r d e r .
0 ASH took a leadership rote i n the implementation of P s y c h i a t r i c
Health F a c i l i t i e s ( PHFs). These f a c i l i t i e s provide acute short- term
treatment i n non- hospital s e t t i n g s . Such f a c i l i t i e s allow
i n d i v i d u a l s t o receive treatment i n t h e i r local area, r e i n f o r c e
family involvement i n p a t i e n t care, and approach a l t e r n a t i v e s t o
h o s p i t a l i z a t i o n i n a more cost e f f i c i e n t manner. C u r r e n t l y , there
are two PHFs open i n northern Arizona, each w i t h a 5- bed capacity.
Two a d d i t i o n a l PHFs w i l l be open i n e a r l y FY 1989- 90, also i n
northern Arizona.
a ASH, i n conjunction w i t h c~ mmunity behavioral healthcare programs,
developed a new concept for those c l ients who have been at ASH, but
who require a more structured environment than establ ished
resident i a I programs. These Reentry Faci I i t i e s ( REFS) w i l l a1 low
c l i e n t s
program
s e t t i n g .
Mar i copa
to reenter the community and progress i n t h e i r treatment
i n a more i n d i v i d u a l i z e d and c l i e n t o r i e n t e d r e s i d e n t i a l
There are c u r r e n t l y 47 REF beds a v a i l a b l e i n Arizona, 32 i n
County and 15 i n Pima County.
S t a f f i n g and Budget
ASH was allocated 945.25 f u l l - t i m e equivalent employees ( FTEs) for f i s c a l
year 1988- 89. ASH'S current s t a f f i n g increased by 72 p o s i t i o n s from
f i s c a l year 1987- 88. The a d d i t i o n a l p o s i t i o n s were a l l o c a t e d as part of
a special a p p r o p r i a t i o n i n an e f f o r t to regain medicare c e r t i f i c a t i o n ,
and to provide b e t t e r s e r v i c e t o p a t i e n t s . Nearly 70 percent of those
s p e c i a l l y appropriated p o s i t i o n s were d i r e c t care nursing s t a f f . In
a d d i t i o n , ASH has been able to increase i t s contracted medical s t a f f .
The number of p s y c h i a t r i s t s was increased to 16 from 9 i n previous
years. F u r t h e r , t h e r e are c u r r e n t l y 6 non- psychiatric medical physicians
compared to 4.5 i n 1987.
ASH receives funding from several d i f f e r e n t sources. ASH received
$ 33,330,390 i n funding for f i s c a l year 1988- 89. General fund
appropriations account for over 80 percent of ASH'S revenues. A d d i t i o n a l
operating funds are received from special a p p r o p r i a t i o n s , s e r v i c e
agreements w i t h other State agencies, r e n t a l income, endowment earnings,
p a t i e n t b e n e f i t fund, and donations. The h o s p i t a l ' s statement of FTEs
and actual and budgeted expenditures for f i s c a l years 1986- 87
through 1988- 89 are shown i n Table 1 ( see page 4).
Scope and Met hod0 l ogy
The audit contains f i n d i n g s i n four major areas:
0 ASH'S a b i l i t y t o s t a f f i t s treatment u n i t s with e x i s t i n g s t a f f
a The adequacy of the current management s t r u c t u r e of treatment
programs and uni t s at ASH
0 The adequacy o f food service planning and serving a t ASH and
0 The u t i l i z a t i o n of ASH'S T r a n s i t i o n a l L i v i n g Unit
TABLE 1
DEPARTMENT OF HEALTH SERVICES - ARIZONA STATE HOSPITAL
STATEMENT OF FTEs AND ACTUAL AND BUDGETED EXPENDITURES
FISCAL YEARS 1986- 87 THROUGH 1988- 89
( unaud i ted)
1986- 87 1987- 88 1988- 89
( Actual) ( Actual) ( Budgeted )
FTEs 926.00 874.25 945.25
Personal se rv i ces $ 16,670,947 $ 17,101 ,726
Employee- related 4,397,050 4,341 ,227
P r o f . & outside services 1 ,986,933 2,026,907
Travel, in- state 36,273 43,195
out- of- state 1,102 - 0-
Food 1 ,858,270 1 ,905,003
Aid to i n d i v i d u a l s 4,270 14,635
Other operating 2,614,774 2,565,051
Capital outlay 306,342 . 94,089
TOTAL $ 27.875.961 $ 28.091 ,833 $ 32.161 ,711
Source: Arizona Financial Information Systems and Department of Health
Services Budget Performance Reports
In a d d i t i o n , we conducted an o r g a n i z a t i o n a l c l i m a t e survey of a l l current
ASH nursing s t a f f to determine t h e i r s a t i s f a c t i o n w i t h employment. Four
hundred seventy surveys were mai led out . We received 235 responses,
r e s u l t i n g i n a response rate of 50 percent. Detailed information about
the survey i s found i n the appendix.
Due to time c o n s t r a i n t s , we were unable to address three p o t e n t i a l issues
i d e n t i f i e d during our audit work. Additional information regarding these
areas i s provided i n the section Areas for Further Audit Work ( page 51).
This audit was conducted i n accordance w i t h generally accepted
governmental a u d i t i n g standards.
The Auditor General and s t a f f express appreciation to the Director of the
Department o f Health Services, and to the Superintendent and s t a f f of the
Arizona S t a t e H o s p i t a l for t h e i r cooperation and assistance throughout
our a u d i t .
FINDING I
BECAUSE OF EXTREME STAFFING PROBLEMS. ASH HAS
DIFFICULTY PROVIDING ADEQUATE STAFF ON ITS TREATMENT UNITS
Arizona S t a t e H o s p i t a l ( ASH) has d i f f i c u l t y p r o v i d i n g adequate s t a f f on
i t s treatments u n i t s due to i t s extreme s t a f f i n g problems. Shortages of
s t a f f are a common occurrence on the treatment u n i t s . These shortages
stem from the h o s p i t a l ' s high turnover and extended vacancies. In i t s
e f f o r t s t o ensure s u f f i c i e n t s t a f f on the u n i t s , ASH has a c t u a l l y
perpetuated the shortages. F u r t h e r , the work environment also takes a
t o l l on s t a f f leading to turnover. Because some of these problems are
deep- rooted and complex, the h o s p i t a l cannot be expected to resolve them
q u i c k l y ; however, ASH should begin taking c o r r e c t i v e a c t i o n s .
S t a f f Shortages E x i s t
on Treatment Units
ASH's treatment u n i t s are f r e q u e n t l y s h o r t of s t a f f . Because of the
types of p a t i e n t s the h o s p i t a l i s d e a l i n g w i t h , i t i s important to have
s u f f i c i e n t numbers of s t a f f on the treatment u n i t s . We attempted to
analyze ASH's s t a f f i n g l e v e l s , but no n a t i o n a l standards e x i s t f o r
comparison purposes. However, h o s p i t a l nursing s t a f f have commented that
current s t a f f l e v e l s do n o t p r o v i d e for employee s a f e t y . l n
a d d i t i o n , our analysis of the h o s p i t a l ' s i n t e r n a l s t a f f i n g g u i d e l i n e s
i n d i c a t e s t h a t the u n i t s a r e f r e q u e n t l y s t a f f e d w i t h only the minimum
l e v e l s of s t a f f r e q u i r e d .
H o s p i t a l cares f o r d i f f i c u l t - t o - m a n a g e p a t i e n t s - Adequate s t a f f on the
treatment u n i t s i s important because of the types o f p a t i e n t s t h a t are
cared f o r at ASH. By law, ASH t r e a t s p a t i e n t s who are a danger to
themselves, a danger t o o t h e r s , or who are gravely d i s a b l e d . Thus, s t a f f
a r e d e a l i n g w i t h i n d i v i d u a l s who may have s u i c i d a l or homicidal
tendencies, who may have h a l l u c i n a t i o n s , who may have d i f f i c u l t y
understanding r e a l i t y , and who may have d i f f i c u l t y attending to
( I ) Nursing s t a f f a t ASH includes p s y c h i a t r i c nurse managers ( PNMs), p s y c h i a t r i c nurse
s h i f t supervisors ( PNSS), registered nurses ( RNs), p s y c h i a t r i c 1 icensed p r a c t i c a l
nurses ( LPNs), p s y c h i a t r i c nurses ( PNs), and p s y c h i a t r i c technicians ( PTs).
a c t i v i t i e s of d a i l y l i v i n g , such as grooming, bathing, and dressing.
No national s t a f f i n g standards a r e a v a i l a b l e - During our a u d i t , we
contacted several professi'onal assoc i a t ions for the i r recommendat ions
concerning nursing care s t a f f i n g . ( ' I However, we discovered no
national standards to use for comparison. The requirements from the
Department of Health and Human Services, Health Care Financing
Administration and the J o i n t Commission on the A c c r e d i t a t i o n of Health
Care Organization ( JCAHO) are, according to a national expert, that
s t a f f i n g be " minimally acceptable for safe care." However, these
requirements do not give s p e c i f i c guidance to s t a f f i n g needs. Although
there have been some court cases that have s p e c i f i e d s t a f f i n g r a t i o s ,
those cases are s p e c i f i c t o t h e i r s t a t e mental health care systems and
may not be a p p l i c a b l e f o r other s t a t e h o s p i t a l s .
Hospital s t a f f b e l i e v e s t a f f i n g levels are inadequate - Nursing s t a f f
have s t a t e d t h a t s t a f f i n g on the treatment u n i t s i s not s u f f i c i e n t . The
p s y c h i a t r i c nurse managers ( PNMs) have 24- hour a d m i n i s t r a t i v e
r e s p o n s i b i l i t y over nursing s t a f f on t h e i r u n i t s . During our interviews
w i t h PNMs, frequent examples were provided regarding the need for more
s t a f f . Examples of concerns expressed by PNMs i n interviews include:
e One PNM complained that w i t h only 6 s t a f f working on the u n i t , one RN
i s kept busy a l l day doing s t a f f i n g s ( p a t i e n t conferences), one LPN
i s kept busy a l l day w i t h medications and orders, and two to three of
the p s y c h i a t r i c technicians are frequently o f f the u n i t on escorts,
which may leave only two p s y c h i a t r i c technicians to monitor the u n i t
w i t h a census of 32 p a t i e n t s .
e Another PNM i n d i c a t e d t h a t her s t a f f i n g level of 6 was adequate for a
p a t i e n t census be low 30; however, her census range i s 41 to 47. The
p a t i e n t s on t h i s u n i t are s t i l l being evaluated and s t a b i l i z e d and
thus s t i l l display wide ranges of psychotic behavior.
A d d i t i o n a l l y , s t a f f i n g levels on the night s h i f t s appeared to be a major
concern of the PNMs. The f o l l o w i n g examples h i g h l i g h t these concerns:
0 One PNM of a g e r i a t r i c p s y c h i a t r i c u n i t of difficult- to- manage
patients stated that two persons cannot get 31 c h r o n i c a l l y mentally
( 1 ) Among t h e p r o f e s s i o n a l o r g a n i z a t i o n s contacted were: The American Hospital
Association, the American P s y c h i a t r i c Association, the National A l l iance f o r the
Mentall y 111, the American Nursing Association, and the National I n s t i t u t e o f
Mental Heal t h .
6
and p h y s i c a l l y i l l p a t i e n t s up, cleaned, diapered, and dressed i n the
a l l o t t e d two- hour timespan. Our observations of the g e r i a t r i c
p s y c h i a t r i c u n i t s found that many of these p a t i e n t s were t o t a l l y
dependent on s t a f f for complete care. For example, many of the
p a t i e n t s require l i f t i n g from t h e i r beds i n t o a wheelchair.
a A PNM of a general adult u n i t w i t h 25 p a t i e n t s s t a t e d t h a t two s t a f f
i s not enough to handle a medical o r a p s y c h i a t r i c emergency.
a Another PNM stated that using two people to s t a f f a p a t i e n t u n i t i s
dangerous. During our observations, we noted that because of the
physical design of many u n i t s , s t a f f are frequently out o f each
others eyesight. This could make i t d i f f i c u l t for s t a f f to know that
another s t a f f member i s i n need of assistance. Further, w i t h only
two s t a f f on a u n i t , i f a p a t i e n t became v i o l e n t we agree that i t
would be d i f f i c u l t to both r e s t r a i n the p a t i e n t and c a l l for
assistance.
Unit s t a f f have a l s o i n d i c a t e d t h a t shortages e x i s t , and that these
shortages cause unsafe working conditions. In a survey conducted by our
o f f i c e , 71 percent of the respondents disagreed w i t h the statement that
s t a f f i n g on t h e i r u n i t was adequate to provide s a f e t y f o r
employees. "' Further, i n response to the question " What do you
consider the biggest problem on your job?," the most common answer was
inadequate s t a f f i n g on the u n i t s . In a d d i t i o n , during the period of June
1987 through November 1988, 204 complaints were sent to the
superintendent from nursing s t a f f regarding unsafe working conditions due
to s t a f f shortages.
F i n a l l y , the Department o f Health and Human Services, Healthcare
Financing Administrat i o n ( HCFA) surveyors noted that the h o s p i t a l I s
s t a f f i n g needs are o n l y m a r g i n a l l y met. HCFA i s responsible for
overseeing h o s p i t a l s t h a t receive Medicare reimibursements. To ensure
that h o s p i t a l s meet minimum standards, HCFA conducts p e r i o d i c surveys.
In a recent survey of the h o s p i t a l , i t was noted that although the
h o s p i t a l had increased i t s s t a f f , the current number of licensed nurses
only marginally meets minimal s t a f f i n g standards. The surveyors stated
that they had to combine a l l classes of RN's ( permanent, l i m i t e d , and
seasonal) i n order to b r i n g the h o s p i t a l i n t o compliance w i t h the
standards.
( 1 ) We surveyed a l l e x i s t i n g nursing s t a f f employed a t ASH as of February 8, 1989. O f
the 470 surveys mailed, we received 235 surveys ( 50 % response r a t e ) . See Appendix
f o r r e s u l t s .
7
Hospital i s o f t e n s t a f f e d only a t minimum levels - Although the
h o s p i t a l has developed minimum guidelines for s t a f f i n g the u n i t s , these
guidelines a r e n ' t considered adequate. Minimum guidelines were
established by nursing a d m i n i s t r a t i o n i n September 1988 to represent the
s t a f f i n g necessary to provide for the care of p a t i e n t s . The minimum
guidelines suggest the least number of nursing s t a f f which should be
assigned to each u n i t by s h i f t i n order to provide p a t i e n t care. The
s t a f f i n g o f f i c e uses these guidelines i n i t s d a i l y s t a f f i n g of the
u n i t s . However, during our interviews, many nursing s t a f f at a l l levels
commented on the inadequacy of the g u i d e l i n e s . A m a j o r i t y of the PNMs
s t a t e d t h a t the minimum guidelines were inadequate and, as previously
mentioned, nursing s t a f f f e l t that the current s t a f f i n g levels did not
provide safe working conditions.
While the guidelines were meant to g i v e o n l y minimum levels of s t a f f
needed, the h o s p i t a l i s s t a f f e d at or below these levels two- thirds of
the time. Based on our analysis of actual s t a f f worked for January 1989,
we found that ASH just met the guidelines 57 percent of the time, and
f e l l below t h e i r own minimum standards almost 8 percent of the time.
Further review showed that 7 u n i t s were s t a f f e d below t h e i r minimum over
10 percent of the time w i t h one u n i t s t a f f e d below i t s minimum as much as
23 percent of the time.
Shortages Stem From
Turnover and Vacancies
S t a f f i n g shortages on the u n i t s e x i s t due to excessive turnover and
lengthy vacancies. The turnover rate among nursing s t a f f at ASH i s
extreme. Based on a review of nursing s t a f f terminations for a recent
6- month period, we estimated an annual turnover r a t e o f nearly 50 percent
for both licensed ( RN and LPN) and nonlicensed ( p s y c h i a t r i c technician)
nursing s t a f f . ' " The turnover r a t e f o r one group, LPNs, was
( ' 1 We c o l l e c t e d nursing s t a f f termination data f o r the period of August 2, 1988 t o
January 27, 1989. The data was annualized f o r comparison purposes. Other studies
have also found high turnover. The Department of Admini s t r a t i o n ' s S t a t e s e r v i c e
turnover r e p o r t f o r t h e p e r i o d of July 1988 - December 1988, revealed an
annualized turnover r a t e o f 45 percent f o r Psychiatric Technician I ' s , 21 percent
f o r P s y c h i a t r i c Nurse 11' s and 38 percent f o r P s y c h i a t r i c Nurse s h i f t supervisors.
estimated to be as high as 75 percent.
Vacancies also remain open for extended periods. An analysis of nursing
p o s i t i o n s becoming vacant i n the current f i s c a l year ( 283 t o t a l ) showed
that RN p o s i t ions remained vacant for an average of 40 calendar days and
LPN p o s i t i o n s were vacant an average of 75 days. "' The p s y c h i a t r i c
technician p o s i t i o n s remained vacant for an average of 35 days before
being f i l l e d .
As a r e s u l t o f high turnover and extended vacancies, the h o s p i t a l
operates w i t h a large number of u n f i l l e d p o s i t i o n s . For example, an
A p r i l 7, 1989, vacancy report shows that of the 488 nursing p o s i t i o n s , 79
( or 16 percent) were u n f i l l e d .
E f f o r t s t o Ensure S u f f i c i e n t Numbers
o f S t a f f Contribute to Turnover
In i t s e f f o r t s to ensure that the u n i t s are s t a f f e d at t h e i r minimum
l e v e l s , ASH has a c t u a l l y perpetuated i t s shortages. Because ASH has
problems w i t h i t s scheduling, permanent nursing s t a f f are p u l l e d from
t h e i r r e g u l a r l y assigned u n i t s to cover for s t a f f needs on other u n i t s .
In order to avoid being f l o a t e d , s t a f f frequently c a l l i n s i c k , thus
causing more s t a f f i n g shortages. Further, some s t a f f become so
d i s s a t i s f i e d with f l o a t i n g that they q u i t , causing s t i l l more vacancies.
ASH has problems w i t h scheduling nursing s t a f f - The r e s p o n s i b i l i t y for
scheduling i s divided between the treatment u n i t s and the s t a f f i n g
o f f i c e . The PNMs of each u n i t are responsible for preparing monthly
schedules and submitting them to the s t a f f i n g o f f i c e . When submitted,
these schedules should deploy s t a f f to provide at least the minimum
coverage on each s h i f t . However, the schedules prepared by the PNMs do
not ensure a l l s h i f t s are covered. For example, i n January 1989, the 16
u n i t s averaged 12 s h i f t s where the numbers of s t a f f scheduled f e l l below
the minimum guide1 ine.
One reason for uncovered s h i f t s i s the attempt to give s t a f f at least one
( ' 1 We analyzed a l l nursing p o s i t i o n s t h a t became vacant between J u l y 1 , 1988 and March
24, 1989.
9
weekend day o f f . As a r e s u l t , more s t a f f are scheduled to work on
Tuesday, Wednesday, and Thursday than on the other days. Fewer s t a f fare
scheduled on Monday and Friday and only minimal s t a f f on the weekends i n
attempts to give s t a f f a Friday/ Saturday, Saturday/ Sunday, or
Sunday/ Monday combination of days o f f . In a d d i t i o n , some s h i f t s are more
frequently understaffed than others. For example, one u n i t we reviewed
had a t o t a l of 35 s h i f t s scheduled below the minimum levels - 9 on days,
2 on evenings, and 24 on n i g h t s .
Another problem i s the submission of incomplete schedules. One u n i t ' s
night s h i f t schedule was submitted w i t h only the f i r s t 15 days assigned.
The remainder of the month was l e f t incomplete. Another u n i t had no
nurse coverage scheduled for Fridays or Saturdays. The s t a f f i n g
coordinator explained that when schedules are submitted w i t h such blanks,
i t may be due to u n f i l l e d vacancies, extended leave, or bad scheduling.
S t a f f are frequently floated to cover shortages - Once schedules are
submitted, the s t a f f i n g o f f i c e i s responsible for f i n d i n g coverage for
s h i f t s which do not have enough s t a f f to meet t h e i r minimum g u i d e l i n e s .
This i s frequently done by f l o a t i n g s t a f f . ' " F l o a t i n g i s a term
frequently used at ASH to describe the p u l l i n g o f s t a f f from t h e i r
r e g u l a r l y assigned u n i t to another u n i t where a d d i t i o n a l s t a f f are
needed. Based on our analysis of the s t a f f i n g p a t t e r n for January 1989,
f l o a t i n g i s a frequent occurrence. For example, an average of 12 s t a f f
per day were floated during January. ( However, an improvement was seen
i n A p r i l , with an average of 8 s t a f f floated per day.) S p e c i f i c u n i t s
may be p a r t i c u l a r l y impacted by f l o a t i n g . Nine of the 17 u n i t s f l o a t e d
20 or more s t a f f to other u n i t s during January, and one u n i t f l o a t e d as
many as 62 s t a f f . ASH managemen t has recogn i zed that f l oat i ng i s a
problem and has established a committee to recommend s o l u t i o n s to reduce
the level of f l o a t i n g .
Frequent f l o a t i n g causes sick leave abuse - To avoid being f l o a t e d ,
s t a f f frequently c a l l i n s i c k , thus increasing the u n i t shortages.
( 1 While the s t a f f i n g o f f i c e has a1 t e r n a t i v e s a v a i l a b l e , such as an in- house pool
and nursing r e g i s t r y funds, f l o a t i n g i s the most commonly used method t o cover
f o r nursing shortages.
Several nurse managers have stated that frequent f l o a t i n g r e s u l t s i n s i c k
leave abuse. Nursing o f f i c i a l s report that s t a f f have become too i l l
towork a f t e r being t o l d that they would have to f l o a t . A nursing
a d m i n i s t r a t o r r e p o r t s t h a t s t a f f w i l l look at the schedule to determine
when t h e i r u n i t i s s t a f f e d above the minimum, and c a l l i n s i c k t o avoid
f l o a t i n g . During March 1989, there were 797 sick c a l l s , w i t h a high of
41 c a l l s i n one day. Such heavy use of sick leave can s i g n i f i c a n t l y
a f f e c t s t a f f i n g needs.
Frequent f l o a t i n g c o n t r i b u t e s t o turnover - According to a nursing
s t a f f employee survey conducted by our o f f i c e , nearly 90 percent of the
respondents indicated that f l o a t i n g negatively impacts turnover.
Further, 96 percent of the respondents i n d i c a t e d t h a t f l o a t i n g has a
negative mpact on morale at ASH."' Our survey i n d i c a t e d t h a t s t a f f
resent having to f l o a t to other u n i t s . I n f a c t , 79 percent of the survey
respondents i n d i c a t e d t h a t they would not be w i l l i n g to f l o a t to other
u n i t s on a regular basis, and nearly 20 percent stated that they would be
u n w i l l i n g t o f l o a t even i n emergency s i t u a t i o n s .
S t a f f s ' strong negative reaction t o f l o a t i n g i s l i k e l y due to the impact
of f l o a t i n g on t h e i r work. When f l o a t e d , s t a f f become less e f f e c t i v e
than r e g u l a r l y assigned s t a f f . S t a f f who have been p u l l e d from t h e i r
regular u n i t to work on another u n i t may not know the p a t i e n t s and are
less l i k e l y to recognize changes i n p a t i e n t behavior quickly enough to
intervene before a serious episode occurs. Moreover, since procedures
vary by treatment program, floated s t a f f may be unfami I i a r w i t h
procedures used on the u n i t . S t a f f members have stated that " when you
f l o a t , you don' t know what to do ," and that " we do not know the schedule
or the r o u t i n e . " Further, p a t i e n t s on two u n i t s s u f f e r when s t a f f are
floated to a d i f f e r e n t u n i t . A s t a f f person has assigned d u t i e s and
patients on t h e i r regular u n i t . However, when that s t a f f person i s
floated, those patients do not have a primary care p r o v i d e r . As a
r e s u l t , other s t a f f , who have t h e i r own r e s p o n s i b i l i t i e s , must attempt to
cover . In a d d i t i o n , special assignments, p a t i e n t p r i v i l e g e s , and
programs may be cancelled when s t a f f are f l o a t e d .
( 1 I n a d d i t i o n , approximately 80 percent o f the survey respondents disagreed w i t h
the statement that morale a t ASH i s high.
11
Work Environment Leads
t o S t a f f Turnover
Turnover i s f u r t h e r aggravated by the work environment to which s t a f f are
subjected. Survey r e s u l t s and a d d i t i o n a l w r i t t e n comments from s t a f f
i n d i c a t e that there may be supervisory problems at ASH. Further, ASH
lacks adequate s a l a r i e s and promotional o p p o r t u n i t i e s to e n t i c e s t a f f to
stay.
Many s t a f f d i s s a t i s f i e d w i t h supervisors - Results of our survey
i n d i c a t e that ASH may have problems w i t h some of i t s s t a f f supervisors.
Nearly 30 percent of the respondents indicated a lack of confidence i n
t h e i r superiors' a b i l i t i e s . Further, 87 of the 235 employees who
responded to the survey provided w r i t t e n comments i n d i c a t i n g supervisory
problems on the treatment u n i t s . These comments were s p e c i f i c to poor
management, fear of r e t a l i a t i o n by t h e i r supervisors, u n f a i r h i r i n g and
evaluations, and f a v o r i t i s m shown by supervisors to c e r t a i n s t a f f .
S t a f f d i s s a t i s f i e d w i t h salary and promotional o p p o r t u n i t i e s - I n
a d d i t i o n t o problems w i t h supervision, many nursing s t a f f commented that
ASH provides l i m i t e d salary increases and lacks promotional
o p p o r t u n i t i e s . Approximately 69 percent of the survey respondents
disagreed that t h e i r s a l a r i e s were adequate, and nearly 40 percent l i s t e d
inadequate pay as a primary cause of turnover. In a d d i t i o n , 45 percent
disagreed with the statement that there are o p p o r t u n i t i e s f o r advancement
at ASH.
ASH Needs t o Take Act ions
To Address S t a f f i n g Problems
Because some of these prob lems are deep- rooted and complex, the hospi t a l
cannot be expected to resolve them q u i c k l y ; however, ASH should begin
taking c o r r e c t i v e a c t i o n s . Immediate actions need to be taken to
address problems w i t h f l o a t i n g , supervision, and salary/ promotional
o p p o r t u n i t i e s . F u r t h e r , ASH should consider a study to determine i t s
long- term s t a f f i n g needs.
ASH'S problems are deep rooted and complex - During our audi t , we found
i t d i f f i c u l t to separate ASH'S s t a f f i n g problems and address them
i n d i v i d u a l l y . This i s because of the complex i n t e r r e l a t i o n s h i p of the
s t a f f i n g problems. Figure 1 d e t a i l s t h e complexity of the s t a f f i n g
problems. This emphasizes the need for ASH to take an o v e r a l l look at
i t s s t a f f i n g problems, rather than attempting to implement c o r r e c t i o n s on
a p i ecemea l bas i s
Figure 1
INTERRELATIONSHIP OF STAFFING
PROBLEMS AT ASH
STAFF SHORTAGES
T u R i v m , )
LOW MORALE
FLOATING SICK LEAVE - - ABUSE
ASH needs to take immediate a c t i o n s - In order to address i t s s t a f f i n g
problems, ASH needs to take actions to reduce f l o a t i n g , improve
supervision, and to provide salary increases and promot ional
opportunities for i t s employees.
8 F l o a t i n g - ASH can reduce f l o a t i n g by c e n t r a l i z i n g the scheduling
process i n t o one area o f r e s p o n s i b i l i t y and implementing an automated
scheduling system. By c e n t r a l i z i n g the scheduling process, ASH could
eliminate duplicated e f f o r t on the part of the PNMs, allowing them
more time i n the d i r e c t supervision of t h e i r u n i t s . I t would also
prevent the s t a f f i n g o f f i c e from reworking 17 d i f f e r e n t schedules in
order to ensure adequate s t a f f throughout the h o s p i t a l . According to
area h o s p i t a l s we contacted, automated scheduling systems which can
be used f o r c e n t r a l i z e d scheduling can be purchased for approximately
$ 25,000.
In implementing a new scheduling process, ASH should consider
expanding the use o f f l e x i b l e scheduling o f s t a f f for hard to cover
s h i f t s . For example, one PNM s t a t e d t h a t a d d i t i o n a l help i s needed
during the e a r l y mornings from 5: 00 to 7: OO. Implementation of
10- hour s h i f t s could a s s i s t those u n i t s . In a d d i t i o n , 12- hour
s h i f t s , as used i n other h o s p i t a l s , might be considered for weekend
coverage when s t a f f i n g i s minimal and sick c a l l s can r e s u l t i n use of
expensive r e g i s t r y time or use of the demoralizing f l o a t i n g .
0 Supervision - ASH can improve supervision by providing a d d i t i o n a l
t r a i n i n g for i t s supervisors. ASH supervisors have suffered from a
lack of supervisory t r a i n i n g . Although 14 supervisory t r a i n i n g
cIasses( 1) are provided to ASH supervisors, a review of class
attendance sheetsc2) revealed t h a t not a l I nursing supervisors
have attended a l l classes. For instance, 13 of the 17 PNMs attended
8 or fewer o f the 14 classes a v a i l a b l e . Only 19 of the 32 s h i f t
supervisors attended the supervisory t r a i n i n g .
8 Salary and Promotional Opportunities -- ASH can improve morale by
p r o v i d i n g s a l a r y increases and promotional o p p o r t u n i t i e s . Our survey
resul t s showed that the p s y c h i a t r i c technician posi t ions were most
d i s s a t i s f i e d w i t h t h e i r s a l a r i e s . C u r r e n t l y , according to a DOA
o f f i c i a l , the s a l a r y f o r an entry level p s y c h i a t r i c technician i s
$ 13,660, and a p s y c h i a t r i c technician l 1' s beginning salary i s
$ 14,862. Although State Personnel reviewed the ASH p s y c h i a t r i c
( 1 ) Supervisory t r a i n i n g classes are o f f e r e d through the C e r t i f i e d Pub1 i c Manager
program t h a t i s conducted by the DHS- Staff Development and T r a i n i n g section.
These classes generally l a s t a l l day and may cover two to t h r e e s u b j e c t s p e r
class.
( 2) We reviewed attendance sheets f o r the C e r t i f i e d Public Manager program f o r the
period o f August 4, 1988, through May 8, 1989.
technician s a l a r i e s l a s t spring and found the salary ranges were
adequate, the D i r e c t o r o f DHS notes that the lack of merit pay or
cost of l i v i n g increases over the past few years has resulted i n many
s t a f f being " frozen" at the lower end of these salary ranges.
ASH also lacks adequate promotional o p p o r t u n i t i e s for i t s p s y c h i a t r i c
technicians. C u r r e n t l y , there are f o u r p s y c h i a t r i c technician levels
and 346 p s y c h i a t r i c technician p o s i t i o n s hospital- wide. However,
approximately 50 percent of the p o s i t i o n s a r e l e v e l I ' s , and nearly
30 percent are level 11' s. F u r t h e r , o p p o r t u n i t i e s for promotion to
higher l e v e l s a r e l i m i t e d . Promotion to a l e v e l I I p o s i t i o n i s
l i m i t e d to when a vacancy occurs. Promotion t o a level I l l p o s i t i o n
generally r e q u i r e s a t r a n s f e r to a f o r e n s i c u n i t - something many
s t a f f may not be w i l l i n g to do. Promotion to a l e v e l I V i s
p a r t i c u l a r l y l i m i t e d because only 8 such p o s i t i o n s e x i s t i n the
hospital .
ASH could r e c l a s s i f y i t s p s y c h i a t r i c p o s i t i o n s t o p r o v i d e more of a
career ladder. According to the d i r e c t o r of nursing, i n p r a c t i c e ,
there i s very l i t t l e d i f f e r e n c e between the functions of a l e v e l I
and a level I I . He said that the main d i f f e r e n c e i s that a l e v e l I I
has more experience than a level I . Furthermore, the d i r e c t o r of
nursing f e l t that i f ASH could provide more level 1 1 p o s i t i o n s , s t a f f
morale would improve and s t a f f could promote w i t h i n t h e i r own u n i t or
program. According to a DOA personnel s p e c i a l i s t , ASH could
r e c l a s s i f y i t s p s y c h i a t r i c technician p o s i t i o n s , thus p r o v i d i n g more
of a career ladder.
ASH needs to conduct a study of i t s s t a f f i n g needs - In order to
overcome the problem of chronic shortages of s t a f f on the treatment
u n i t s , ASH should conduct a comprehensive study to determine i t s s t a f f i n g
needs. As mentioned p r e v i o u s l y , ASH r e l i e s on minimum guidelines to
s t a f f i t s u n i t s , and these guidelines are f e l t to be i n s u f f i c i e n t by most
nursing s t a f f . C u r r e n t l y , ASH does not have a v a l i d method to determine
i t s overal l s t a f f i n g needs.
A lack of national standards was, i n p a r t , the impetus for several states
to undertake t h e i r own s t a f f i n g s t u d i e s . We obtained information from
both F l o r i d a and Maryland which have recently conducted s t a f f i n g studies
for t h e i r state h o s p i t a l s . The F l o r i d a study was conducted under a
5- month contract for the F l o r i d a Department of Health and R e h a b i l i t a t i v e
Services. The $ 80,000 contract provided for s t a f f from the U n i v e r s i t y of
F l o r i d a and for part- time n a t i o n a l c o n s u l t a n t s . The Maryland Department
of Health and Mental Hygiene obtained a $ 100,000 federal grant and
u t i l i z e d state employees d u r i n g a two- year s t a f f i n g study. Both studies
considered such factors as:
0 An assessment of p a t i e n t needs,
a A computation o f the tasks performed by each d i s c i p l i n e of s t a f f ,
0 A measurable statement o f what p a t i e n t treatment i s supposed to
ach i eve,
r A survey of any b a r r i e r s that would prevent p a t i e n t s from being
discharged, and
r Time and motion studies to determine the length of time usually taken
to accomplish p a t i e n t r e l a t e d a c t i v i t i e s .
ASH conducted i t s own study i n 1987. However, the study was not
s u f f i c i e n t l y comprehensive to f u l f i l l the h o s p i t a l ' s needs. Although
information was gathered, t h i s study did not include c r i t i c a l components
for a comprehensive study such as an analysis of postcoverage
requirements, p a t i e n t s ' needs, and s t a f f r o l e s .
Although ASH has h i r e d a consultant to review i t s current s t a f f i n g , the
type of study needed may again requi re more time and resources than ASH
has committed. The c o n s u l t a n t ' s report i s to be completed i n l a t e
October or e a r l y November 1989. Included i n the request for proposal for
the c o n s u l t a n t ' s services i s the development of s t a f f i n g models for a l l
c l i n i c a l care, support and a d m i n i s t r a t i v e s t a f f , as well as s p e c i f i c
recommendations for the automation of s t a f f scheduling, the monitoring of
s t a f f u t i l i z a t i o n , and s p e c i f i c s t a f f i n g standards. The t o t a l cost of
the study w i l l be $ 8,950. Although t h i s report w i l l provide information
to h o s p i t a l a d m i n i s t r a t i o n regarding s t a f f i n g needs, given the time and
money committed for t h i s study, we are not sure that i t w i l l provide the
comprehensive information needed to make long- term s t a f f i n g decisions.
As noted earl i e r , other states have expended considerably more monies to
h i r e consultants to conduct comprehensive studies o f t h e i r needs, and
these studies were not as broadly defined as what ASH i s proposing.
1. ASH should c e n t r a l i z e the scheduling function w i t h i n the s t a f f i n g
o f f i c e .
2. ASH should determine the system needed to automate i t s scheduling
function, and request funds for t h i s purpose. The system should take
i n t o account the a c u i t y on the u n i t s , the u n i t s ' census, and
a c t i v i t i e s scheduled on the u n i t s i n order to ensure adequate s t a f f
on a l l shi f t s .
3. ASH should expand the use of f l e x i b l e scheduling to provide s t a f f for
problem s h i f t s and heavy workload periods.
4. ASH should ensure that a l l nurses i n supervisory p o s i t i o n s attend the
courses a v a i l a b l e to improve supervisor/ employee r e l a t i o n s .
5. ASH should consider expanding promotional o p p o r t u n i t i e s f o r i t s
nursing s t a f f by:
a Allowing f l e x i b i l i t y i n the number of levels of s t a f f , thereby
e l i m i n a t i n g a cap on the number of p s y c h i a t r i c technician I1
p o s i t i o n s a v a i l a b l e ,
a Providing a d d i t i o n a l p s y c h i a t r i c technician I l l p o s i t i o n s t o
allow the s t a f f to promote on u n i t s outside the Behavior
Management program, and
a Requesting a d d i t i o n a l funding from the L e g i s l a t u r e for t h i s
purpose .
6. ASH should conduct a comprehensive study to determine i t s s t a f f i n g
needs. This study should consider such factors as:
a The goals of the h o s p i t a l
a Expected outcomes of i t s treatment programs
a Patient demographics
a Patient needs assessment
a A r o l e and task analysis
I f ASH lacks s u f f i c i e n t resources to perform a comprehensive s t a f f i n g
analysis, i t should seek a d d i t i o n a l funds to f u l f i l l the need for a
comprehensive study.
FINDING I I
ASH NEEDS TO CONSIDER RESTRUCTURING ITS TREATMENT PROGRAM
AND UNIT POSITIONS TO IMPROVE SUPERVISION
AND PROGRAM MANAGEMENT
The Arizona S t a t e H o s p i t a l needs to consider r e s t r u c t u r i n g i t s treatment
program and u n i t management. The current s t r u c t u r e i s fragmented, which
may lead to inadequate supervision and a lack of c o o r d i n a t i o n . ASH
should evaluate i t s current s t r u c t u r e and consider adding program
managers s i m i l a r t o those used by other h o s p i t a l s . I t should also
consider designating head nurses and lead p s y c h i a t r i c t e c h n i c i a n s .
Current S t r u c t u r e - As shown i n Figure 2 ( page 21 1 , ASH has 17
treatment u n i t s which are organized i n t o 6 treatment programs. P a t i e n t s
are assigned to a treatment program based on t h e i r treatment needs, level
o f f u n c t i o n i n g , c h r o n i c i t y o f i l l n e s s , and age. Each treatment program
i s under the general d i r e c t i o n o f a p s y c h i a t r i s t . ASH c u r r e n t l y has 16
p s y c h i a t r i s t s , a l l of whom are on c o n t r a c t . The p s y c h i a t r i s t s are
considered to be the m u l t i d i s c i p l i n a r y team leaders who, along w i t h the
psychologists, have the r e s p o n s i b i l i t y t o ensure t h a t the p a t i e n t s have
an i n d i v i d u a l i z e d , s p e c i f i c , and current treatment p l a n .
As shown i n Figure 3 ( page 22), each u n i t i s s t a f f e d w i t h i n d i v i d u a l s
from various d i s c i p l i n e s such as nursing, s o c i a l work, and psychology.
I n a d d i t i o n , ASH has medical s p e c i a l i s t s and r e h a b i l i t a t i o n t h e r a p i s t s
that work w i t h the p a t i e n t s on a d a i l y b a s i s . C u r r e n t l y , u n i t s are
headed by a p s y c h i a t r i c nurse manager ( PNM) who has 24- hour per day
a d m i n i s t r a t i v e r e s p o n s i b i l i t y over the n u r s i n g s e r v i c e s and treatment
program. ' ) I n a d d i t i o n , the PNM i s responsible f o r the u n i t ' s budget
and for program e v a l u a t i o n and p l a n n i n g . R e p o r t i n g to the PNM i s the
p s y c h i a t r i c nurse s h i f t supervisor ( PNSS) who has r e s p o n s i b i l i t y f o r
( 1 ) The h o s p i t a l ' s p s y c h i a t r i s t s have c l i n i c a l r e s p o n s i b i l i t y over the treatment
programs. Thus, under t h e i r d i r e c t i o n , the PNMs a s s i s t i n implementing p a t i e n t
treatment p l ans .
supervising the p s y c h i a t r i c and medical n u r s i n g s e r v i c e s f o r a work
s h i f t . The other nursing s t a f f on the u n i t are responsible f o r p r o v i d i n g
professional medicaI/ surgicaI nursing care t o p a t i e n t s and generally
report to the PNSS. F i n a l l y , each u n i t i s s t a f f e d w i t h p s y c h i a t r i c
technicians ( PTs) who provide a v a r i e t y of paraprofessional p s y c h i a t r i c
r e h a b i l i t a t i v e d u t i e s . These PTs report to and are supervised by the
licensed nursing s t a f f on the u n i t .
However, as i l l u s t r a t e d i n Figure 3 ( page 22), while there are other
d i s c i p l i n e s working on the u n i t s , each reports to t h e i r own supervisor or
d i r e c t o r . Thus, there i s no one i n d i v i d u a l at the u n i t or program level
that has o v e r a l l r e s p o n s i b i l i t y for a l l d i s c i p l i n e s working on the u n i t s .
ASH Should Evaluate Current
Structure and Consider Changes
ASH should evaluate the need for program managers, head nurses, and lead
technicians. Program manager p o s i t i o n s could be established to provide
o v e r a l l a d m i n i s t r a t i o n of the treatment programs. In a d d i t i o n , a head
nurse could provide the d a i l y c l i n i c a l supervision of nursing s t a f f .
Moreover, a lead technician could be responsible for ensuring technician
a c t i v i t i e s are undertaken. F i n a l l y , t o s t r u c t u r e programs w i t h these
p o s i t i o n s , ASH would need to implement a dual r e p o r t i n g system.
Overall a d m i n i s t r a t i o n could be provided by a program manager -
Establishment of program manager p o s i t i o n s could provide o v e r a l l
administration for ASH'S treatment programs. We contacted other State
and local h o s p i t a l s to determine the s t r u c t u r e o f t h e i r programs and
found that a l l o f the h o s p i t a l s u t i l i z e d a p o s i t i o n simi l a r to a program
manager. The basic concept of such a p o s i t i o n i s to provide o v e r a l l
coordination of the program and to ensure that q u a l i t y care i s provided.
Some of the functions that are c a r r i e d out by the program manager include
coordinating therapies for p a t i e n t s , planning a c t i v i t i e s , budgeting,
implementing program p o l i c i e s and procedures, and p r o v i d i n g f o r the
h i r i n g , o r i e n t a t i o n , and t r a i n i n g of s t a f f . A d d i t i o n a l l y , some of the
hospital representatives we interviewed s t a t e d t h a t a program manager
p o s i t i o n could be held by an i n d i v i d u a l from any d i s c i p l i n e ( i . e .
nursing, s o c i a l services, psychology, or p s y c h i a t r y ) .
Although ASH c u r r e n t l y u t i l i z e s p s y c h i a t r i c nurse managers to perform
some of the above mentioned f u n c t i o n s , based on our work and the
practices o f other h o s p i t a l s , we see the need for a program manager to
improve coordination of a l l the u n i t s w i t h i n a treatment program. ASH'S
superintendent agreed that a program manager p o s i t i o n would be b e n e f i c i a l
i n b r i n g i n g the u n i t s w i t h i n a program together a d m i n i s t r a t i v e l y .
However, ASH would need 6 a d d i t i o n a l p o s i t i o n s t o e s t a b l i s h program
managers for each of i t s treatment programs. The Southern Arizona Mental
Health Center w i t h i n DHS u t i l i z e s s i m i l a r p o s i t i o n s w i t h a salary range
of $ 32,284 to $ 48,559. Using these figures and i n c l u d i n g an employee
related expense allowance of 25 percent, ASH would require an estimated
$ 242,000 to $ 364,000 to fund the s i x pos i t i ons .
Head nurse c o u l d p r o v i d e c l i n i c a l supervision - Establishment of a head
nurse p o s i t i o n would provide increased c l i n i c a l supervision of nursing
s t a f f . Our contacts w i t h other h o s p i t a l s u t i l i z i n g a program manager
p o s i t i o n revealed that these h o s p i t a l s also had head nurses to provide
for the c l i n i c a l supervision of the nursing s t a f f . ASH c u r r e n t l y has
PNMs that are responsible for the day- to- day operations of the u n i t s .
However, because they are so h e a v i l y involved w i t h the a d m i n i s t r a t i v e
aspects o f t h e i r p o s i t i o n s ( most s t a t e they spend 75- 90 percent o f t h e i r
time on these f u n c t i o n s ) , according to several s t a f f surveyed, they are
often not a v a i l a b l e to provide c l i n i c a l supervision for t h e i r s t a f f .
However, w i t h the establishment of a program manager, the PNM p o s i t i o n
could be replaced w i t h a head nurse. Therefore, ASH would not need to
a l l o c a t e new p o s i t i o n s , but could designate e x i s t i n g s t a f f for the head
nurse p o s i t i o n .
Lead technicians could a s s i s t in t h e s u p e r v i s i o n o f technical s t a f f -
Lead technicians on each u n i t could a s s i s t i n the supervision of
technical s t a f f . Although nurses are responsible for supervising the
p s y c h i a t r i c technicians, they also have many other d u t i e s that take them
away from d i r e c t contact w i t h both the s t a f f and the p a t i e n t s . For
example, t h e i r d u t i e s include providing general nursing t o p a t i e n t s ,
observing p a t i e n t s and reviewing medical records, t r a n s c r i b i n g
p h y s i c i a n s ' o r d e r s , and p a r t i c i p a t i n g i n the implementation and
evaluation of p a t i e n t care treatment plans. As a r e s u l t , there may be no
one i n charge to p r o v i d e s u p e r v i s i o n i n the absence of the licensed
nursing s t a f f . The f o l l o w i n g case examples i l l u s t r a t e t h i s p o i n t :
a I n observing one u n i t throughout the day, the auditor found i t
d i f f i c u l t sometimes to locate the p s y c h i a t r i c technician ( PT) s t a f f .
A t one p o i n t , the a u d i t o r was alone i n the dayroom for approximately
20 minutes w i t h no s t a f f i n s i g h t . During that time, three p a t i e n t s
became very a g i t a t e d and v e r b a l l y abusive, t r y i n g to provoke a
f i g h t . During t h i s i n c i d e n t , the auditor noted two PTs walking
through the dayroom, but they made no attempt to r e d i r e c t the
p a t i e n t s .
a During another u n i t observation, 23 p a t i e n t s were out on the p a t i o
without any supervision by u n i t s t a f f for several minutes. During
that time, two p a t i e n t s began to argue. One p a t i e n t threatened to
h i t the other p a t i e n t . However, a t h i r d p a t i e n t persuaded one of the
two arguing p a t i e n t s to move to another p i c n i c t a b l e . Although 12 of
the patients were p a r t i c i p a t i n g i n an outdoor a c t i v i t y w i t h a
recreational t h e r a p i s t , the t h e r a p i s t was not w i t h i n earshot of the
argument; thus, the argument was not observed by any s t a f f from that
u n i t .
a Another u n i t was observed i n the p a t i e n t c a f e t e r i a during the lunch
meal. Four PTs accompanied approximately 25 patients to the
c a f e t e r i a . During the meal, the auditor observed the s t a f f s i t t i n g
at one of the tables t a l k i n g w i t h one another; they did not appear to
be monitoring the p a t i e n t s . A t the end of the meal, the auditor
observed one p a t i e n t rummaging through the trash and eating food that
had been discarded by the other p a t i e n t s . However, because the s t a f f
were seated at a t a b l e , away from the trash area, t h i s incident was
not observed by anyone other than the a u d i t o r .
Although ASH c u r r e n t l y has lead technician p o s i t i o n s , most u n i t s only
have one such p o s i t i o n , which i s not enough to cover even one s h i f t for a
f u l l week. Unit supervision could be improved i f ASH provided more lead
technician p o s i t i o n s for a l l u n i t s . Similar to the head nurse p o s i t i o n ,
t h i s would not require a d d i t i o n a l p o s i t i o n s . Therefore, ASH would only
have to designate e x i s t i n g s t a f f as lead techs. However, i f a d d i t i o n a l
p o s i t i o n upgrades are necessary, the salary increase per person would
range from $ 2,128 - $ 3,585.
Figure 4 illustrates our proposed structure of ASH treatment programs
using program managers, head nurses, and lead technicians. Within this
structure, the lead technician would report to the head nurse on the day
shift, and to the psychiatric nurse shift supervisor on the evening and
night shift, when the head nurse is not available.
Dual reporting system - With the establishment o f program managers,
head nurses, and lead technicians, ASH would need to implement a dual
reporting system. Although the program manager would have overall
responsibility for the program and handle all administrative functions,
there would still be a need for clinical direction from the various
disciplines. Most of the hospitals that we contacted had a dual
reporting system in which the staff reported to the program manager and
to the director of their respective discipline ( i . e, director of nursing,
director of social work, director of psychology). Thus, each hospital
had head nurses and lead social workers responsible for supervising staff
and preparing performance ratings and who also reported to both the
program manager and to their department directors.
FIGURE 4
PROPOSED STRUCTURE OF ASH
TREATMENT PROGRAMS
Program
Manager
7-
Pmych Nurnr 1 Shltt 1 supv.
1 Lead
Psychiatric
Technician
Nurse
RECOWENDATIONS
1. ASH should evaluate the current s t r u c t u r e of i t s treatment programs
and u n i t s , and consider adding program managers, head nurses, and
lead technicians.
2. The L e g i s l a t u r e should consider funding the program manager p o s i t i o n s .
FINDING I l l
ASH NEEDS TO IMPROVE THE FOOD SERVICE
FOR ITS PATIENTS
ASH needs to improve i t s d i e t a r y services t o i t s p a t i e n t s . Although
n u t r i t i o u s meals are important to p s y c h i a t r i c p a t i e n t s , ASH's meals do
not meet recommended standards. ASH's f a i l u r e to provide n u t r i t i o u s
meals i s due to poor planning. F u r t h e r , the manner i n which food i s
served i s i n e f f i c i e n t and p r o b l e m a t i c .
ASH meals are prepared at the main k i t c h e n w i t h i n the h o s p i t a l . Meals
are prepared for both p a t i e n t s and employees a t the h o s p i t a l as w e l l as
Department of C o r r e c t i o n ( DOC) inmates i n the Phoenix area. In t o t a l ,
approximately 5,450 meals are prepared d a i l y - 1,750 p a t i e n t meals, 100
employee meals, and 3,600 inmate meals. The h o s p i t a l has four d i n i n g
h a l l s where p a t i e n t s are served t h e i r meals.
Foods Served t o ASH
P a t i e n t s Are Not N u t r i t i o u s
Although n u t r i t i o u s meals are important to p s y c h i a t r i c p a t i e n t s , meals
served to State hospi t a l p a t i e n t s do not meet recommended standards. We
analyzed both p a t i e n t menus and the meals. served to p a t i e n t s and found
t h a t the foods served t o ASH p a t i e n t s are high i n c h o l e s t e r o l , f a t , and
sodium. The f a i l u r e o f the h o s p i t a l to provide proper d i e t s can impact
p a t i e n t care.
An analysis of ASH menus reveals that ASH has not planned foods t o meet
p a t i e n t s d i e t a r y needs. ASH has a master menu which contains a l l meals
t o be served w i t h i n a four- week cycle f o r each type o f p a t i e n t d i e t . The
O f f i c e of N u t r i t i o n Services w i t h i n DHS conducted an a n a l y s i s f o r our
o f f i c e of the menus f o r regular and modified d i e t s f o r the t h i r d week of
ASH'S master menu. The r e s u l t s of the analysis showed c h o l e s t e r o l ,
sodium, and t o t a l f a t exceeded recommended amounts f o r a l l menus. For
example, meals planned f o r p a t i e n t s on regular d i e t s had a c h o l e s t e r o l
content as high as 203 percent above the recommended l e v e l , a sodium
content as high as 230 percent above recommended l e v e l s , and t o t a l f a t
content as high as 44 percent above recommended l e v e l s .
F u r t h e r , a l a b o r a t o r y a n a l y s i s of foods served t o p a t i e n t s also reveals
that foods served are n o t meeting recommended d a i l y g u i d e l i n e s . The
D i e t a r y Guidelines f o r Americans recommends that 50 to 60 percent of
t o t a l c a l o r i e s come from complex carbohydrates, 15 t o 20 percent from
p r o t e i n , and 20 t o 30 percent from f a t . We c o l l e c t e d an example of each
of the meals served f o r p a t i e n t s on regular d i e t s and on mechanical s o f t
d i e t s f o r the week of A p r i l 24 through A p r i l 28."' These foods were
sent to a l a b o r a t o r y f o r a n a l y s i s . The r e s u l t s of the analysis showed
that the meals were too high i n f a t , and too low i n complex
carbohydrates, as shown i n Table 2.
TABLE 2
RESULTS OF ANALYSIS OF
REGULAR AND MECHANICAL SOFT DIETS
SERVED TO ASH PATIENTS DURING THE WEEK
OF APRIL 24- 28, 1989
Recommended ASH Regular ASH Mechanical
Standard D i e t Soft D i e t
(% o f Total (% o f Total (% o f Total
Dai ly C a l o r i e s ) Dai ly C a l o r i e s ) Dai l y C a l o r i e s )
P r o t e i n 15- 20% 22% 1 9%
Carbohydrates 50- 60% 30% 3 9%
Fat 20- 30% 48% 42%
Source: Analysis performed by Northview Laboratories, I l l i n o i s
Because n u t r i t i o u s meals are important f o r a healthy l i f e s t y l e , p a t i e n t
care i s being compromised by inadequate food s e r v i c e . A healthy d i e t i s
important f o r a l l i n d i v i d u a l s i n preventing serious i l l n e s s . Research
has shown that d i e t s high i n f a t and c h o l e s t e r o l can c o n t r i b u t e t o
coronary heart disease. F u r t h e r , d i e t s w i t h high sodium l e v e l s can lead
to h i g h b l o o d pressure. Although n u t r i t i o u s meals are important for a l l
( 1 The mechanical s o f t d i e t i s one o f nine o f the special d i e t s f o r ASH p a t i e n t s . It
i s provided f o r p a t i e n t s who have d i f f i c u l t y chewing sol i d foods.
28
i n d i v i d u a l s , n u t r i t i o n i s e s p e c i a l l y important t o p s y c h i a t r i c p a t i e n t s .
According to the c h i e f of the O f f i c e of N u t r i t i o n Services at DHS, " As
d i e t therapy i s a c r i t i c a l component i n the medical management of a
p a t i e n t , inappropriate d i e t a r y intake can adversely a f f e c t the
n u t r i t i o n a l and medical status of the p a t i e n t . " She f u r t h e r s t a t e d t h a t
p s y c h i a t r i c p a t i e n t s o f t e n r e q u i r e modified d i e t s as part o f t h e i r
treatment, and t h a t " i n a p p r o p r i a t e d i e t a r y intake can a l t e r blood values
and i n t e r f e r e w i t h expected medication a c t i o n . "
ASH'S F a i l u r e To Provide
N u t r i t i o u s Meals I s Due To
Poor Planning
ASH'S f a i l u r e to provide n u t r i t i o u s meals i s due to poor planning.
F i r s t , the menus used to plan meals are inadequate. Also, ASH lacks
standardized recipes for food preparation. Further, because of poor
purchase planning, food items are frequently s u b s t i t u t e d .
ASH menus do not meet p a t i e n t s ' d i e t a r y needs - ASH has ten d i f f e r e n t
menus - one for p a t i e n t s on regular d i e t s and nine for p a t i e n t s on
special d i e t s . However, as indicated e a r l i e r , the menus do not contain
n u t r i t i o u s meals for the p a t i e n t s . i n a d d i t i o n , according to the O f f i c e
o f N u t r i t i o n S e r v i c e ' s a n a l y s i s of ASH menus, the menus contain e r r o r s
f o r p a t i e n t s on special d i e t s . For example, menus f o r p a t i e n t s on
vegetarian d i e t s contain items such as red meat, p o u l t r y , and f i s h . The
low cholesterol d i e t has a f a t content of 30 to 40 percent o f t o t a l
c a l o r i e s , although i t should not exceed 20 percent. The menus for low
cholesterol d i e t contained such items as french f r i e s , gravy, b u r r i t o s ,
sour cream, and hot dogs; a l l of which are inappropriate items.
The menus also contained other d e f i c i e n c i e s . F i r s t , menu items were
frequently repeated. For example, i n the f o u r t h week of the menu cycle,
hamburger i s used i n f i v e of the week's meals. Further, the menus do not
always specify the p o r t i o n of food to be served. Also, the menus are not
always s p e c i f i c enough about the type of food item being served. For
example, the menu may s t a t e that f r u i t i s to be served, but i t may not
specify what type of f r u i t , or whether the f r u i t i s to be fresh or canned.
ASH's e x i s t i n g menus were not developed to meet the n u t r i t i o n a l needs of
ASH p a t i e n t s , but instead were designed to f a c i l i t a t e food production.
ASH prepares meals for Department of Corrections inmates i n the Phoenix
area prisons. "' As a r e s u l t , ASH prepares approximately 3,600 meals
d a i l y for inmates. According to ASH's food service manager, when ASH
obtained the DOC c o n t r a c t , the previous food service manager along w i t h
the DOC d i e t i t i a n developed a new master menu to serve both the patients
and the inmates. However, the new menu did not contain menus for the
p a t i e n t s on s p e c i a l modified d i e t s . Thus, the cooks were preparing meals
for the ASH p a t i e n t s on modified d i e t s from the o l d ASH menu, and meals
for ASH p a t i e n t s on regular d i e t s as well as the inmates from the new
menu. This was causing production problems. Therefore, the food service
manager adjusted the menu to include the modified d i e t s . However, the
menus c u r r e n t l y used at ASH have resulted i n meals which are d e f i c i e n t i n
meeting ASH'S p a t i e n t s ' needs.
In order to eliminate the menu d e f i c i e n c i e s , ASH has contracted w i t h a
consultant to develop new menus. ASH c u r r e n t l y has two registered
d i e t i t i a n s on s t a f f , but because of t h e i r already large workload, ASH
contracted w i t h a consultant to redo i t s menus.
ASH lacks standardized recipes f o r meal preparation - In a d d i t i o n to
lacking adequate menus, ASH lacks standardized recipes for food
preparation. Lack of standard recipes has several impacts. F i r s t , lack
of standard recipes could r e s u l t i n cooks preparing meals based on t h e i r
preferences or based on ingredients a v a i l a b l e . For example, one cook may
include tomatoes i n stew, while another may not. Further, lack of
standard recipes makes i t d i f f i c u l t to assess the n u t r i t i o n a l value of
the food served. For example, i f cooks use varying amounts of meat when
preparing spaghetti sauce, the p r o t e i n value of the food would also
vary. F i n a l l y , without standard recipes, food purchases cannot be
accurately estimated because the amount and types of ingredients needed
( 1) These p r i s o n s i n c l u d e t h e A1 hambra Reception and Treatment Center, the Arizona
Center f o r Women, the Aspen Correctional Center, the Flamenco Mental Health Center,
and the Alamo U n i t .
to prepare an item would not be a v a i l a b l e . In connection w i t h
redevelopment of the menus, ASH also plans to use the contract consultant
to prepare standard recipes for the items on the menus.
Poor planning causes excessive substitutions - ASH frequently makes
s u b s t i t u t i o n s to i t s menus. ASH's food service manager prepares weekly
menus from the master menu. However, these menus deviate s u b s t a n t i a l l y
from the master menu. "' For example, we compared the menu developed
for the week of March 5- 11, 1989 against the master menu and found that
the menu had 21 items which varied from the master menu. Further, the
actual meals served weekly f r e q u e n t l y d e v i a t e from the weekly menus. For
example, during a 5- day period i n which we observed the food service,
three of the breakfast meals contained s u b s t i t u t i o n s t o the weekly menu.
According to the food service manager, the most frequent cause of
s u b s t i t u t i o n s i s shortages of the food item.
To decrease s u b s t i t u t i o n s , ASH needs to develop r e l i a b l e estimates of
food needs. C u r r e n t l y , because ASH does not track the number o f p a t i e n t s
on each type of modified d i e t , i t cannot estimate the needs o f these
p a t i e n t s f o r f u t u r e purchases. However, an average of nearly 50 percent
of ASH p a t i e n t s are on special d i e t s . ASH's lack of standardized recipes
also complicates purchases because ingredients cannot be estimated.
Final I y , ASH incorporates past usage when ordering nonperishable food
items. However, according to an o f f i c i a l i n procurement, past usage
figures are often skewed by s u b s t i t u t i o n s and other problems. Thus, they
may perpetuate old problems rather than r e f l e c t future food needs.
ASH Does Not Provide
Adequate Service of Foods
ASH'S method of serving foods i s inadequate. The food serving process i s
i n e f f i c i e n t and does not ensure that p a t i e n t s get the foods they need.
Method of serving patients i s i n e f f i c i e n t - Currently, the h o s p i t a l
frequently uses only one person to serve p a t i e n t s coming through a
According t o the food s e r v i c e manager a t ASH, he sends a copy o f the master menu t o
the ASH warehouse each week. The warehouse informs him khat foods a r e n ' t
a v a i l a b l e . Based on the shortages, he prepares a weekly menu from the foods which
are avai 1 able.
serving I i n e . This causes delays i n serving patients due to the many
duties involved i n serving the p a t i e n t s . The server i s confronted w i t h
the task of serving anywhere from 20 to 55 p a t i e n t s who are only given 20
minutes to receive t h e i r food and e a t . During our observations we noted
that while serving, the server i s responsible f o r :
0 Locating the p a t i e n t ' s d i e t card to review what type of foods the
patient i s allowed to eat
a Monitoring the cold l i n e selections made by the p a t i e n t to see i f i t
i s i n l i n e w i t h the d i e t card
a Serving the hot food items i n accordance w i t h the d i e t ( t h i s can get
complicated since there are 10 d i f f e r e n t menus for any given meal)
0 Locating special items for p a t i e n t s
a C o n t r o l l i n g the condiment selections
According to the food service manager, only 2 of the 17 u n i t s are
r o u t i n e l y assigned more than one food service worker on the serving
I i n e . The reason for assigning only one person to serve food i s that ASH
lacks enough s t a f f to be able to provide more than one person for t h i s
task. However, i f kitchen s t a f f are unavailable, ASH may want to
consider r e q u i r i n g s t a f f from the u n i t s t o a s s i s t the servers while the
u n i t ' s patients are being served.
In addition to delays i n being served, p a t i e n t s are not assured of
g e t t i n g the foods prescribed. Nearly 50 percent of the h o s p i t a l p a t i e n t s
are on special d i e t s . However, both regular and special d i e t s are
sometimes v i o l a t e d by e i t h e r the server or the patients themselves. We
performed observations of the c a f e t e r i a serving lines at various meals
during two separate weeks and noted the f o l l o w i n g problems.
a During one afternoon meal, a server was observed attempting to serve
hot dogs to two vegetarian p a t i e n t s .
a During a breakfast meal, a server reviewed a p a t i e n t ' s d i e t card and
then searched for peanut b u t t e r t o give the p a t i e n t . However, the
card c l e a r l y stated that the p a t i e n t had a food a l l e r g y t o peanut
b u t t e r . A f t e r an extensive search to f i n d peanut b u t t e r , the server
then offered the peanut b u t t e r t o the p a t i e n t .
a During a breakfast meal, the server forgot to give cereal to several
p a t i e n t s .
0 During one lunch, the d i e t cards for two u n i t s d i d not a r r i v e . The
servers served these p a t i e n t s without the cards.
0 During our observations, we noted that the condiments, i n c l u d i n g
b u t t e r and s a l t , are located at the end of the serving l i n e and are
not r o u t i n e l y c o n t r o l l e d . Thus, those patients on low sodium and low
f a t d i e t s are able to take these items.
In a d d i t i o n , during our observations we noted servers u t i l i z i n g i n c o r r e c t
serving equipment and serving i n c o r r e c t p o r t i o n s .
Other h o s p i t a l s have a check person who i s responsible for seeing that
patients are served t h e i r prescribed d i e t s . The food service manager at
the Maricopa Medical Center indicated that the food service supervisor
checks each tray at the end of the serving l i n e to ensure i t contains the
appropriate menu items. The c h i e f of d i e t e t i c services at the Veteran's
Administration Hospital i n Phoenix i n d i c a t e d t h a t the service l i n e has a
checker at the end of the l ine who i s responsible for checking that each
tray contains the items s p e c i f i e d on the d i e t card. This p o s i t i o n i s
always f i l l e d by a high level experienced food service worker. ASH
occasionally uses the d i e t c l e r k s to monitor the c a f e t e r i a serving l i n e s ,
but t h e i r use i s l i m i t e d because o f other r e s p o n s i b i l i t i e s .
RECWENDATIONS
1. ASH should ensure that the menus developed by i t s contracted
consultant meet the recommended d a i l y guidelines.
2 . Once standard recipes are developed by ASH'S c o n t r a c t e d c o n s u l t a n t ,
ASH should monitor food preparation to see that a l I cooks f o l low the
rec i pes.
3. ASH should improve i t s procurement process for food items by basing
the food survey estimates on the menus and recipes developed by the
consultant, and by tracking the number o f p a t i e n t s served special
d i e t s t o be able to estimate future needs.
4. ASH should improve i t s s e r v i c e o f foods by:
e Adding servers to the food service l i n e s to assist i n serving
p a t i e n t meals,
e Having a food service worker check food trays to see that
patients received only foods prescribed on t h e i r d i e t cards, and
e Providing t r a i n i n g to food service workers i n p o r t i o n control
and i n reading d i e t cards.
FINDING IV
ASH HAS IMPROVED THE USE OF ITS TRANSITIONAL
LIVING PROGRAM; HOWEVER, OTHER UNITS WITHIN THE HOSPITAL
NEED TO BE MADE MORE AWARE OF THE PROGRAM'S FUNCTIONS
ASH has improved the use of i t s t r a n s i t i o n a l l i v i n g u n i t ( TLU), however,
the functions of TLU have not been communicated t o o t h e r u n i t s outside o f
the program. H i s t o r i c a l l y , TLU has been u n d e r u t i l i z e d . Although a
recent reorganization of the program has improved i t s use, other u n i t s
w i t h i n the h o s p i t a l do not seem to be aware of TLU's functions.
In 1984, the L e g i s l a t u r e , recognizing the need for a program to provide
graduated steps of care between the h o s p i t a l treatment u n i t and the
community l i v i n g s i t u a t i o n , established a l i n e item designating funding
for a t r a n s i t i o n a l l i v i n g u n i t ( TLU). P r i o r to that t i m e , there was no
such program. TLU treatment i s aimed at b r i d g i n g the c h r o n i c a l l y
mentally i l l c l i e n t between the i n p a t i e n t u n i t and the community
placement. I t i s designed to meet the needs of those p a t i e n t s who are
e i t h e r unprepared to enter the community, or who have such s i g n i f i c a n t
social s k i l l s d e f i c i t s as to make community reentry d i f f i c u l t . To
f a c i l i t a t e the t r a n s i t i o n , TLU provides a wide range of therapeutic,
educational, and p r a c t i c a l s k i l l s to i t s p a t i e n t s , such as, cooking,
cleaning, shopping, communi t y transportat ion, and personal s a f e t y .
Patients are expected to be ready for discharge w i t h i n 60 to 90 days o f
placement on the u n i t .
From i t s implementation i n September 1984 through March 31, 1989, TLU
expenditures totaled over $ 1.4 m i l l i o n . TLU i s the most expensive adult
treatment u n i t operating at the h o s p i t a l . According to the 1987- 88
annual r e p o r t , other adult u n i t s ' average d a i l y costs per p a t i e n t range
from $ 121 t o $ 203, TLU costs $ 212 per patient per day.
TLU Has Been
U n d e r u t i l i z e d
H i s t o r i c a l l y , TLU has been u n d e r u t i l i z e d . Since i t s inception, the TLU
r a r e l y operated at capacity. In a d d i t i o n , the p a t i e n t length o f stay
( LOS) i n the program was longer than projected for many p a t i e n t s , and TLU
had r e l a t i v e l y few discharges. F i n a l l y , the r o l e of the TLU had not been
c l e a r l y defined.
During i t s f i r s t four years, TLU was not e f f i c i e n t l y u t i l i z e d - Because
TLU provides an important function by a s s i s t i n g p a t i e n t s i n preparing for
l i v i n g i n the community, the u n i t should provide services t o as many
p a t i e n t s as possible. However, although only 12 spaces were a v a i l a b l e on
the u n i t for the more than 550 discharges a year, the spaces were not
kept f i l l e d . Based on our review o f d a i l y census records for TLU between
September 1984 and October 1988, we found that TLU achieved maximum
occupancy only 55 of the 1,512 days i t was i n operation, o r o n l y 3.6
percent of the time. "' As shown i n Figure 5 ( page 37), although the
u n i t had a capacity for 12 p a t i e n t s , the average monthly census ranged
between 8 and 10 p a t i e n t s for much of the u n i t ' s existence.
Some p a t i e n t s remained i n the TLU program longer than projected - While
TLU often operated below capacity, some p a t i e n t s who were i n TLlJ stayed
longer than projected. According to the former u n i t supervisor, p a t i e n t s
were expected to be discharged w i t h i n 90 days of placement on the u n i t .
However, as depicted i n Table 3 ( page 38), 42 percent of the discharges
i n 1985- 86 and 50 percent of the discharges i n FY 1986- 87 stayed on TLU
longer than 90 days. In FY 1987- 88, 64 percent of the discharged
p a t i e n t s stayed longer than 90 days; ir! f; lct, they averaged 130 days on
the u n i t . Some p a t i e n t s ' stays have been extremely lengthy; f o r example,
one p a t i e n t remained on the u n i t for 313 days. A July 14, 1987, TLU
report noted that TLU had experienced an increase i n p a t i e n t length of
stay, and a t t r i b u t e d the increase to two " probable" f a c t o r s : 1) the
u n i t ' s acceptance of lower functioning p a t i e n t s , and 2) s t a f f shortages.
( 1 The census dropped t o f o u r p a t i e n t s during June and July 1988. According to the
ASH superintendent , continued funding was uncertain, and ASH was prepari ng t o close
the u n i t . However, funding was continued, and the census was eventually increased.
FIGURE 5
TRANSITIONAL LIVING UNIT
AVERAGE MONTHLY CENSUS
SEPTEMBER 1984 THROUGH OCTOBER 1988
TABLE 3
TRANSITIONAL LIVING UNIT
LENGTH OF STAY
FISCAL YEARS 1984- 85 THROUGH 1988- 89
( BASED ON PATIENTS DISCHARGED FROM HOSPITAL)
Length of
Stay ( a)
( I n Days) FY 1984- 85
1 - 30
31 - 60
61 - 90
91 - 120
121 - 150
151 - 180
181 t
Total
Discharged
Number of Patients Discharged
( a) Covers September 1984 through June 30, 1985.
( b ) Does n o t i n c l u d e two discharges w i t h unknown admission dates or one p a t i e n t who was
discharged on day o f admission.
( c ) Does n o t i n c l u d e two discharges w i t h unknown admission dates.
( d l Covers July 1988 through March 1989. a
Source: Auditor General analysis of TLU P a t i e n t Census Records, Data
Control Section, ASH
a
TLU discharged r e l a t i v e l y few p a t i e n t s i n i t s f i r s t four years - The
combination of a lower census and longer than projected length of stay
resulted i n r e l a t i v e l y few p a t i e n t discharges during TLU's f i r s t 50 months
of operation. Through October 1988, TLU discharged 100 p a t i e n t s from the
h o s p i t a l . Based on TLU's capacity of 12 p a t i e n t s and the 90- day projected
length of stay, TLU could have discharged 4 p a t i e n t s per month, or as many
as 188 patients between December 1984 and October 1 9 8 8 . ' ' ) Thus, TLU
discharged only about one- half of i t s p o t e n t i a l . The low discharge rate
was a r e s u l t o f lengthy p a t i e n t stays on the u n i t and the i n a b i l i t y to
maintain a higher p a t i e n t census.
I n past years, the r o l e of TLU may have been unclear - The
u n d e r u t i l i z a t i o n of TLU may be due, i n p a r t , t o the need for a c l e a r l y
defined program r o l e . In a July 1987 annual report to the ASH
superintendent, the TLU supervisor stated, " TLU's r o l e w i t h i n the h o s p i t a l
organization continues to seem somewhat unclear to much of the h o s p i t a l
s t a f f . " Based on our interviews of some personnel i n the two u n i t s which
most often referred p a t i e n t s to TLU, u n c e r t a i n t y as to TLU's r o l e was
evident. The current TLU p s y c h i a t r i s t acknowledged h i s lack of
understanding of what objectives were i n place on the u n i t p r i o r to h i s
appointment to TLU i n November 1988. Another p s y c h i a t r i s t expressed h i s
b e l i e f that anyone outside the TLU program had l i m i t e d knowledge about i t
and that few p s y c h i a t r i s t s and s t a f f were i n t e r e s t e d i n using TLU.
A recent reorganization of TLU has improved i t s u t i l i z a t i o n . Since the
reorganization of TLU, ASH has been able to increase i t s p a t i e n t census,
reduce the average length of stay i n the program, and discharge more
p a t i e n t s .
ASH estimates p a t i e n t s should stay on the u n i t 90 days. Further, TLU maximum
capacity was 12 p a t i e n t s ( u n t i l November 1988). Thus, t a k i n g i n t o account a
three- month preparation time f o r p a t i e n t s assigned to TLU i n September 1984, TLU
could have discharged as many as 188 p a t i e n t s between December 1984 and October
1988. ( 90- day length of stay per bed = 4 discharges per year; 12 bed capacity x 4
= 48 discharges per year or 4 discharges per month. 4 discharges/ month x 47 months
= 188.)
ASH reorganized the TLU program - Recently, ASH reorganized i t s TLU i n
order to increase i t s capacity and to provide a safer environment for the
patients and s t a f f and t o provide a f u l l - t i m e p s y c h i a t r i s t . P r i o r to
November 1988, TLU occupied two cottages j u s t outside the fenced h o s p i t a l
grounds. In November 1988, ASH closed the two cottages and moved the
program to a b u i l d i n g w i t h i n the h o s p i t a l grounds. A main factor i n the
move was safety o f p a t i e n t s and s t a f f . According to the ASH
superintendent, the cottages had e l e c t r i c a l w i r i n g problems which made
them a safety hazard t o p a t i e n t s . Further, he stated that the l o c a t i o n
of the cottages outside of the fenced grounds d i d not provide a safe
envi ronment for s t a f f who were requi red to inspect the cottages and make
rounds during the n i g h t . The move provided a d d i t i o n a l b e n e f i t s , however,
i n that ASH was able to increase the capacity to 16 patients from 12
without any a d d i t i o n a l increase i n funding for the program.
Another aspect of the reorganization was p o s i t i o n i n g the u n i t under the
d i r e c t i o n of nursing services and devoting a f u l l - t i m e p s y c h i a t r i s t to
the u n i t . P r i o r to the move, TLU was under the d i r e c t i o n o f the social
services u n i t , and the program had a part- time p s y c h i a t r i s t who spent
only four to s i x hours per week on the u n i t . According to the current
p s y c h i a t r i s t assigned to TLU, when TLU was reorganized, the
superintendent d i r e c t e d him to increase the u n i t ' s census and discharge
patients i n a more timely manner.
In recent months, TLU's performance has improved - For the period
November 1, 1988, through March 31, 1989, TLU's census has r i s e n . Figure
6 ( page 41 ) shows that TLU's census has steadi l y increased since November
1988. The average d a i l y census on TLU increased from 7 i n November 1988,
to 14 i n March 1989!')
Wh i l e the average census has i nc reased on TLU s i nce November 1988, the
average p a t i e n t LOS has declined. As previously noted, the average
( ' 1 Although ASH1s capacity f o r TLU p a t i e n t s has been increased t o 16, TLU c u r r e n t l y
maintains an a v a i l a b l e bed f o r p a t i e n t s i n Reentry F a c i l i t i e s ( REFS) who may
require readmission t o ASH. Thus, the u n i t may o f t e n be l i m i t e d t o only 15
p a t i e n t s t o accommodate any p o s s i b l e REF readmi ssi ons.
FIGURE 6
TRANSITIONAL LIVING UNIT
AVERAGE MONTHLY CENSUS
SEPTEMf3ER 1984 THROUGH MARCH 1989
The maximum capacity was 12 p r i o r t o November 1988.
Max imum Capac i ty - 16
( Nov . 1988) ( a)
12
11
10
V) 0 5
41 a--
C- <
0- 7-•
6 --
5 --
4
3
2 --
--
--
length of stay during FY 1987- 88 was 130 days. However, f o r p a t i e n t s
admitted since mid- November 1988, the average length o f stay has dropped
to 48.2 days.
F i n a l l y , since i t s reorganization i n November 1988, TLU has been able to
discharge more p a t i e n t s . For the 5- month period of November 1988 through
March 1989, TLU discharged 15 p a t i e n t s or an average of 3 p a t i e n t s a
month. Moreover, the monthly discharge rate appears to be increasing.
In March 1989, TLU discharged 5 p a t i e n t s .
ASH Needs to Comnunicate TLUfs Functions
to I t s Other Hospital Units
ASH needs to make other u n i t s w i t h i n the h o s p i t a l more aware of i t s TLU
functions. Since i t s reorganization, the types of p a t i e n t s targeted for
the program have been changed. However, h o s p i t a l personnel w i t h i n other
u n i t s of the h o s p i t a l have expressed u n c e r t a i n t y as t o TLU's r o l e .
Types of patients targeted for TLU has changed - Since i t s
reorganization, the types o f p a t i e n t s admitted to TLU have changed.
According to the TLU p s y c h i a t r i s t and ASH'S superintendent, TLU i s to
target more p a t i e n t s from the Psycho- Social R e h a b i l i t a t i o n Program
( PSRP). Patients w i t h i n t h i s program tend to have chronic, longer term
mental disorders. Since i t s reorganization, a much larger p o r t i o n of the
admissions to TLU are coming from the PSRP. We reviewed admission
records for the 12- month period of Apri l 1, 1988, through March 31,
1989. From A p r i l 1 , 1988, u n t i l i t s reorganization in November 1988, TLU
had 18 admissions, of which 5 admissions or 28 percent of the p a t i e n t s
came from the PSRP. However, between November 1988 and March 31, 1989,
TLU has had 17 of 24 admissions or 71 percent of the p a t i e n t s coming from
PSRP .
TLUfs role i s s t i l l unclear - Despite the improvements made i n the TLU
program, i t s r o l e at ASH remains unclear. Some of the h o s p i t a l personnel
are s t i l l not knowledgeable of TLU's goals and program o b j e c t i v e s .
Interviews w i t h several social workers as well as two p s y c h i a t r i s t s and a
psychologist indicated a lack o f knowledge or understanding regarding
e i t h e r TLU's goals, o b j e c t i v e s , o r p a t i e n t c r i t e r i a . Moreover, although
a new TLU program d e s c r i p t i o n was developed, i t seems to have had l i t t le
exposure to other s t a f f outside of the t r a n s i t i o n a l l i v i n g program. Of
those i n d i v i d u a l s interviewed, no one acknowledged having a copy o f , or
even reading, the new TLU program d e s c r i p t i o n . As a r e s u l t , they are
unable to e f f e c t i v e l y determine which p a t i e n t s t o r e f e r t o the program
because they are unsure of i t s purpose.
RECOWENDATIONS
1. ASH needs to provide more i n f o r m a t i o n t o the other treatment program
u n i t s to educate the employees as to TLU's r o l e at the h o s p i t a l .
2. ASH needs to ensure that TLU i s e f f i c i e n t l y u t i l i z e d by maintaining a
f u l l census and discharging p a t i e n t s w i t h i n TLU's guideline of 90
days whenever possible.
OTHER PERTINENT INFORMATION
During the course of the a u d i t we developed information regarding ASH'S
Medicare c e r t i f i c a t i o n and the c o n d i t i o n of i t s physical p l a n t .
Medicare C e r t i f i c a t i o n
Background - The Department of Health and Human Services, Health Care
Financing Administration ( HCFA) i s responsible for overseeing h o s p i t a l s
that receive Medicare reimbursements. I n order t o receive reimbursement,
h o s p i t a l s must meet Medicare's Conditions of P a r t i c i p a t i o n . There are
also two Special Conditions o f P a r t i c i p a t i o n that must be met by
p s y c h i a t r i c h o s p i t a l s i n order to receive Medicare reimbursement. The
f i r s t condition includes f o l l o w i n g special medical records requirements
for p s y c h i a t r i c h o s p i t a l s . This requires a f a c i l i t y t o maintain records
on a l l p a t i e n t s i n order to determine the degree and i n t e n s i t y of the
treatment provided to i n d i v i d u a l s served by the i n s t i t u t i o n . The second
condition includes u t i l i z i n g special s t a f f requirements for p s y c h i a t r i c
h o s p i t a l s . This requires a f a c i l i t y to meet s t a f f i n g requirements as the
Secretary of the Department of Health and Human Services finds necessary
for the i n s t i t u t i o n to carry out an a c t i v e program of treatment.
According to the superintendent, the Arizona State Hospital i s e l i g i b l e
to receive medicare reimbursement for approximately 200 of i t s p a t i e n t s .
These reimbursements are not p a r t of the h o s p i t a l ' s budget, but are
deposited i n t o the S t a t e ' s general fund. In the past, Medicare
reimbursements have t o t a l e d approximately $ 1.8 mi l l i o n annual l y .
ASH was d e c e r t i f i e d by HCFA i n e a r l y 1988 - As a r e s u l t of a survey
conducted i n October 1987 and a f o l low- up survey i n February 1988, HCFA
determined that ASH no longer met the requirements for p a r t i c i p a t i o n as a
provider of services under Medicare. The r e s u l t s of the surveys found
that the two Special Conditions of P a r t i c i p a t i o n f o r P s y c h i a t r i c
Hospitals were not met. Although ASH submitted a c o r r e c t i v e a c t i o n plan
to HCFA to address the noted d e f i c i e n c i e s and a follow- up survey was
conducted, according to a HCFA o f f i c i a l , " the e x i s t i n g d e f i c i e n c i e s
continue to s e r i o u s l y l i m i t the h o s p i t a l ' s capacity to f u r n i s h an
adequate level or q u a l i t y of care o r s e r v i c e s . " S p e c i f i c a l l y , ASH did
not meet the f o l l o w i n g standards:
e P s y c h i a t r i c E v a l u a t i o n - Although p s y c h i a t r i c evaluations for newly
admitted p a t i e n t s were u s u a l l y complete and t i m e l y , the annual
p s y c h i a t r i c reviews s t i l l showed major d e f i c i e n c i e s . These
d e f i c i e n c i e s included delays i n c h a r t i n g evaluations ( none of the
charts reviewed contained a medical h i s t o r y during the course of
h o s p i t a l i z a t i o n ) , inadequate mental s t a t u s exams, and the lack of
inventories of p a t i e n t s ' assets i n some charts reviewed.
e Treatment Plan - I n the m a j o r i t y o f the 43 medical records
reviewed, there was no documented evidence t h a t p a t i e n t s were
involved i n a c t i v e treatment. According to the HCFA surveyor, the
registered nurses, a c t i v i t y t h e r a p i s t s , and social workers were not
involved i n w r i t i n g treatment notes.
e Progress Notes - The progress notes by physicians were usually done
in a timely manner, but they lacked content. In a d d i t i o n , the
progress notes recorded by nurses and social workers were not
documented w i t h the frequency required.
e Personnel - The number of p s y c h i a t r i s t s was not s u f f i c i e n t to
provide care for the p a t i e n t s . In a d d i t i o n , although the number of
RNs was adequate, there was not documented evidence that the p a t i e n t s
were receiving nursing care. F i n a l l y , the standard specifying the
need for a d i r e c t o r of i n p a t i e n t p s y c h i a t r i c services and medical
s t a f f was not met.
ASH made attempts t o regain c e r t i f i c a t i o n - A f t e r ASH'S Medicare
agreement was terminated on February 16, 1988, i t prepared for an
a d m i n i s t r a t i v e appeal i n an attempt to regain c e r t i f i c a t i o n . I n October
1988, ASH o f f i c i a l s attended an a d m i n i s t r a t i v e appeal at the HCFA
Regional O f f i c e i n San Francisco. However, a f t e r reviewing the documents
submitted at that time, HCFA stated that the evidence provided d i d not
support a change i n the conclusion made at the time of the follow- up
v i s i t conducted i n February 1988. Therefore, the termination of Medicare
c e r t i f i c a t i o n remained i n e f f e c t .
Medicare c e r t i f i c a t i o n regained - According to the h o s p i t a l
superintendent, ASH made several improvements i n i t s continued e f f o r t s to
regain Medicare c e r t i f i c a t i o n . F i r s t , i t increased b o t h n u r s i n g and
contracted medical s t a f f . In a d d i t i o n , ASH increased the frequency of
chart documentation t o b r i n g the p a t i e n t s ' medical records up to HCFA
standards. Further, the treatment planning process was amended again to
meet HCFA requirements. F i n a l l y , ASH has attempted to increase the
a v a i l a b i l i t y of occupational t h e r a p i s t s f o r i t s p a t i e n t s .
In mid- February 1989, HCFA surveyors v i s i ted ASH again. The purpose of
t h i s v i s i t was to determine i f ASH was now i n compliance w i t h the two
Special Conditions of P a r t i c i p a t i o n for P s y c h i a t r i c H o s p i t a l s . During
I) t h e i r v i s i t , the surveyors noted some areas where ASH was s t i l l
d e f i c i e n t , but they were not of s u f f i c i e n t importance to a f f e c t the two
special conditions. For example, treatment goals and objectives were
frequently stated i n general terms, and there were i n s u f f i c i e n t numbers
of therapeutic s t a f f ( i . e . r e c r e a t i o n a l and occupational t h e r a p i s t s ) and
a lack of a c h i e f medical o f f i c e r . While there were s t i l l some
d e f i c i e n c i e s noted, the surveyors i n d i c a t e d t h a t i n t h e i r opinion ASH was
i n compliance. This opinion was confirmed i n a June 1, 1989, l e t t e r to
the d i r e c t o r o f Health Services from the HCFA regional o f f i c e . The
l e t t e r stated that ASH was again c e r t i f i e d r e t r o a c t i v e to March 26, 1989.
ASH Facilities
Background - The Arizona S t a t e H o s p i t a l encompasses approximately 97
acres w i t h approximately 60 s t r u c t u r e s i n the complex. While there are
460,953 sq. f t . of usable b u i l d i n g area, only 241,681 sq. f t . are usable
f o r p a t i e n t treatment. The remaining footage i s u t i l ized for
warehousing, engineering, o f f i c e space, food preparation, and other
support space for the h o s p i t a l . Most of the b u i l d i n g s used for p a t i e n t
treatment were constructed i n the 1950s. The f o l l o w i n g t a b l e i d e n t i f i e s
the b u i l d i n g s c u r r e n t l y being used for p a t i e n t treatment and the year
they were constructed:
PATIENT TREATMENT FACILITIES
Patient Treatment Building Year Constructed
Chol l a
Jun i pe r
Granada
Kach i na
Encan to
Other b u i l d i n g s v i t a l t o the operation of the h o s p i t a l are also quite
o l d . For example, the power p l a n t , which contains three b o i l e r s and
provides c e n t r a l h e a t i n g and c o o l i n g f o r most of the h o s p i t a l complex,
was constructed i n 1909. Likewise, the u t i l i t y tunnel system located
under the f a c i l i t y was also constructed i n 1909. Furthermore, there are
presently three vacant b u i l d i n g s w i t h i n the fenced perimeter of the
h o s p i t a l that were constructed i n the e a r l y 1900s. According t o a
h o s p i t a l o f f i c i a l , one of the b u i l d i n g s has been vacant for more than 15
years, and a second b u i l d i n g has been vacant for approximately 10 years.
Current condition of the physical plant - Based on observations,
interviews, and a number of h o s p i t a l r e p o r t s , the physical p l a n t at ASH
presents some problems f o r p a t i e n t safety and e f f i c i e n t treatment. As
noted i n the ASH s t r a t e g i c plan, f a c i l i t i e s and equipment are outdated,
d e t e r i o r a t e d , and i n need of r e p a i r . S i m i l a r concerns are also c i t e d i n
the 1987 ASH Advisory Board Annual Report. Some of the d e f i c i e n c i e s
which need to be addressed include:
a Overcrowded c o n d i t i o n s . Some u n i t s have a census i n excess of
established c a p a c i t y . A d d i t i o n a l l y , some u n i t s have l i m i t e d dayroom
area for p a t i e n t use.
a Problems w i t h broken sewer l i n e s and seepage i n t o the tunnel area
under the f a c i l i t y . Since the tunnel area contains pipes wrapped
w i t h asbestos, the asbestas has to be removed p r i o r to repai r i n g the
l ines.
a Asbestos i n h o s p i t a l s t r u c t u r e s and i n the tunnel system under the
h o s p i t a l . Continued asbestos containment and minor abatement had
been planned for FY 1988- 89.
a Three vacant b u i l d i n g s i n the h o s p i t a l complex which pose a p o t e n t i a l
hazard to p a t i e n t s who are able to secure unauthorized e n t r y .
a Breaks i n water l i n e s . On two occasions during the a u d i t , the
h o s p i t a l experienced breaks i n main water l i n e s which i n t e r r u p t e d the
water supply. B o t t l e d water had to be made a v a i l a b l e for p a t i e n t and
s t a f f use.
ASH seeks a Master Plan - In FY 1988- 89 the Department of Health
Services set aside $ 90,000 for an a r c h i t e c t u r a l study of ASH. DHS
s o l i c i t e d proposals from q u a l i f i e d a r c h i t e c t u r a l / p l a n n i n g f i r m s f o r
development o f a master p l a n f o r a 500- bed State mental h o s p i t a l w i t h a
100- bed expansion c a p a b i l i t y . "' Add i t i onal l y, the requested
proposals were to i n c l u d e " a comprehensive report on e x i s t i n g f a c i l i t i e s ,
appropriate renovations and/ or demolition o f e x i s t i n g f a c i l i t i e s , and
construction of new f a c i l i t i e s . " A contract was entered i n t o on February
17, 1989, w i t h the f i r m o f Anderson, DeBartolo, and Pan, lnc. The firm
completed a plan f o r the Hospital i n July 1989. The plan recommends
constructing a l l new p a t i e n t treatment u n i t s , and u t i l i z i n g e x i s t i n g
f a c i l i t i e s for 89 percent of a l l other h o s p i t a l functions. The plan
recommends six major phases of c o n s t r u c t i o n , each centered around
c o n s t r u c t i o n o f a p a t i e n t treatment program. Although the plan allows
phased construction of the h o s p i t a l dependent on c o n s t r u c t i o n fund
a v a i l a b i l i t y , the t o t a l cost of implementing the plan i s estimated at
$ 80,337,400, w i t h a completion date of mid 1996.
( 1) The current h o s p i t a l capacity as noted i n the Arizona State H o s ~ i t a l Strateaic.
Plan. 1988- 1997, i s 515 p a t i e n t s .
AREAS FOR FURTHER AUDIT WORK
Do ASH'S Laundry F a c i l i t i e s and Services Meet the Hospital and P a t i e n t s '
Needs?
ASH'S laundry f a c i l i t y provides laundry services for most of the
h o s p i t a l . The f a c i l i t y was constructed i n 1950 and, according to a
recent ASH study, contains obsolete equipment which frequently breaks
down and i s worn to a p o i n t o f d i s r e p a i r . ASH developed three options
for i t s laundry operations: 1) continue current operations, however,
there may be p o t e n t i a l for l i a b i l i t y due to the poor condition of the
equipment; 2) replace the e x i s t i n g laundry equipment and r e f u r b i s h the
laundry bui lding at an estimated cost of nearly $ 1.4 mi l l i o n ; or 3)
continue l i m i t e d operations, such as p a t i e n t c l o t h i n g , and contract for
" flatwear" services ( sheets, towels, pillowcases, e t c . ) .
In a d d i t i o n t o concerns w i t h the laundry's equipment, concerns were
expressed about the laundry o p e r a t i o n ' s a c c o u n t a b i l i t y f o r p a t i e n t
c l o t h i n g . Several treatment u n i t personnel i n d i c a t e d t h a t p a t i e n t
c l o t h i n g i s sent to the laundry, but o f t e n i s not returned. One employee
commented that her u n i t does i t s own laundry because i f i t was sent to
the central laundry, " i t doesn't come back."
Further audit work i s needed to determine to what extent ASH should
continue i t s laundry services, and whether a c c o u n t a b i l i t y f o r p a t i e n t
c l o t h i n g can be improved.
Would Increased Automation Improve Hospital E f f i c i e n c y and
Effectiveness?
C u r r e n t l y , ASH does many of i t s operations without the a i d of computers.
For example, p a t i e n t d i e t a r y information, treatment c h a r t i n g , and p a t i e n t
status reports are kept manually. In some cases, i n f o r m a t i o n t r a n s m i t t e d
between u n i t s i s done by h o s p i t a l personnel v i a the use of a g o l f c a r t .
Further audit work i s needed to determine i f increased automation could
improve h o s p i t a l operations.
Should ASH Continue To Provide Food Services To The Department of
Corrections?
ASH entered i n t o a contract w i t h DOC i n 1987 t o p r o v i d e meals and other
services f o r inmates and prison employees i n the Phoenix area prisons.
ASH c u r r e n t l y prepares an estimated 3,600 meals a day for the Department
of Correct ions ( DOC), representing approximately 66 percent of the meals
prepared i n the ASH k i t c h e n . According to ASH'S food service manager,
the meals served to the h o s p i t a l p a t i e n t s and the prison inmates are
v i r t u a l l y the same, except the inmates receive larger p o r t i o n s . Menus
were coordinated to f a c i l i t a t e food production. However, our analysis of
the foods being served to ASH p a t i e n t s found that the p a t i e n t ' s
n u t r i t i o n a l needs were not being met a p p r o p r i a t e l y . In a d d i t i o n ,
although DOC provides inmates to a s s i s t i n preparing meals, ASH personnel
commented on the d i f f i c u l t i e s o f using inmate labor - high turnover, need
for frequent t r a i n i n g , and d i f f i c u l t y i n supervising the inmates work.
Further a u d i t work i s needed to determine whether: 1) the h o s p i t a l has
the means to provide d i e t a r y services to both the h o s p i t a l as well as the
prison ( adequate f a c i l i t i e s and personnel), 2) the h o s p i t a l should
continue t o use inmate labor, and 3) the contract w i t h DOC should be
con t i nued .
ARIZONA DEPARTMENT OF HEALTH SERVICES
ROSE MOFFORD, GOVERNOR
TED WILLIAMS. DIRECTOR
Office of the Director
October 24, 1989
Mr. Douglas Norton
Auditor General
2700 North Central, Suite 700
Phoenix, AZ 85004
Dear Mr. Norton:
We have reviewed the second draft of the performance audit on the Arizona State Hospital
( ASH). This draft, dated October 17, 1989, appears to be essentially unchanged from that
developed on October 3, 1989. Our previous commentary, provided to your staff on
October 13, 1989, therefore continues to reflect our response to this audit. It is unclear to
us why our input regarding staff development, supervision, improved food services and
increased Transitional Living Unit utilization were not incorporated into the report's text,
Two additional issues were noted subsequent to the October 13th conference:
I. Page 5 refers to nursing staff commentary that " current staff levels do not provide
for employee safety". This concern has not been recently raised by either the Joint
Commission for the Accreditation of Healthcare Organizations ( JCAHO), the Health
Care Finance Administration ( HCFA) or State licensure. ASH management believes
that while additional staff may be needed for therapeutic reasons, there has not been
any evidence that current staffing guidelines are below the " safe" level for patients
or staff.
The reported progress in recent years ( page 2) does not reference any of the
advancements made in regards to increased medical care available to patients or the
active Quality Assurance program now in place a t the facility, The increased
number of physicians ( including four new Board certified non- psychiatric medical
providers) now deliver a more advanced level of health care that is consistent with
community standards. The Hospital- wide Quality Assurance program allows for
increased accountability and timely corrective action for identified areas of
potentially inadequate care.
We request that you consider inclusion of the above points, as well as our previous
commentary, in your final report.
Thank you for your willingness to review this response.
Sincerely,
Ted Williams
Director
The Department of Health Services is An Equal Opportunity Affirmative Action Employer.
State Health Building 1740 West Adams Street Phoenix, Arizona 85W
- --- -- ;-
- ;: 3- 2% r- ARIZONA DEPARTMENT OF HEALTH SERVICES , --/ < . /
--,/ Office of the Director
I) ROSE MOFFORD. GOVERNOR
TED WILLIAMS. DlRECTOR October 1 1, 1989
Mr. Douglas R. Norton
Auditor General
2700 N. Central Avenue, Suite 700
Phoenix, AZ 85004
Dear Mr. Norton:
The Department of Health Services and the administration at the Arizona State Hospital
have reviewed the preliminary report draft from the performance audit completed at the
Arizona State Hospital during 1988- 89.
Our responses to the recommendations are attached. They have been reviewed with the
State Hospital's Administration, as well as Boyd Dover, Assistant Director of the Division
of Behavioral Health Services.
Thank you for the opportunity to review the preliminary draft and affording us the
opportunity to discuss these issues with you. . Sincerely,
Ted Williams
Director
TW: jl
Attachment
The Department of Health Services is An Equal Opportunity Affirmative Action Employer.
State Health Building 1740 West Adams Street Phoenix, Arizona 85007
FINDING ONE
BECAUSE OF EXTREME STAFFING PROBLEMS, ASH HAS DIFFICULTY
PROVIDING ADEQUATE STAFF OF ITS TREATMENT UMTS
RECOMMENDATION # I ASH should centralize the scheduling function within the
staffing off ice.
RESPONSE ASH nurse staff scheduling could be centralized and this issue
is now being considered by Nursing Administration.
RECOMMENDATION % 2 ASH should determine the system needed to automate its
scheduling function and request funds for this purpose. The
system should take into account the acuity on the units, the
units' census and activities scheduled on the units in order to
ensure adequate staff on all shifts.
RESPONSE ASH scheduling should be automated. While the current
manual scheduling method takes census, acuity and staff
availability into consideration, a computerized approach
would be preferable. ASH will complete a cost analysis and
implementation schedule. This will be submitted to the DHS
Director by April I, 1990 to seek additional funding.
RECOMMENDATION # 3 ASH should expand the use of flexible scheduling to provide
staff for problem shifts and heavy workload periods.
RESPONSE The ASH Nursing Department initiated a " task force" to
address the " floating issuen. The recommendations of this
process ( see Attachment 1) include limiting floating to within
each program, increasing orientation to each unit and
encouraging units to provide for their own coverage ( rather
than to depend on registry or floating). Psychiatric Nurse
Managers must also share schedules before implementation.
RECOMMENDATION # 4 ASH should ensure that all nurses in supervisory position
attend the courses available to improve supervisory/ employee
relations.
RESPONSE ASH is finalizing a Hospital specific supervisory training
program. This program will be a prerequisite to enrollment in
the Certified Public Manager ( CPM) program. This program
will orient training to the level of each supervisor's
responsibility and is being developed with input from each
discipline,
RECOMMENDATION # 5 ASH should consider expanding promotional opportunities for
its nursing staff by:
RESPONSE
Allowing flexibility in the number of levels of staff,
thereby eliminating a cap on the number of psychiatric
technician I1 positions available.
Providing additional psychiatric technician 111 positions to
allow the staff to promote on units outside the Behavior
Management program, and
Requesting additional funding from the Legislature for
this purpose.
ASH does not determine individual employee salaries. Efforts
to obtain upgrades or reclassifications have been hampered by
projected budgetary deficits. Any reorganization in the
Psychiatric Technician classification must be done only after
a comprehensive evaluation of the Hospital's staffing needs.
Further, the creation of more Psychiatric Technician I1
positions or even I11 positions is only a temporary solution for
the promotional issue. The State and Hospital need to provide
cross training into other specialties ( i. e., Nursing) or fields
( i. e., Fiscal Services), thus allowing employees greater job
satisfaction and opportunity.
RECOMMENDATION / I6 ASH should conduct a comprehensive study to determine its
staffing needs. This study should consider such factors as:
RESPONSE
The goals of the Hospital
* Expected outcomes of i t s treatment programs
Patient demographics
Patient needs assessment
* A role and task analysis
If ASH lacks sufficient resources to perform a comprehensive
staffing analysis, it should seek additional funds to fulfill the
need for a comprehensive study.
The Arizona State Hospital ( ASH) has contracted with
HamiltonIKSA, a nationally recognized health care planning
firm, to complete an analysis of the Hospital's current
staffing needs, The analysis, due to be completed by the end
of October 1989, will provide a staff- to- patient ratio for each
population of patients treated at ASH. Both direct care and
support staff needs will be determined.
The process to obtain this evaluation was initiated in June
1989. The fact that Hamilton/ KSA had previously been
involved in the Hospital's Master Planning process will allow
for their use of previously obtained program information.
This prior knowledge has allowed for a more cost effective
evaluation process, Existing budgetary limitations created
the impetus to provide the most cost efficient mechanism for
obtaining the information in a timely fashion.
FINDING TWO
ASH NEEDS TO CONSIDER RESTRUCTURING ITS TREATMENT PROGRAM AND UNIT
POSITIONS TO IMPROVE SUPERVISION AND PROGRAM MANAGEMENT
RECOMMENDATION # I ASH should evaluate the current structure of its treatment
programs and units and consider adding program managers,
head nurses and lead technicians.
RESPONSE Any proposals for reorganization must take into consideration
the entire needs of a treatment program, not just nursing
services. Several organizational structures have been
previously considered and, in fact, they have been utilized at
ASH over the past two decades. The need for a separation
between administrative functions and clinical care has merit,
however, the current limitations placed on the Hospital's
budget prohibit the implementation of this or any significant
increases in non- direct care positions.
RECOMMENDATION / I2 The Legislature should consider funding the Program Manager
posit ions.
RESPONSE I. Program Managers may be of some help and should be
considered only after thorough investigation of the
implications of reporting to two supervisors.
2. Psych Nurse Shift Supervisors ( PNSS) are assigned
exclusively to the PM and Night Shifts. The Psychiatric
Nurse Manager ( PNM) currently supervises the entire
nursing day shift staff as we11 as the 2 PNSS's.
3. JCAHO Standards ( NR4.3) as well as State standards
dictate that " a registered nurse plans, supervises, and
evaluates the care of each patient". Psych techs need a
career ladder but they cannot be on a level with the PNSS,
but must report to the PNSS. The current structure for
psych techs, which ranges from I through IV, provides a
career ladder, but will be evaluated by Nursing
Administration in terms of definition and provision of tech
leadership on all shifts.
4. All such evaluations will be completed by April 1, 1990.
FINDING THREE
" ASH NEEDS TO IMPROVE THE FOOD SERVICE FOR ITS PATIENTS"
RECOMMENDATION / I1 ASH should ensure t h a t the menus developed by its contracted
consultant meet the recommended daily guidelines.
RESPONSE ASH has made arrangements with a contract dietician to
develop master menus which meet the recommended daily
guidelines for nutrition. The master menu for the fall/ winter
cycle was implemented by a contract Registered Dietician on
a monthly basis,
RECOMMENDATION f 2 Once standard recipes are developed by ASH'S contracted
consultant, ASH should monitor food preparation to see that
all cooks follow the recipes.
RESPONSE Standard recipes have been developed by a contract dietician
for the falllwinter menu. These recipes have been
implemented effective October 1, 1989. The food preparation
is being monitored by a Chief Cook to ensure all cooks follow
the standard recipes.
RECOMMENDATION / I3 ASH should improve its procurement process for fo