DHHS officials support changes
By Matthew Whittle
Published in News on September 22, 2010 1:46 PM
Work at Cherry Hospital, the state's psychiatric hospital for the eastern region, has become more dangerous since mental health reform began, state officials admit. However, they also say that new and improved processes and procedures are being put in place and that the new administration should be given time to make things better.
Despite all the recent problems at Cherry Hospital, the state psychiatric facility's administration seems to have the unwavering support of those higher up in the N.C. Department of Health and Human Services.
Recognizing that hospital director Philip Cook has only been in the position for 17 months, Luckey Welsh, director of state-operated health care facilities, and Laura White, state hospital leader, both said recently they think Cherry is moving in the right direction -- although they acknowledged the last few months have not been an easy time.
However, they also said that such hard times -- and the types of difficult patients that Cherry has had -- are likely here to stay.
"Our role here is to be sort of the safety net," Welsh said.
And at Cherry that net covers North Carolina's eastern 36 counties.
He explained that under the mental health reform legislation enacted in 2001, the state's goal became keeping mental health patients in their communities where they could be served by local doctors and treatment centers, including the psychiatric wards of community hospitals, with the state facilities being available for the most acute patients now, and in the future.
"Our goal is for patients to be cared for in their communities whenever possible, and to come to us when their needs can't be met there," Welsh said. "So what we're finding is the lengths of stay are longer and they're more aggressive."
And really, Ms. White said, that's "almost by design" -- not only at Cherry, but also at Broughton and Central Regional. "We see ourselves as the safety net. We're doing what we should be."
But when asked if this new concentration of patients is putting staff in danger, Welsh and Ms. White acknowledged that the job can be dangerous, but said that they are working to train staff and put them in positions to avoid injury as much as possible.
And when comparing staff injury numbers at each of the hospitals since January, as reported by the state Department of Health and Human Services, Cherry Hospital has the most -- 251 at Cherry, 186 at Central Regional, 175 at Broughton and 102 at Dorothea Dix.
Unfortunately, that information differs from what is publicly reported online, which shows Cherry with 48 injured staff members since January, compared to none at Broughton, Central Regional and Dorothea Dix -- a reporting problem Ms. White said state officials are trying to correct.
Officials also said they are working to correct discrepancies in how each hospital defines, interprets and deals with claims of abuse and neglect.
Another area of concern, they said, is in how incidents are reported to the state Board of Nursing, which doesn't seem to be quite in line with the rest of the industry.
"That's an area that we're trying to talk about -- what we're calling neglect and abuse and what we should be reporting to the registry," Welsh said.
However, he explained, the hospitals have a duty to report anything to the state Board of Nursing that they consider to be a form of abuse or neglect -- even if it turns out to be short of what the state licensing body considers to be an offense.
"They have their own definitions and thresholds," Welsh said. "We report based on what we should report. They're reluctant, though, to impact people's livelihoods."
And in Cherry's case, in which according to the Board of Nursing, just five of 54 reported cases came back with some sort of action being taken, Welsh said he does not feel that those numbers show a problem with over-reporting.
"I don't think you can look at it as we over-reported," he said. "But I'd rather explain over-reporting than under-reporting."
CPI and medication
"Our first and foremost concern is for this to be a safe place," Welsh said.
And that means properly protecting and restraining patients when necessary.
They praised Cherry for being one of the first of their state facilities to go to the Crisis Prevention Institute method of intervention -- a move that was made by Cook's administration in April 2009.
"This is the national standard. It really is the gold standard," Welsh said.
And, he continued, the state has committed to doing more to make sure employees are well-versed in the proper techniques -- something that's already happening at Cherry.
"In talking to Philip, he recognized the difficulties they were having the last three, four, five months. He also recognized that the training of the staff was not where it should be, so he held more intensive training," Welsh said.
And now, the state Legislature has invested more money in training efforts for all of the state's facilities, he said.
"You just can't change without better education and better accountability," Welsh said. "And I don't think in the past we've had the funds to do that."
But that doesn't mean they expect everything to go perfectly with every intervention.
"We're trying to bring in a different culture of understanding that errors are made because we're human. If the technique's just not right, that's a training issue, and we're trying to make sure we have additional training," Welsh said.
The zero-tolerance policy, he explained, was never meant to punish people trying to do their jobs correctly.
"The (DHHS) secretary (Lanier Cansler) never intended to do anything to someone who makes a human mistake. We're going to be fair with you. But if you do something intentionally, if you abuse somebody, we will take terminative action," Welsh said.
And so, he continued, there's no excuse for people to "stand back and do nothing -- you can't do that. That's wrong."
Ultimately, though, the goal is to intervene in a situation before it gets to the point of needing a physical interaction.
They also explained that medication can be used, but only as part of a patient's psychiatric treatment plan -- not as a chemical restraint.
"If we get to that point, and it is part of the psychiatric treatment, we would do that," Ms. White said.
But, Welsh stressed, "the giving of medication is a physician's decision, not an administrative one. That's a clinical decision they make."
State officials downplayed the concerns that Cherry Hospital and others are not adequately staffed, though they admitted that there currently is too much reliance on temporary agency nurses. Currently the hospital employees 104 permanent nurses and 34 agency nurses.
"We need more full-time, permanent people. We're having to resort to agency staff, which we do not like," Welsh said. "But staff ratios, we feel like we have budgeted for all our facilities to be adequately staffed."
The problem, though, is that not all of those nurses are available to deal with the 2010 average daily census of 161. (Broughton's average daily census has been 251 with 193 nurses employed, and Central Regional's average daily census has been 186, with 227 nurses employed.)
The problem is that because of Cherry's location, there isn't a large pool of people who can fill those permanent positions when they come open, hence the reliance on agency staff, which Welsh said, isn't ideal. Plus, he said, state hospitals, even when they can find nurses with a background in behavioral health, have a hard time competing with private health care facilities in terms of benefits, salaries and more.
"That's true both of Broughton and Cherry, our rural hospitals. It's not as bad with Umstead/Dix/Central," Ms. White said.
But they do see a brighter future ahead for Cherry Hospital, especially as a new leadership team begins to take its place. Already hired are a new chief medical officer and a new chief nursing officer, expected to start in October, and they hope to hire a new chief psychiatrist soon.
"We're trying to put the right people there in the leadership. That's where we can start a positive movement at Cherry. One person can't do it," Welsh said. "You don't change the culture overnight. Change brings people who resist change. The work force at Cherry primarily comes from Goldsboro and Wayne County -- longtime employees. (But) changing a culture and organization in a small community takes more time. Once a hospital has a core group of workers and gets that reputation .... We've got to get a buy-in from those core people who work there, and we're on that road."
One marker on that road is the renovations being done to create several new wards, including the psychiatric intensive care ward for the most acute and aggressive patients. Despite the $400,000 price tag, officials said that with the new facility still about four years away, the need to do something now to improve conditions at the hospital was just too great.
But even as things improve, the state officials acknowledged there will be mistakes and setbacks.
"In hospitals, in health care, we have mistakes every day. But it's (usually) done within the privacy of that medical center and the families. Our mistakes, big and small, are out in the open.
"Our goal is to give (staff) the education, the training, the support and the staffing that they need to do a great job. I will defend the people we have and the job they're trying to do under difficult circumstances. Most of our employees do a great job. We want them to be part of the solution. We do things wrong. We're human beings taking care of human beings. Our goal is to make it as perfect as we can. Cherry can be a great hospital. It's not a great hospital today," Welsh said. "I think we're on the right move. I believe we're making positive steps forward. I don't think we're where we need to be.
"Our ultimate goal is for the people of this state to trust all of our facilities to take care of their family members."