Quality Improvement Committee
Inpatient and Tomorrow

Written by Kathi Stringer
Revision [A]

Before my first hospitalization, I was a self-employed government sub-contractor, a key supplier for Hughes Aircraft. I built and designed parts for the medical, electronic and aerospace companies. My company produced parts on CNC machines along with automatic screw machines. I designed and engineered parts to resolve my customers’ problems. I was certified per MIL-I-45208A (Military) and familiar with ISO-9000 family standards.

I owned a job shop, and a ranch in south Corona in which I enjoyed improving and building the structures myself. I learned how to operate heavy equipment, the loaders and dozers. I loved to learn and try new things. I owned a western wear store in Norco and other properties. I had a nice home, and drove nice cars. I owned a $30,000 Eliminator pickle-fork speedboat when Cadillac Sevilles’ were selling for $14,000. I achieved this before 30 years of age. I was the poor kid that went through foster homes, beaten and abused from my dad (too ugly to restate here) but determined to make a better life for myself. I did that! I was able to do this because I believed that people were basically good, and cared for each other. I looked at the better side of life and took responsibility for myself once I was old enough to get away with it.

Then one day, when I was at the lowest part in my life, when I needed help the most, when I was severely depressed, I was involuntary hospitalized. I was not prepared to be called crazy and coo-coo by inpatient mental health staff. Now, keep in mind; I came from a competitive part of the world. I was used to administrative meetings, respect, and equal form of communication. I had no idea what went on in these sorts of places. The only thing I knew of mental hospitals was what I saw on television. I was accustomed to mutual respect from business acquaintances. Not this. It wasn’t the patients that made the place wacko, but some of the staff. This was a different world. I was not prepared for name-calling, and the condescending communication. I wasn’t prepared for the blank-faces on some of the staff, as though they wore a masque. Some adopted the attitude that I didn’t exist because I objected to their machine-like treatment of me as a non-person, or their off-handed insults. My self-esteem was shot after these types of interactions.

After being completely blown out of the water from receiving this kind of ‘treatment’ I began visiting the college book departments to understand why I was treated so badly. I found out quickly that staff behavior was quite different than what they were teaching in the schools. I decided to dive deeper into the phenomena of book treatment modalities vs. staffs’ mistreatment on the job. Why was this happening? I continued to search. However, the in-depth information I was seeking was not available at the local colleges. With some research, I subscribed to the scholarly journals from the APA, and their book catalogs. I bought scores of books from the prestigious Aronson publishers, and also their video lectures of cutting edge treatment modalities.

What did I find out? A common theme was lacking. The root of the problem appeared to be from weak management from lack of high-energy training. Staff management was deficient in areas of encouragement and support to deliver affective treatment modalities to boost team moral toward patient satisfaction. It simply did not exist as demonstrated by the employee performance on the job.

The First Step, Trial Run:

I figured the best way to reach those receptive for information would be through the Internet. I put together Kathi’s Mental Health Review. I began writing research papers in hopes to reach, and encourage staff to try effective treatment modalities. For example, I addressed the importance of building a strong therapeutic alliance to improve treatment compliance. I wrote about supplying the patient with new positive models through role-identification, and methods to deescalate the situation. The results are encouraging. Professionals that are using these suggestions are noticing performance improvement. They are noticing the heavy atmosphere lift off the unit, and they are encouraged with new effective tools. I am receiving responses and request for permissions to republish my work at universities, family-to-family support groups and other institutions.

The Paradoxical Problem

There is much information available that will get things moving in a better direction. EXCEPT, it seems those that are writing the books, the most knowledgeable, are doing exactly that, writing, and not working with the clients as their careers have blossomed. And, individuals that need this information the most are working in the fields/units have no time to find this information, let alone research and glean off what is necessary to make those improvements, and put a plan together. Not only that, but reading and understanding the information is only one aspect, next is transferring that information into a ‘supportive’ work environment that encourages change rather then frowning on it.

Current Examples of Staff Behavior

Have you ever been inpatient? Imagine this! You are standing on the ‘wrong’ side of the Red Line. You hear someone yell, “Step back away from the Red Line!” You look around, and no one else is where you are standing. You figure this staff person is demanding this from you. You are not used to be spoken to in such condescending tones. You feel heat on the back of your neck, and react, “Or what?” Then comes the demeaning response, “or you will go into seclusion and restraints!” That happened to me. Since I was bullied and abused as a child, those same dynamics were awakened and this staffer was clueless. Those dynamics inspired me to fight back as a child, to get beyond the bullies and become successful. However, here stood the bully again because he did not have the training to be a healer. I could not leave the situation because the door was locked. And, I would not respond to this type of communication. I did not move, not with his derogatory voice. Instead, I and was drugged and strapped to a bed. How many resources did that take up? Consider the following healing response. First use empathic body language, “Your safety is important to us. Really, it is! Come on this way,” with an inviting smile. With some coaching, the drugs and restraints would have been avoided, and a therapeutic alliance would have developed further toward treatment compliance. Instead, treatment was set back with hatred and resistance. The difference? Empathy, insight and skills acquired through training. The question is, do we use the resources in training to heal on the front end (positive), or to clean up the mess at the back end (negative). Either way, the resources are spent. The difference is, will the resources be spent positively or negatively?

The Solution:

Knowledge, support, encouragement and team moral for a job well done. It’s not enough to have the knowledge. It takes a coach! Someone to come up with new cutting-edge game plans, to review current strategy, to build the excitement of employing effective tools and getting acknowledgement and validation from team members.

You will comply!

This type of oversight sets up quality compliance rather then performance improvement. In the service business, the preponderance is on the latter. The distinction is important because rigid quality standards reflect heavily in manufacturing products, whereas, performance improvement reflects human service standards toward excellence. Although, quality compliance is a component for performance improvement, it can jeopardize service delivery when the task of endless signatures and documentation control interfere with the actual service. For example, I recall a time during an inpatient admit when a nurse was checking off her initials on blank forms from the top to the bottom of the page. She did one page after another. Finally I asked, “What are you signing off on?” She said, “I’m signing off on the signatures that will be added later. I hate doing this.” In effect, we have a nurse signing off on paperwork BEFORE the tasks were performed. The equivalent would be signing a blank check. Yet, the auditors will have no way of knowing this is going on because by the time they see the paperwork, the information is there. Because of this type of compliance model, the resources were spent on useless paperwork rather then performance improvement toward consumer satisfaction.

The above example has demonstrated that it is more important ‘how we do things’ then ‘what is done’ when striving for performance improvement. With training, support and encouragement, we can change how things are done. With effective management, we can increase the energy and team motivation with recognition and mutual support. This attitude, willingness and training, will decrease the need for more and more oversight documentation that gobble up service delivery.

Consider this analogy:

Suppose we ask an individual with little or no training to drive a car across town. We ask that after every turn, every stop, every signal, the driver describe and initial the events as he is driving. On the other hand, suppose we ask a second driver with expert training to drive the same route without the heavy documentation. Which driver would be more likely to out-perform the other? The driver with the training, of course. Further, lets suppose the first driver made mistakes due to the heavy focus on documentation and ended up in a car accident. What would make more sense for corrective action, train the driver, or increase the documentation? Train the driver. We see this same sort of problem when staff are documenting as the patient is spiraling down toward a crash. The staff are distracted and not aware.

This is not to imply that we do not need documentation. We do. And the documentation needs to be objective, factual and accurate. However, like everything universally effective, there must be ‘balance.’ We must balance the documentation with the training. Either of these variables out of balance will decrease performance.

Why training is so important for team alliance and performance.

Group training that incorporates exchanging recent inpatient experiences and role-play for critical examination and feedback will promote interest. For instance, lets say a patient is getting agitated and a staffer sees this as an opportunity to use his training, as a challenge to deescalate the situation, rather then being ‘put-out.’ The staffer employs skills and tools reviewed in training, and a fellow staffer notices. “Hey, you handled that great! The client is actually beginning to respond in a positive way. High five!” Or “Hey, I checked out how you handled that. I’m impressed! How did you do that exactly?” In cases like these, the work has become more stimulating now and techniques are observed and refined for performance improvement. The work has moved into a sense of accomplishment through knowledge.

Why getting inpatient help is good for families and caseworkers.

Lets suppose you are at the end of your tether working with a difficult family member. You talk them into going inpatient to get their medication adjusted. During the admission staff behaves in an amateur fashion and it slighted with insults or body indicators. Your family member harbors rage and this spills out after discharge.

Lets look at another situation. A case manager decides her client needs hospitalization because the client is getting difficult to manage, and she needs a much-needed break. During the admit, the staff demonstrate problems with professional behavior from lack or training or accountability. The client lies to get out of the hospital and is carrying a bad experience back into the office of the case manager. The case manager is frustrated because instead of getting the client back in better shape, she now has more on her plate to deal with. This sort of thing happens all the time.

I remember that during one admit a code ‘blue’ was called. A female staffer jumped up and ran out to respond to the call. When she returned, she said to her friend, “I’m so pumped! I live for take-downs! That is why I took this job!” Unfortunately, positions like this allow the sadistic to act out their fantasies. Even though it cannot be entirely screened out, the job environment can take on a different kind of air that would frown on such attitudes. For example, when a team effort is ongoing, and reflected on daily basis, a comment like this would come off as team betrayal that would jeopardize team efforts for success.

Data Reliability

Data reliability is important. Not only what is collected, but also ‘how’ it is collected. For example, at this time in Riverside County Mental Health and for years past, there is no documented procedure how various grievances are collected. Depending on the payer, some are routed to Patient Rights’, some to Quality Improvement at the hospital, and some to the Quality Improvement Committee (QIC). And some end up sitting on an inpatient supervisors desk and doesn’t get routed at all, but ‘none’ are logged in a comprehensive database, because there is no cohesive model for collecting the grievances. The results end up being scattered and of little value. This is problematic because grievances identify areas for performance improvement that are not getting addressed.

Nothing Changes, If Nothing Changes

To be objective, lets consider the impact on the department if grievances were taken more seriously. Trends and patterns would develop. This would lead to change and accountability. Yet, under the current model that is already heavy with documentation, it is likely that the requirement for documentation would increase. This pseudo corrective measure would impede improvement since training; frequency of training, and comprehension of the training material is not the focus of current performance improvement.

Further, studies indicate that some individuals in management will be resistant to change. They do not want their comfortable apple cart upset. A change in performance may invite unmotivated management to rise to new challenges, new innovations. They might actually have to start applying themselves.

Lack of Contact with Trained Professionals

In today’s inpatient settings, the persons with the most training have the least amount of contact with the patient. It is not unusual for a nurse to sit behind a glass barrier the entire shift without speaking with the patients. However, Mental Health Workers (MHW’s) that have most contact with the patient have little and no training. I have personally witnessed the training of MHW’s that amounted to a ‘walk-through’ before starting the next day. Problems arise when the nurse is relying on information as interpreted by the worker. The nurse charts the MHW’s perception and NOT the nurses. Since the MHW does not have training on objective reporting, things get distorted as they are presented to the nurse. Next, it is not usual for the nurse to order interventions without personally assessing the situation for herself. In essence, all her training is of little value in these matters. The lack of empathy training from the MHW’s can worsen the situation.

Temporary Help

Inpatient units rely heavily on temporary help from agencies. This impedes performance improvement because hospitals have far less control over the training environment. And, the temporary staff has significantly less motivation since their jobs are not as attractive. A first step to improve performance would entail designing a framework with employees that are consistent with the job environment and job training.

It appears at this time, the use of temporary help through outside agencies satisfies staffing requirements for auditors, with the emphasis of the county mental health management getting paid rather then performance improvement for the consumer.

Community Interest

The one single, and most effective instrument for change was designed by ledgistion to include community individuals interested in the delivery in mental health to be included in a public process. This instrument is 1810.440 of Title 9, which invites and includes community citizens to Plan, Design, and Execute a Quality Improvement Plan. This community of citizens, which includes private contractors and county employees, are referred to as the Quality Improvement Committee (QIC). However, much of the process and resources of QIC are ambiguous and not understood since its inception years ago. It would be imperative that QIC have a handbook, or procedure manual. This would encourage, and empower interested individuals to participate in an informed member. A handbook would demonstrate the flow with examples how meaningful change was identified, planned, designed and executed through Flow Step-Models.

Summary for Performance Improvement
What We Need:

QIC Handbook (not the QIC plan)

QIC resources in accordance with 1810.440, to plan, design and execute a QI plan.

Consideration for Permanent Employees

Data reliability and models for data flow

Training, training and training.

Receptive work environment for change

Motivated management geared toward excellence via training