In a previous post I discussed a recent local news article that pointed out the increase in incidents of aggression at one of the state's major psychiatric facilities and a threatened loss of Medicare funding unless certain deficiencies were corrected. The deficiencies were determined by an investigation of the facility by the Centers for Medicare & Medicaid Services (CMS). No specifies from the report were available from the news article or the Minnesota Department of Human Services. They did provide me with a contact person at CMS and after another forwarded e-mail, I was sent 4 attachments detailing the results of the investigation. I will report on those reports in this post. The documents were all typed on a standard government form as noted in the graphic below. The entire CMS report is written in the column labelled "Summary Statement of deficiencies...". No comments were written in the column labelled "Provider's Plan of Correction...":
I have coded them AMRTC 1-4 for convenience and will refer to them that way in the summaries below.
AMRTC-1 is a 34 page document that states the visits was done to see if the hospital was in compliance with 42 CFR Part 482 for acute care hospitals. The survey was conducted from 10/19 to 10/23/2015. The report indicates that there is a 108 patient capacity at the facility and that 30 records were reviewed as the basis for the report. Problems were found in 2/30 cases with regard to patient care. There were additional administrative problems that also resulted in noncompliance with the federal standard. There were problems noted It was determined that the hospital was not in compliance with the Conditions of Participation of 42 CFR Part 482. The main finding of the first report is that The Governing Body of the hospital failed to ensure that services provided by staff or contracted staff were proved in a safe and effective manner. The highlighted areas include failure to assure that quality processes were in pace to minimize or prevent medical errors, failure to assure that comprehensive nursing plans were developed, and a patient's rights condition that occurred when a patient was given forced medications that were prohibited by a court order.
The Quality Assessment Performance Improvement (QAPI) programs extended across a number of clinical and nonclinical disciplines. In some cases, they involved the administration not doing what they stated they would do in their descriptions of quality improvement. The best example I can think of is the reference to Six Sigma. I have always found it a questionable practice to apply engineering management processes to any medical field. I sat through a presentation of this paradigm in a previous job and it just seemed like the standard management buzzwords that we hear in different iterations by people who think they are inventing management every 5-10 years of so. At that job we suffered through a couple of presentations and printed Powerpoints and it faded as soon as it came up. We moved on to a different paradigm. Since it was widely promoted, the Six Sigma approach has been shown to not be uniformly effective in business and manufacturing models. What the proponents of Six Sigma to medical fields don't seem to understand is that measurement is a limiting factor and it has nowhere near the precision or accuracy of measuring products in electronics or automobiles. At the philosophical level the administration probably made the common error of espousing a philosophy that they could not live up to. I am not aware of any major healthcare corporation that uses the Six Sigma management model and they probably have many more resources than a state hospital.
One of the case examples cited was an agitated patient who was physically aggressive and received olanzapine and then intramuscular haloperidol despite a court order excluding haloperidol and risperidone. The psychiatrist and nurse involved were questioned and said they were unaware of the order at the time the medication was administered. The patient got this medication for a period of 3 days before it was discontinued. CMS investigators comment how the physician in this case could be held in contempt of court for ignoring a District Court judge's order. There was a question of whether or not there were two different orders and the one barring the medications showed up later. As a physician who has worked with different court orders in these cases for over 20 years, I can attest to the fact that they are not necessarily clear. In many cases there is a temporary order until the final document can be typed up. It would seem that the quality process here would be to appoint a person to make sure the latest order is in the chart and read by the attending physician before any medication orders are written. There is also a question of how paper documents from the court are placed in an electronic record and how easily they can be read in that record.
At the end of the document problems with the care of 10 different patients with different diagnoses and problems are reviewed. These clinical examples were given to illustrate that that patient with varied problems were all given treatment plans that were not comprehensive, even in the case of patients with aggressive or self injurious behavior. The reports describes this as:
"Interventions on the Patient Treatment Plan were generic and were normal functions of the professional disciplines involved in the patient's care and were not individualized to the patient."
What does all of this mean? A recent article in the StarTribune (1) had quotes from several mental health experts and advocates about the state of affairs at AMRTC. The commentary seemed to vary in the level of outrage expressed as "egregious" and "appalling" and "no excuse." As an expert - when I read the report it seems to scratch the surface. Would correcting the deficiencies in the report right the ship out at AMRTC? Possibly - but the previous news report suggests there is a much bigger problem. That report was about incidents of aggression, how they were increasing, and there was an opinion that aggressive inmates transferred based on new legislation was the main reason. A union representative was quoted as saying that some of the inmates transferred from correctional facilities had "taken over" and that they were more aggressive than non-correctional patients. None of those problems are specifically addressed in the report. The report comments on problems in the care of specific individuals, only one of whom seem to be as aggressive as two of the patients mentioned in the original article (2). The errors in the report may be largely documentation and reading errors, but administrators always emphasize "if it isn't documented it did not happen." Some of the problems at AMRTC have been decades in the making.
For a long time the message given to most professionals in the state is that the state hospital system including AMRTC (like practically all other hospitals in the state system) was going to be shut down. Only the practical fact that there is always a backlog of committed patients waiting to get in to AMRTC prevents it from being shut down. But the key question remains - is this really the attitude of managers at the level of the State of Minnesota?
The second problematic attitude that I have heard about constantly is written about in the recent article (1):
"Nearly half of the 101 patients currently there no longer meet the hospital-level criteria for care but are kept at the hospital because they have nowhere to go in the community. In 2013 alone, patients spent a total of 13,800 unnecessary days at Anoka-Metro after they were treated — enough to care for another 140 patients, according to a state legislative report."
This is a good example of circular reasoning. The reason why patients spend so-called "unnecessary days" at AMRTC is that there are no other facilities that can manage their behavior. I am aware of programs where very aggressive individuals are managed in very small settings (2 to 4 resident group homes) and the staff is taught to physically restrain them when they become very aggressive. That is really an unacceptable long term solution to the problem for many reasons. It is time to stop pretending that long term hospitals are acute care hospitals and that they should be managed like acute care community hospitals. A transient reduction in symptoms does not mean that a patient at AMRTC is spending "unnecessary days" at the hospital. If they cannot successfully transition to a community placement - they probably need to be there.
The real and unaddressed issues (beyond the CMS report):
1. The effect of the message that state hospitals should all be closed: As a psychiatrist in the state, this is what I have been hearing for a long time. It is really not possible to develop a quality of care focus or have the necessary stable staffing patterns of experienced staff, when those same staff are hearing that the state is trying to close down the facility and that many people at the facility don't need to be there. Instead - the facility should be managed as one that can provide state-of-the-art care to patients with complex problems including violence and aggression. Another aspect of that is eliminating the positions of experienced staff to save money. You will never have a high quality program using this approach and yet the state has used this approach.
2. The effect of management from higher levels: This seemed to stand out as I read the issue of "generic treatment plans" from the CMS report. At some level all treatment plans become "generic treatment plan". The evidence is that you can purchase treatment planning texts for nursing, psychotherapy and to a lesser degree psychiatry that will show you generic treatment plans for an entire list of problems. Is the problem really a generic treatment plan that covers most interaction or the lack of a treatment plan that addresses a high degree of aggression? I would contend that it is the latter.
Complicating that issue are previous stories about how plans were implemented by state administrators with no psychiatric experience to address patient aggression. I sat in on one of these sessions that suggested that a focus on the aggressive person as a psychologically traumatized individual was the best way to proceed, but not much specifics after that. Is at least part of the problem that state hospital staff have inadequate guidance on what to do about aggression? Are they reluctant to intervene early or clearly document what happened and their response because the response from administrators is inconsistent? Are they being advised to use interventions that are ineffective?
3. The lack of teamwork and possibly a split staff: One of the most dangerous problems in any inpatient psychiatric environment is staff splitting - some of the staff are praised and well liked and other are criticized and disliked. This emotional environment in inpatient care leads to problems in patient care. Splitting needs to be minimized or eliminated largely by recognizing that professionalism and the objective analysis and treatment of problems is the real priority. I have been in treatment environments where staff were disliked or falsely accused and that lead to major problems in patient care and episodes of aggression. It also leads to staff turnover. The attitude of administrators can be particularly insidious and create an immediate rift among the staff.
4. The influx of inmates into AMRTC that is caused by the current public policy of rationing community psychiatric care and the resulting shift in the cost of care to the correctional system: Instead of addressing the widespread problem of rationing psychiatric care for the severely mentally ill - the solution is currently to dump at least some of them from law enforcement facilities to a rationed long term care facility. How is that a solution to anything?
These are the real problems at AMRTC and within the state system as far as I can tell. This is all based on what I read in the papers, the CMS report, and my extensive inpatient and out patient experience as well as experience treating aggressive people. The CMS report while noting significant problems does not come close to addressing these issues and makes it seem that addressing problems in patient care or documentation will correct the problem with aggression within this system.
I doubt it is that easy.
George Dawson, MD, DFAPA
1: Chris Serres. Anoka state mental hospital violated basic rules for patient care, feds say generic treatment plans, other issues put mental hospital's federal funding at risk. StarTribune January 16, 2016.