COUNTY OF ORANGE HEALTH CARE AGENCY OFFICE OF THE DIRECTOR DAVID L. RILEY DIRECTOR MAILING ADDRESS: 405 W. 5 th STREET, 7 th FLOOR SANTA ANA, CA 92701 TELEPHONE: (714) 834-6021 FAX: (714) 834-3660 E-MAIL: driley@ochca.com FOR INFORMATION ONLY TO: Supervisor Janet Nguyen, First District, Chair Supervisor, Bill Campbell, Third District, Vice-Chair Supervisor John M. W. Moorlach, Second District Supervisor Shawn Nelson, Fourth District Supervisor Patricia C. Bates, Fifth District SUBJECT: Response to OCEA Allegations Regarding Correctional Medical Services On Thursday July 22, 2010, your offices received a large binder regarding Jail Healthcare that included an Orange County Employees Association (OCEA) summary of grievances, staff petitions of no-confidence, and copies of a 2008 Grand Jury Report and the 2009 Office of Performance Auditor Report on Correctional Medical Services. OCEA did not share a copy of these documents with the Health Care Agency (HCA) or the County Executive Office (CEO) despite good faith efforts by HCA to work with OCEA on jail health issues. HCA received a copy from the County Executive Office. The binder is the latest in a series of OCEA communications to a variety of audiences regarding jail healthcare management. Most of the issues raised by OCEA are a reiteration of issues previously identified and responded to by HCA. The approach taken by OCEA is consistent with their past practice of blaming management. In October 2007, when Correctional Health Services had a different Division Manager, OCEA submitted a similar petition of no confidence. The current submission by OCEA is dramatic and inflammatory yet, as with their other correspondence, contains many inaccuracies and mischaracterizations. Their continuing negative portrayal of HCA and Correctional Medical Services (CMS) management does not reflect the significant positive changes that have occurred and is not conducive to good faith labor relations. OCEA s strategy is divisive and hinders CMS s efforts to improve morale and establish and maintain a positive environment. HCA continues to make sincere efforts to work with OCEA and has done so over the past several months. The following provides background information regarding correctional healthcare and a description of HCA s strategy to manage and further improve jail healthcare services. The
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 2 attachment provides responses to specific OCEA contentions a number of which are either fully or partially inaccurate. CORRECTIONAL HEALTHCARE HCA s Correctional Medical Services Division provides medical, dental, and pharmacy services to adults incarcerated at the four Orange County adult correctional facilities: Intake/Release Center, Men s Jail, Theo Lacy, and the James A. Musick facility. Services are provided around the clock, seven days per week. The correctional healthcare program (which includes both medical services and mental health services) is administered through a Memorandum of Understanding with the Orange County Sheriff, who holds statutory responsibility for the healthcare of inmates. HCA contracts with Western Medical Center - Anaheim and a physician group for acute inpatient and specialty physician services. CMS has 182 staff, including physicians, nurses, pharmacists, dentists, dental assistants, medical records specialists, and other clinical or support staff. These remarkable and professional staff members do an outstanding job under challenging conditions in delivering excellent treatment and care to inmates requiring medical treatment. The Correctional Healthcare mental health and dental programs are especially noteworthy as state and national models for their excellence. CMS, the focus of the OCEA binder, has a budget of $33.2 million 92% of which is net county cost. Approximately 60,000 inmates enter the Orange County jail system each year; the jails currently have an average population of 4,866 inmates. The legal context for providing medical, dental and mental health services is different in jails from that in the outside community. In no other healthcare setting are such services constitutionally guaranteed. The County is required to provide jail inmates with the level and scope of health and mental health services commensurate to that provided in the surrounding community. CMS cares for an inmate population that engages in multiple high-risk behaviors (smoking, drug use, etc.) prior to incarceration, and who often have significant untreated medical, dental and mental health issues. The inmate population has rates of HIV, Tuberculosis, Hepatitis C and mental illness that far exceed the rates of these conditions in the general population. The volume of healthcare delivered in the jail system is substantial. Approximately 75% of the inmates have an open medical file and 35% of the inmates require ongoing mental health treatment. For the month of May, 2010, there were 7,984 RN sick calls, 1,114 Nurse Practitioner occurrences, 714 M.D. occurrences, 1,510 mental health cases opened, 730 dental encounters and 156 outpatient on-site specialty clinic appointments (optometry and OBGYN).
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 3 Despite CMS s challenging population and the level of care required, CMS has consistently received positive remarks from external review sources about the healthcare provided. While identifying operational areas for improvement, the 2008 Grand Jury and the 2009 Office of the Performance Audit reports stated: The nursing and executive staffs of Correctional Medical Services interviewed are highly professional, competent and dedicated to providing a high level of medical service to the inmates housed in Orange County Jail facilities. (May 2008, Orange County Grand Jury Report) inmates at Orange County jail facilities are receiving excellent professional nursing care (May 2008, Orange County Grand Jury Report) The audit team identified the following areas where CMS is providing quality services: Basic inmate health care, initial health screening during inmate booking, medication supply and distribution, an overall commitment to inmate care (Office of Performance Auditor Department) In addition, a recently released report from United States Department of Justice that summarizes 2000-2006 Local Jail death data identifies the Orange County Jail system death rate as the lowest of the nation s 30 largest jurisdictions. 1 On July 20, 2010, your Board approved an agreement with the federal government to provide housing and healthcare to 838 new Immigration and Customs Enforcement (ICE) detainees. According to the Sheriff s Department, the quality and capability of the HCA Correctional Healthcare programs were key factors in the federal government s selection of the Orange County jails to house ICE inmates. Despite extremely challenging timeframes, the correctional healthcare programs designed and budgeted programs to assist the Sheriff and County in implementing this important new program. The successful implementation of ICE is a current priority of the correctional healthcare management team. IMPROVEMENTS CMS has responded to external assessments, has assembled a high quality clinical management team, and has made a number of program improvements over the past two years. 1 The Department of Justice Bureau of Justice Statistics maintains statistics on the number and characteristics of deaths reported each year by approximately 3,000 local jails nationwide, please see Local jail deaths, 2000-2006 - Statistical tables at:http://bjs.ojp.usdoj.gov/content/dcrp/jailsindex.cfm.
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 4 External Assessments CMS management has responded to external reviews and adverse events. For example, after a 2007 jail death, CMS conducted an internal review and implemented several operational and systems changes, including: Purchased new medical equipment and supplies, initiated training, and revised procedures for staff response to emergency situations. Implemented new technology for packing medications at the Main Jails. Implemented a computer shared drive making more information available electronically to all staff and providing an improved means of sharing information. Initiated all staff meetings to discuss issues and improve information. The following are examples of changes made in CMS after a May 2008 Grand Jury review: Appointed a clinical Registered Nurse Educator to develop and implement a nursing education program, including nursing orientation. Hired a Correctional Medical Services Director of Nursing. Expanded recruitment efforts to additional nursing schools. Implemented digital radiology for TB screening and expanded the radiology hours to enhance efficiency. In response to the March 2009 Office of Performance Audit comprehensive review of CMS, HCA implemented 41 of 43 (95%) agreed upon recommendations, and submitted four informational status reports to your Board. The two outstanding recommendations pertain to replacing the electronic medical record an effort being planned which is challenging and complex with major budgetary implications. Below are some of the major actions that have led to increased accountability, efficiency, and productivity: Revised LVN nursing shifts to eliminate overlapping staff schedules and a realized reduction in overtime costs. Increased functionality of the current automated records system to 1) provide quicker access to medical care via electronic appointment scheduling, 2) improve quality assurance activities, 3) reduce pharmaceuticals waste, and 4) streamline the medication
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 5 distribution process. Additional electronic search and query capabilities have also increased accessibility to vital medical information to ensure appropriate patient care. Revised pharmacy staffing schedules at Theo Lacy to provide expanded coverage on Sundays, and improve the medication distribution process. Strengthened security of controlled substances through staff measures, increased OCSD jail security measures, and monitoring. Strengthened contract language pertaining to reporting in 2009-10 hospital and provider contracts to ensure high quality, cost-efficient services. Established on-site optometry and obstetrics/gynecology clinics to eliminate the need to transport over 40 inmates each month to off-site medical clinics. Additional in-house specialty medical clinics are planned to further reduce off-site inmate scheduling, transportation and security concerns. Decreased contract hospital census through increased monitoring, and utilization review activities. The average daily inpatient census at the contract hospital between January 2010 and June 2010 was 33% lower than the September 2008 to December 2008 census (12.61 vs. 8.45). Implemented an electronic supplies inventory system to ensure availability of needed supplies and equipment, and reduce overstocking. Partnered with the Sheriff s Department to streamline the background process for new hires. Assembled a High Quality Clinical/Administrative Management Team Over the past two years, HCA has formed a high quality, action oriented clinical and administrative leadership team to continue program and clinical improvements at CMS and implement new programs. The following are key team management team selections: Appointed a CMS Director of Nursing in September 2008 after an extensive statewide recruitment. The individual selected, who was recruited from an Orange County community hospital, has strong nursing executive leadership experience, and has been a driving force in establishing and enforcing new nursing standards and expectations of accountability. This position had previously been a several-year vacancy. Appointed a new Division Manager for all Correctional Healthcare Services in December 2008. This individual is a seasoned 20 year manager who previously managed the HCA Health Disaster Management Division where she lead physicians, nurses, and other staff
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 6 in working with the community physicians, hospitals, clinics, and cities in the establishment of a coordinated medical disaster response system. She also oversaw the County emergency medical services program. Appointed a new CMS Medical Director in May of 2010 after a nationwide recruitment. This individual has substantial experience in correctional healthcare including serving as the chief medical officer of a large prison facility in San Diego County. OTHER ISSUES In their binder, OCEA made many non-specific claims regarding excessive discipline and punitive actions, higher turnover, and staff shortages. The following are HCA responses: Standards and Discipline OCEA contends that management is punitive and excessive in disciplining staff. With the full endorsement of the agency, the current management team has emphasized accountability and standards of care administered in a fair and objective manner. The CMS management team has successfully resolved a number of long term staff personnel matters which were affecting teamwork and morale. The volume of formal discipline, when necessary, is consistent with other areas of HCA. Examples of recent reasons for discipline include: Poor nursing assessments and failure to follow medical orders which resulted in a patient missing heart medication. Falsification of a medical record. Excessive profanity and failure to complete work. Inappropriately accessing Personal Health Information. Failure to follow medication distribution and documentation procedures. Staffing and Turnover OCEA claims that CMS staffing is insufficient. Budgeted Correctional Healthcare line nursing positions are adequate. CMS line nursing positions have increased from 120 positions in 2006/07 to 123 positions in FY 2009/10 a 2.5% increase. During that same timeframe, the inmate population has dropped from 7,000 in 2007 to 4,866 inmates a 31% decline. Even with the addition of 838 ICE detainees, the inmate population will be down by 13% from the number in 2006/07.
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 7 The current vacancy rate for Correctional Healthcare positions is 6.8% (not including the new ICE program). HCA is actively recruiting to fill these and other clinical vacancies. Forty three candidates for Correctional Healthcare are currently in some stage of the Sheriff s background investigation process. OCEA states that HCA continues to experience severe staff attrition and staff shortages; however, CMS attrition rate for FY 2009/10 was 6%, the lowest CMS turnover in the last four years. The majority of that turnover was related to the retirement of high seniority staff. FUTURE ACTIONS Following are planned future actions regarding CMS labor relations and staff developments issues: Establish a Correctional Healthcare nursing council to increase communication and focus on nursing standards throughout the correctional healthcare programs. Membership is planned to include line and supervisory nursing staff from CMS and Correctional Mental Health. Form a best practices committee responsible for identifying methods to improve communication, productivity, efficiency, and accountability in the workplace that will include line staff and CMS management. (This committee was proposed to OCEA several months ago.) Initiate further steps to improve communication and morale including all staff meetings, newsletters, management rounds, and correctional healthcare web page. As part of continuing leadership development, enroll the Correctional Healthcare leadership team in the Orange County Leadership Academy. One correctional healthcare program manager has already attended. The Correctional Healthcare Division Manager will be attending the fall 2010 class. Others will be enrolled in future programs. Continue current aggressive measures to recruit and fill existing CMS clinical vacancies. In conclusion, the County has a quality CMS program that is delivering excellent and professional healthcare services in the Orange County jails. HCA remains committed to exploring opportunities to work with OCEA on good faith initiatives to improve communication and labor/management relations at CMS in accordance with the current County/OCEA Memorandum of Understanding.
RESPONSE TO OCEA ALLEGATIONS RE: CORRECTIONAL MEDICAL SERVICES Page 8 If you have any questions, please contact David Riley at (714) 834-6021. David L. Riley, Director DLR: pt: 10-074 Attachment cc: Thomas G. Mauk, County Executive Officer Stephen Dunivent, Deputy CEO Nick Berardino, Orange County Employees Association Lisa Major, Orange County Employees Association
ATTACHMENT OCEA #1 HCA continues to experience severe staff attrition, staff shortages, retention problems and low morale. Data on attrition follows: Correctional Medical Services FY 07-08 Attrition Rate FY 08-09 Attrition Rate FY 09-10 Attrition Rate 8.47% 6.19% 6.03% This data reflects that attrition is actually down. Retirements constitute a large percentage of the low attrition that does exist. Sixty four percent of the turnover in FY 2009/10 is due to the retirement of high seniority staff. With respect to morale, CMS was rated an average level of job satisfaction (3.2 on a 5 point scale) in employee surveys conducted over the last year; these results were comparable to HCA s overall results in the 2007 County of Orange Employee Survey. Regarding staff shortages, OCEA claims that CMS staffing is insufficient. CMS line nursing positions have increased from 120 positions in 2006/07 to 123 positions in FY 2009/10 a 2.5% increase. During that same timeframe, the inmate population has dropped from 7,000 in 2007 to 4,866 inmates a 31% decline. Even with the addition of 838 ICE detainees, the inmate population will be down by 13% from the number in 2006/07. The current vacancy rate for Correctional Healthcare positions is 6.8% (not including the new ICE program). HCA is actively recruiting to fill these and other clinical vacancies. Forty three candidates for Correctional Healthcare are currently in some stage of the Sheriff s background investigation process. OCEA #2 The performance audit found that the allocation of four Supervising Comprehensive Care Nurse positions is insufficient. The performance audit actually found that the number of four is excessive. CMS currently has two Supervising Comprehensive Care Nurse positions.
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 2 OCEA #3 The performance audit found that inmate health is not a priority or a non-core service for HCA. The performance audit actually found that inmate health care is a priority, though being a noncore service for HCA. Correctional Healthcare continues to be a first tier priority in funding and support within HCA as evidenced by the strong budgetary support in spite of $70 million in HCA budget reductions over the past two years. -------------------------------------------------------------------------------------------------------------------- OCEA #4 The performance audit found that medication orders are not included in the inmate s medication package when filled by the pharmacy. The performance audit actually finds that some new medication orders are not included. Due to medication packaging times for the entire jail operations, there are instances when new medications or stat medications may be ordered or an inmate has returned from the hospital - those instances prevent the order from being complete from the pharmacy during packaging times. OCEA #5 HCA s reference to the low number of jail deaths demonstrates lack of insight and disregard for providers, and a complete lack of understanding of the goals and objectives of healthcare in Correctional Healthcare. HCA points to the low number of deaths because it is an available measurement of the quality of health care being provided in the Orange County jails as compared to other jurisdictions. OCEA #6 There is insufficient staffing. Correctional Healthcare line nursing staff has increased from 120 positions in 2006/07 to 123 positions in FY 2009/10 a 2.5% increase. During that same timeframe, the inmate population has dropped from 6,570 in 2006/07 to 4,866 inmates a 25% decline. Even with the addition of 838 ICE detainees, the inmate population will be down by 13% from the number in 2006/07. There are CMS vacancies and leaves of absence for physicians and nurse classifications for which HCA is actively recruiting. A number of physician, nursing, and other clinical candidates are currently in the Sheriff s background investigation process.
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 3 OCEA #7 The current Correctional Healthcare organizational structure does not provide a meaningful opportunity for participation by providers across multidisciplinary lines. There are a number of opportunities for participation: The Policy and Procedure Committee (front line and Senior Nurses) meets monthly and is typically attended by 4-7 line nursing staff depending upon daily staffing levels. The Nursing Quality Improvement Committee (front line nurses and supervisors) meets monthly. The Director of Nursing and Assistant Director of Nursing have weekly meetings with Senior Nurses and Supervising Nurses to discuss operational needs, scheduling, recruitment, etc. The Medical Director meets weekly with the physicians and nurse practitioners. The Sheriff Department and Correctional Healthcare staffs meet monthly to discuss operational needs (front line staff participate). A Formulary Task Force was established which includes front line nursing staff participation. HCA invited OCEA to meet with the Division Manager on a regular basis to work together collaboratively on staff concerns and, again, OCEA has not accepted this invitation. A Task Force to review issues in the women s Observation Unit included supervisors and line workers. In April, 2010, management also proposed implementation of a Best Practices Committee to enhance communications with staff. OCEA was invited to participate and originally supported the approach; however, OCEA abruptly withdrew their support. OCEA #7 Non-medical professionals occupy the executive levels of Correctional Healthcare. Actually, clinical professionals predominate in the management of Correctional Healthcare. The Correctional Healthcare management team includes the following:
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 4 Division manager Director of Nursing (RN) Medical Director (MD) Chief Pharmacist (PhD) Chief Dentist (DDS) Assistant Nursing Director (RN) The HCA Division Manager is not a clinician; however, she is an experienced health care manager with background in working with multi-disciplinary healthcare clinical professionals to coordinate and manage programs. Modern health care management recognizes the role and value of trained management professionals within healthcare organizations. As the most obvious example, most hospital administrators are healthcare managers, not clinicians. OCEA #8 Issues relating to the Female Observation Unit were addressed by the performance audit in the 2009 performance audit. The current female observation unit was not opened until the fall of 2009 and was not addressed at all in the performance audit. OCEA #9 There remain a substantial number of recommendations from the Grand Jury and Performance Audit that have not been implemented or addressed. HCA s response to the Performance Audit issued in March 2009 included implementation of 41 of 43 (95%) agreed upon recommendations. The two outstanding recommendations pertain to implementing an electronic medical record an effort currently being planned. This is a challenging and complex initiative with major budgetary implications. Some examples of improvements in response to the performance audit that have increased accountability, efficiency, and productivity: Revised LVN nursing shifts to eliminate overlapping staff schedules. Increased the functionality of the current automated records system to 1) provide quicker access to medical care via electronic appointment scheduling, 2) improve quality assurance activities, 3) reduce pharmaceuticals waste, and 4) streamline the medication
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 5 distribution process. Additional electronic search and query capabilities have also increased accessibility to vital medical information to ensure appropriate patient care. Revised the pharmacy staffing schedules at Theo Lacy to provide expanded coverage on Sundays, and improve the medication distribution process. Strengthened security of controlled substances through staff measures, increased OCSD jail security measures, and monitoring. Strengthened contract language pertaining to reporting in 2009-10 hospital and provider contracts to ensure high quality, cost-efficient services. Established on-site optometry and obstetrics/gynecology clinics to eliminate the need to transport over 40 inmates each month to off-site medical clinics. Additional in-house specialty medical clinics are planned to further reduce off-site inmate scheduling, transportation and security concerns. Decreased contract hospital census through increased monitoring, and utilization review activities. The average daily inpatient census at the contract hospital between January 2010 and June 2010 was 33 % lower than the September 2008 to December 2008 census (12.61 vs. 8.45). Implemented an electronic supplies inventory system to ensure availability of needed supplies and equipment, and reduce overstocking. Established an Electronic Health Record planning group to evaluate CMS IT needs and develop an RFP for the purchase and implementation of a complete medical health record system within three to four years, contingent upon funding. OCEA #10 Communications between staff and management is poor. There are a number of approaches to share information and promote communications at CMS, including all staff meetings ( town halls ), departmental staff meetings (nursing, physician, dental, and pharmacy), special purpose meetings (formulary, training, policy and procedure, and special issue), monthly newsletters, shared electronic folders for written materials including policies and procedures. Correctional Healthcare plans to initiate further steps to improve communication and morale including more frequent all staff meetings, management/supervisory rounds, and a correctional healthcare web page.
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 6 OCEA #11 LVN schedules remain inefficient. The current eight hour shifts actually represent an efficient use of staff, but are not favored by some of the LVNs. This matter has been the subject of exhaustive discussion between HCA and OCEA. Neither HCA nor OCEA has been able to devise a schedule for the 12 hour shifts favored by some LVNs that would not require additional unbudgeted expenses. OCEA #12 Electronic approval of medication orders is not occurring. Physician electronic approval of medication orders via the automated system was implemented on 3/20/10; however, there have been compliance challenges. When inconsistencies are identified, staff are counseled on the requirement to enter medication orders within 72 hours and are provided additional training. OCEA #13 There is currently no validation that undistributed medications are properly returned to the pharmacies. Any medications which are not administered are documented by nurses indicating why the medication was not given (refused, inmate has been released, inmate in court, etc,) and the medication is returned to the pharmacy to be destroyed or restocked. OCEA #14 Implementation of the update query in CHART has not occurred. The current automated system is limited in this capability and proposed software modifications were not operationally feasible. An alternative solution was implemented, which has reduced the inconsistency of medication repackaging. CMS also now receives hourly updates from Automated Jail Systems from the Sheriff s Department which has reduced the need for LVN medication packaging. OCEA #15 Contract physicians fail to input discharge planning orders in the electronic medical records.
Response to OCEA Allegations RE: Correctional Medical Services Attachment Page 7 An alternate solution was implemented. Hospital compliance concerns prevented contract hospital physician direct input into CHART. As an alternate solution, deputies deliver hospital discharge summaries to CMD when the inmate is returned from the hospital to the jail. OCEA #16 The CHART system continues to be a source of errors, greater than 500 per year. It is unclear as to how this data was determined. Correctional Healthcare will review this issue. OCEA #17 Statistical summaries of medical services delivered by CMS remain inaccurate. The current system is dependent on accurate data input. Correctional Healthcare management is exploring methods of capturing data which is more efficient and accurate. OCEA #18 The creation of a task force of high performance HCA employees did not include line staff. While the nucleus of the Task Force was management, line staff members were involved in the planning and implementation of performance Audit recommendations.