Changes urged at state mental facilities
By ALAN JUDD
The Atlanta Journal-Constitution
Published on: 01/09/08
Not enough "competent medical personnel."
Staffing shortages that leave patients vulnerable to suicide, assault and medical emergencies.
Salaries for front-line workers on a par with those paid in fast-food and housekeeping jobs.
This depiction of Georgia's psychiatric hospitals emerges in a critical but measured report by a team of state-paid consultants who recommend more hiring, better pay and a much greater emphasis on medical care in the seven state-run facilities.
The consultants — doctors, nurses and administrators assembled by the Medical College of Georgia — spent nine months examining the state hospitals at the request of the Department of Human Resources. They urged sweeping changes to a hospital system already under intense scrutiny following dozens of deaths and cases of patient abuse in the past six years.
Their report, submitted late last month, identified numerous chronic problems: the hospitals' failure to detect serious medical conditions in patients, poor supervision of suicidal and aggressive patients, and insufficient monitoring of the potentially lethal side effects of psychotropic medications.
The hospitals, the consultants concluded, must develop "a culture of quality." But, they said, "correcting deficiencies to turn the system around will be slow and deliberate, requiring continued commitment and support over time."
The report amplifies articles in The Atlanta Journal-Constitution last year that revealed dangerous conditions in the state hospitals. The newspaper reported that at least 115 state hospital patients died from neglect or abuse or under other suspicious circumstances from 2002 through 2006. As many as 21 more questionable deaths occurred in 2007, the newspaper found.
The articles prompted the U.S. Justice Department to open a civil rights investigation into patient treatment. In addition, Gov. Sonny Perdue created a commission to study an overhaul of the state's mental health care system.
The state's mental health agency says it already has begun making changes, adopting uniform medical practices and assigning primary-care physicians to all seven hospitals.
In a statement Tuesday, an agency spokeswoman, Kenya Bello, said: "We asked for the review in order to get an objective understanding of where our strengths are and where we need to improve. The report provides us with that insight as well as thorough direction on how we can better integrate psychiatric and medical care."
As they released interim reports on individual hospitals last year, the consultants said, other facilities voluntarily adopted proposals for improvements.
"We got the impression things were being fixed as we were going along, as much as they could," Dr. Peter Buckley, co-director of the consulting team, said in an interview Tuesday.
But the problems facing the hospitals are "complex system issues," said Buckley, chairman of the department of psychiatry at MCG. "They don't reside in any one particular person or any one particular position. They are all interrelated."
More than 40 solutions
The consultants' interim documents offered an unvarnished view of poor care and medical errors. Their final report takes a gentler tone. It praises the quality of care for long-term patients with developmental disabilities and the resiliency of many employees, in particular those with long tenures.
"In general," the report says, "the core staff at the facility level are committed to their jobs, and have continued to show compassionate care and dedication to their job in the face of staffing shortages, patient care challenges and, recently, exposure in the media."
Still, the consultants identified numerous conditions that threaten the safety of the hospitals' patients. They recommended more than 40 potential solutions — but did not address how much they would cost, or how the state should pay for them.
The consultants found staffing shortages among every group of workers at every hospital. These shortages cause poor planning for patients' treatment after they leave the hospitals, the consultants said, as well as incomplete assessments of new patients and less oversight on the hospital wards. The results include "increased risk of assaultive behaviors, suicide attempts ... [and] unobserved or [un]noted medical conditions and de-compensating psychiatric conditions."
"Although the severity of the problem differed between individual facilities," the consultants wrote, "without exception this was the most consistent and significant challenge at each facility."
Matters are especially critical among the lowest-level employees.
"The Health Service Technician job classification requires no prior health or mental health experience or education," the report says, "yet Health Service Technicians are the primary attendants and care givers to patients. ... Salaries for this position compete with fast food restaurants and housekeeping personnel."
Higher pay proposed
The consultants recommended pay raises to bring state hospital workers' salaries closer in line with those at private facilities. Higher pay, the report says, would improve employee morale and decrease turnover, leading to better patient care.
The quality of care also would improve, the consultants said, if the hospitals hired "competent" medical staff who could recognize and treat patients' medical conditions as well as their psychiatric disorders.
The consultants recommended that the facilities ask Georgia medical schools to train the hospitals' clinical staffs in "the basic recognition and management of medical conditions."
Many failings, they said, could be traced to "the absence of clinical practice guidelines, or guidelines that may not be considered best practice."
The report continues: "Variations from known standards of care, variations of care because of lack of standards or lack of coordinated care not only constitute an ineffective treatment environment, but also create situations of danger for patients."
Although most of the report focuses on hospital performance, it also recommends state-level administrative changes. The consultants suggested the state appoint three to four associate medical directors to oversee the hospitals' quality of care. They also recommended "expedited and thorough investigations" of patient deaths and other serious events.
Buckley said the consultants did not offer "overly prescriptive" solutions or cost estimates. The state officials who run the hospitals, he said, will have to draw their own conclusions.
"We provided a direction," Buckley said, "and, hopefully, a fair, balanced recommendation."
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