Chapter 6

Monitoring is the systemic observation of a mental health facility, its staff, its patients and/or its records. Monitoring is important because it provides information about the ways an institution functions, and why. An Advocate identifies institutional policies and practices, analyzes how they affect patients, and asks how they can be changed to improve life for patients. Monitoring usually focuses on finding patterns as opposed to one-time occurrence, looking at patients' problems in the aggregate rather than individually. Although the process may be initiated by an individual complaint or informal observation, monitoring focuses on the institution and institutional change. Monitoring should have a high degree of organization, formality and objectivity in the investigation, documentation and use of information. It is a kind of research - a scientific, methodical study of the institution.

Monitoring is based on the notion that presenting solid, detailed evidence about life at the institution is the best argument for changing the institution. Monitoring helps to settle factual disputes about how isolated an egregious incident is. It allows the Advocate to show that a specific problem has occurred, is a regular occurrence, and warrants corrective measures. The organized, formalized, and empirical nature of monitoring makes it more consistent with the clinical perspective and reduces the objections of mental health personnel to the abstract and rhetorical quality of advocacy.

The success of a particular monitoring project will be determined by the quality of the evidence, the credibility of the monitor, and the efficacy of the final product. Learning to identify, document and report problems is a valuable skill in increasing the overall effectiveness of the Advocate. Preparation involves two steps:

A. Preparation

1. Develop a plan.

The Advocate's first task is to identify the questions to be answered by the monitoring project. Although full-scale review of a facility for compliance with all legal requirements can be very effective, focusing on a specific issue may be a more effective use of limited resources and enable the Advocate to provide more specific recommendations. Once the Advocate knows the questions to be answered, she/he can develop her/his plan for answering the questions.

  • Would the questions best be answered by the patients themselves?

  • Do the patients' records have the answers to the questions?

  • Will observing the facility reveal that information? Where?

  • Are there several sources of information that we can check?

Developing the plan involves creating the instruments to be used, identifying personnel to be involved and establishing the procedure and timeline for collecting the information. At this stage the Advocate should set the goals and priorities of the specific project. Considerations of time, resources (experience, money, equipment), and suspected seriousness and pervasiveness of the problem are all relevant to determining goals.

2. Develop the tool/instrument.

Even extremely simple monitoring projects can benefit from using a standard from on which to collect information. The form helps to organize and standardize the record review, interview or observation, keeping the monitor on track and establishing objectivity and credibility for the exercise. Forms can be designed as checklists, grids, or questions and answers. They should be developed with a format that follows the flow of information to be retrieved and be usable and readable by both the collector and the analyzer of the information.

3. Practicing.

Once the monitoring procedure and forms are developed, it is helpful to do some trial runs. In the case of record reviews, several charts should be used to test the instruments and procedure. Interviews and surveys should be tested as well.

Evaluate whether you are getting the kind of information you are looking for in the format you can use and in the amount of time you will have available. If the questions are repetitive or confusing or the charts aren't available when and where you thought they were, modify your plan.

B. How and What to Monitor

1. Records

Although the fact that activities have been documented does not ensure that they have been effectively accomplished, the written record is an important indicator of whether the facility recognizes its obligations and has made attempts to comply.

In reviewing records, the Advocate is looking at two things: what the records says and what the records fail to say. The Advocate is interested in both the form of the record (ie., whether information is provided and is accurate and accessible) as well as the substance of the record (i.e., whether the information provided shows that the facility has performed up to the standards it is required to by law).

A good general principle is that records speak for themselves. Advocates should presume that a particular word means what is says. When a record is silent regarding a particular event, that event has not occurred. The burden is on the facility to explain any event that has occurred and why it was not documented. .

The most important principle in chart reviews is for the Advocate to remain alert and flexible. Avoid becoming routinized in the review. Follow-up on unusual comments or notations and read progress notes of all involved staff carefully.

Record reviews provide an excellent opportunity to show how well a facility understands and follows required procedures. They can be conducted as part of a special visit to the facility, and monitored as part of the Advocate's preparation for the certification review or capacity hearing, or other advocacy functions.

2. Policy and Procedure Review

Review of policies and procedures for general facility review should include (but are not limited to) an analysis of the following provisions:

  • Cal. Welf. & Inst. Code § 5325-5325.1 rights are all included;

  • Rights are denied only for "good cause" as defined in 9 C.C.R. § 865.2 (check examples, if any) and only when less restrictive alternatives are not available;

  • Rights denied are related to the specific behavior complained of and are to be restored when "good cause" no longer exists;

  • Rights are not denied on a programmatic basis, as a condition of admission, as a punishment, as part of a treatment program, or treated as a privilege to be earned;

  • Rights denials are documented in the record according to C.C.R. 9, § 865.3;

  • Rights denials are documented in reports submitted quarterly to the Office of Patients' Rights;

  • Involuntary Detention and Treatment Standards and Procedures are consistent with legal requirements;

  • Informed consent and capacity hearing procedures are consistent with legal requirements;

  • Voluntary status is offered to all patients who are willing and able to accept treatment;

  • Seclusions and restraints are to be used only under the conditions set forth in 9 C.C.R. § 865.4 and relevant provisions of 22 C.C.R. § 865.4;

  • Electroconvulsive therapy is administered only under the conditions set forth in Cal. Welf. & Inst. Code § 5326.7 et seq.;

  • Policies provide for appropriate investigation and reporting of special incidents, including alleged sexual assaults;

  • Patients are permitted access to their treatment record (Cal. Health and Safety Code § 25252);

  • Patients are given proper information about their treatment and denials of accessare consistent with the statute (Cal. Welf. & Inst. Code § 51152);

  • Patients are to be given an opportunity to participate individualized treatment planning and an aftercare plan (Cal. Welf. & Inst. Code § 5622).

For a further discussion of the advocate’s role in reviewing policies and procedures, see Chapter VII. Policy and Procedure Review.

3. Interviews

There are occasions when interviews will be the best or the only way in which to get information. The best example of this strategy is the patient survey, an impressive and useful device for understanding the subjective experience of the patient. A great deal of what goes on in a psychiatric facility is known only to the patients. While mental health clinicians may be skeptical of the individual patient's opinion, they are less inclined to argue with the collective assessment. (See attachment #___ for an example of a patient survey)

4. Site Reviews

Regular observation of a facility is a component of all good advocacy work.

Direct, personal observation serves as a check on the information obtained in record reviews and interviews. It also helps to "round out" statistical data and personalize the advocate's understanding of the implications of problems for patients. Finally, observation alone may be the only way to provide the valuable data needed to make any institutional changes.

Observations can be recorded on standardized forms or in journal fashion with time and place in specific entries.

Facility site reviews can include a check that:


  • patients' rights posters are current, in predominant language and prominently placed;
  • patients' rights handbooks are available;
  • private telephones are available and working;
  • visiting hours are posted and observed;
  • patients are allowed to wear their own clothing;
  • patients have their individual storage space to which they have access;
  • patients have their own spending money and personal possessions;
  • property entrusted to facility's care is properly safeguarded;
  • patients have access to outdoors;
  • patients have privacy;
  • patients are treated with dignity and respect;
  • patients are provided information about their medication, patients' rights and commitment process;
  • patients have activities in which to participate;
  • patients are receiving appropriate and desired medical treatment;
  • patient census is within limits;
  • facility, including seclusion rooms, is clean and free of hazards;
  • facility is comfortable, to the extent possible.

Physical evidence and demonstration are other types of evidence available to the advocate. Showing an administrator 10 broken beds or a telephone that is out of service are better than simply telling him. By producing a used syringe an Advocate can show how they are being improperly discarded. Cockroaches in a jar, mildewed pillows and soured milk are all examples of physical evidence that can be used effectually to resolve problems.

4. Other Sources Of Information

Many agencies conduct investigations and collect information about psychiatric facilities, including the facilities themselves. Find out about internal quality assurance methods, audits and medical reviews conducted by the facility or its parent organization. Ask to see the most recent reports or findings. In county systems, these functions are often conducted by different departments that are less invested in and protective of the information. Get it and review it.

Always ask the facility for the latest report of the state Department of Health, Licensing and Certification division (or the county Health Department or Department of Social Services, if appropriate). Contact the department directly for more complete information about the latest licensing review or investigation. If specific problems are suspected, contact the state Office of the Attorney General, Bureau of Medi-Cal Fraud ((800)952-5225), the Occupational Safety and Health Administration ((415)486-3410) or, in the case of particular medical personnel, the state Board of Medical Quality Assurance ((916)920-6013) for their findings or to confirm a pending investigation.

C. Organizing and Analyzing Monitoring Data.

After information is collected it must be organized and analyzed. This usually means counting the number of specific responses and identifying a percentage. Initial organization of the information will usually follow the structure of the forms used to collect it. As Advocates work with the information, relationships between different sets of facts may emerge. Look for these relationships. Try different correlates. In monitoring, the Advocate is looking for patterns and trends. What constitutes a pattern or trend - "what is statistically significant" - will require an analysis in each situation. A general rule is that the larger the sample, the more reliable the generalization. But even several patients credibly indicating that a serious problem exists is important to consider. Weigh the seriousness of the issue and the accuracy and credibility of the evidence together with the actual numbers and percentages.

Reporting Monitoring Data

Once information is analyzed and organized, the advocate will want to develop a presentation of the results - the final product. Committing monitoring results to writing is valuable as both a strategy and record-keeping measure. Having something in writing always makes it more important, more permanent and more easily circulated to others.

Reports of monitoring exercises are not necessarily long. Some of the best monitoring exercises are short and uncomplicated. For longer reports, there should be a single concise summary - an accurate representation of the material in the body of the report. Needless to say, reports that are well written, proof-read and well organized are the goal. Remember that presentation is also a matter of the language that is used. A report should be just that - a report of your finding, your conclusions and your suggestions. Avoid proselytizing or patronizing.

A report should include:

A good report will emphasize serious problems and may mention smaller problems. Trivial documentation errors are not worth arguing about; there are real issues to address. Give credit when and where it is due. Don't overlook the good performance of an employee who is trying hard. Mention it in the report and point it out as an example of good work that can be done. Refer to and empathize with problems facing staff and administration, including cost constraints, poor working conditions, bureaucratic mandates. If possible, show how your suggestions can positively address those problems.

If possible, counter arguments against your position within the report. Be creative in developing and presenting support - extrapolate from related legal principles, demonstrate your analysis step-by-step and contrast the facts and law where illuminating. Explain the practical reasons for the legal policy. Where appropriate, give medical or psycho-social support for your argument.

Return to Table of Contents