Orange County Health Care Agency Behavioral Health Services

1. Orange County Health Care AgencyBehavioral Health Services Creating Change in Hospital Staff Barbara Rocha, LCSW Patients’ Rights Coordinator Patients’ Rights Advocacy Services

2. Our Staff • Coordinator: Barbara Rocha, LCSW • Advocates: • Myra Kanter, RNC • Patti Yamamoto, RN • Michael Merryman, MFT Intern • Jim Marquez, MFT Intern • Office Support: • Trang Thai

3. Our Staff • Community Health Aide: Melody Marler • Volunteer: Robert Reed

4. History of our Department • Orange County is a county of 3 million residents with 12 designated facilities and 552 designated beds. • In 2004 three advocates were dividing the calls between them as the complaints calls came in. • It was rare that any advocate consistently responded to a complaint at the same facility. • It was hard to discern trends of abuses or behaviors at any one facility. • Services focused on rapid responses and services provided by phone unless charts needed to be reviewed or grave abuses were alleged.

5. A change is requested • One hospital requested that they be assigned a single Advocate. • This assignment gave us the opportunity to preview the advantages to having one person consistently responding to complaints at a specific facility. • We requested that this Advocate have a set time they would be on the units each week and we offered to provide Patients’ Rights Groups. The hospital scheduled a Patients’ Rights group on each unit each week.

6. Results • This allowed us to establish a pattern of face-to-face services and contact every patient on each unit. • We were able to consistently interact with the unit Managers and Supervisors and we learned the names and roles of all staff on the units. • We had the opportunity to provide consultation to staff regarding Patients’ Rights issues as we dealt with each complaint. • Complaints initially climbed by two-thirds as more patients with complaints were willing to talk to an Advocate than to call us. They later leveled off to one third more than the previous year

7. We end up doing more • We realized that by having a single contact we were providing more services to this facility and offered to assign a specific Advocate to every designated facility who would be there weekly and would be able to offer a Patients’ Rights Groups: all of the hospitals accepted our offer for groups. • As we continued to provide services in this manner the number of patients we were able to see face-to-face increased by 400% from the services provided in 2004 to services in 2005. In our data base we now record complaints and inquiries as well as outreach, consultation, grievances, PR groups, Probable Cause Hearings, CEU classes and Clinical Reviews. • In the groups we cover basic rights, how to advocate for yourself and due process. Afterward we contact individual patients to see if they have questions or concerns; so no patient is singled out for talking to the assigned Advocate. If a patient has a complaint it is handled that day by the advocate. We investigate all complaints and provide information on community resources and linkages.

8. Our reception on the units change • When we first started out on our fixed schedules, we were greeted with a lot of staff suspicion: “What did we do?” “Why are you here? Are we worse than the other hospitals”, “Are we in trouble?” • As we continued to show up as scheduled, we noticed that the patient calls slowly decreased to almost no calls. Increased access to an Advocate had reduced patient anxiety levels. The patients identified us as their allies as they came to know us as a familiar face, we found they were more likely to talk to us first, then follow up with a phone call. • Hospital staff were able to guarantee patients that someone would be there to address their concerns in person. Punitive calls about staff stopped as the patients became educated about their rights and tried out self advocacy. Staff were able to help the patients understand the difference between rights and privileges or programming.

9. Our reception on the Units change • Hospitals developed lists of questions from the patients and from the staff, including the Physicians for the Advocates to address in group. • As we role modeled trustworthiness and fairness, even in complicated situations, the hospital staff relaxed. • We eliminated distrust by enlisting the staff in problem solving and providing leadership rather than attacking or blaming them for the problem. • We consistently monitored any solutions to problems to make sure issues were completely resolved.

10. Staying Objective We address time in each staff meeting to talk about the unit assignments and will consider rotations as new staff come aboard. We make sure we stay neutral and objective and not start to align with the hospital staff or burn out and become overly critical. Every staff member has supervision time with me to monitor their assignments and to provide support and encouragement. I have scheduled time with the Medical Director to discuss high profile rights issues, problem facilities and to discuss our direction and goals.

11. To date • Staff have been unwavering and assertive about what needs to be changed by the hospitals. • This became a teaching effort as we tried to “become the change you want to see” (Gandhi) • By providing information in the groups, we taught both the patients and the staff. • We were determined to make an impact by educating and encouraging hospital staff to take a pro active stand on Patients’ Rights.

12. The first avenue toward change: EDUCATION • Advocates alone could not make the difference in patient care. Nor could we be there every minute to monitor staff behavior, we needed to change the way hospital staff saw themselves and their responsibilities to patients.

13. Education and Consultation • One of our staff developed a one-hour Patients’ Rights in-service that we went through the Orange County Quality Review and Training Team to get accredited in order to be able to give one hour of Continuing Education Credit (1 CEU) for MD, RN, LVN, MFT, LCSW and LPT licenses. This in-service is in your folders, along with the post test which is our Jeopardy-type game. • We immediately offered our in-service to all the designated facilities and stressed using our staff as consultants. “Call us with any concerns as soon as a question comes up.” We encouraged staff to think about Patients’ Rights first. • We educated anyone who was willing to come to our in-service. Every person who is aware of the need to treat patients with respect and dignity could advocate for the patients what ever their job classification in the hospital. We included housekeeping, unit clerks and anyone who expressed interest in the training. • We reinforce educating any staff present whenever we deal with complaints or audits.

14. Education and Visibility • We educated consumers in clubhouses and drop-in centers on Self Advocacy. We became consultants on the MHSA Consumer Action Advocacy Committee. We developed a Self-Advocacy brochure. • We attend the Orange County Celebrate Recovery Picnic and have a table of materials with staff available for consultation, information and referral every year. • We attend the Meeting of the Minds Conference each May as an exhibitor and have materials available and play Jeopardy with conference attendees. • We are regular speakers for the various NAMI-OC groups throughout the year for education and questions to further their understanding about Patients’ Rights. • We have endeavored to keep the issue of rights of the Mentally Ill in the community awareness by being visible at events and offering education within the mental health community, including attending the Mental Health Board.

15. Audits as Education • We decided to use our time on the units to audit the charts of complaints or at least one chart per month per facility; instead of a yearly audit where we did all the chart reviews at once. We collect the chart audits over 10-12 months for an informal annual review and do a formal review as part of re-designation every two years. • We give a copy of each chart audit to the unit Administrator or Director of Nursing as soon as the audit is completed and point out the good examples as well as any deficiencies. • Getting the immediate results keep awareness of Patients’ Rights issues alive on the units as they know we will audit the charts with complaints or at least one random chart a month. We target any chart with a denial of rights, especially Seclusion and Restraints, we also do a quarterly ECT chart. • We are careful to point out excellent examples of documentation of good cause for denial of rights, as well as insufficient documentation. This becomes a learning tool that is immediate, and the hospitals become aware that any chart may be audited. • This has increased the diligence of the hospital’s own audit process: since we have adopted this process the incidence of errors on Patients’ Rights issues has gone down dramatically per our audits.

16. Audits as Education • By staying on top of an issue by a continuous audit, problem areas were extinguished relatively quickly as there was an expectation that we would continue to examine the charts for compliance. • After a while the compliance became ingrained and we found no further evidence of non-compliance. • Once an audit issue is resolved we focus on another rights issue and rewrite the audit to feature an increased focus on this new issue. • It was easy to cover a large number of charts at all designated facilities with a small additional investment of staff time, but it provided a large payoff in hospital staff education.

17. The second avenue toward change: Positive Reinforcement • “Example is not the main thing in influencing others. It is the only thing.” • Albert Schweitzer

18. Be an Agent of Change “As it is our nature to be more moved by hope than fear, the example of one we see abundantly rewarded cheers and encourages us far more than the sight of many who have not been well treated disquiets us.” Francesco Guicciardini

19. Praise Good Examples • We started a simple program recognizing the staff we felt were an example of treatment with respect and dignity. • We give them a small card that said that we felt they handled a situation with respect and dignity and thanked them for supporting Patients’ Rights. We include a small key chain that says “above and beyond”. • We then sent a letter to the CEO of their facility naming the person as exemplifying treatment with respect and dignity (copy of the letter is in your folder). A copy of the letter was also sent to their unit Administration including the Director of Nursing, their direct supervisor and with copies to the Medical Director and Inpatient Services for Orange County Behavioral Health Services. • The letters to the CEO’s had a big impact on the unit staff, unit administration and ultimately on patient care.

20. The Pen is mightier than the sword • By looking at something that was already right and going directly to the top of the organization we insured that both the staff and Patients’ Rights issues were noticed. • I purposefully directed the letters to the head of the hospitals to insure that quality staff who may be one of many in a large organization were noticed and honored for their efforts. • This put a spotlight not only on the staff that was commended, but the unit as well. It also showed a different side of the relationship of Patients’ Rights to patient care. • We traditionally only commented on rights violations, but now we were commenting on what was right; on what was a clear example of treatment with respect and dignity, the basic patients’ right.

21. Getting Hospital Staff Onboard • Since August of 2005 we have sent out about 40 letters a year to our designated hospitals, and outpatient programs acknowledging about 100 staff members a year. • This represents about three staff members observed per Patients’ Rights Advocate per month.

22. Reactions The response to the first letters was dramatic: • One CEO took the letter to the Board of Directors of the hospital and let the unit administration know how pleased he was that Patients’ Rights had noticed their staff. • One CEO took the time to come over and meet the Patients’ Rights Advocate as the days the Advocate is on the unit is on the letter. • One facility gives any staff member who got a letter two movie tickets and they are honored in a staff meeting. • One hospital has incorporated the Patients’ Rights letters into their reward system the same as a patient’s thank you letter as one point; with 5 points they get a gift certificate.

23. Reactions • In one hospital, when a staff member gets a card, it is placed in the window at the Nursing station for everyone to see. • One Hospitals reads the letters in the staff meeting. In every instance, the feedback to our department, and to Behavioral Health Administration has been that the letters have been a source of great pride to the recipients and have made a difference in unit morale.

24. Our image gradually changes • We are seen as a source of help to improve patient care by improving adherence to Patients’ Rights. • By praising what is right staff are willing to work on what could be improved because you have been fair about seeing both sides. • We have opened a dialogue with all staff about our expectations that patients should be treated with respect and dignity.

25. Here’s how we did it • Consistency • Education • Consultation • Praise good examples • Relentless follow up • Utilize county resources • Share clear expectations about defending Patients’ Rights

26. Consistency • Show up when you say you will. • Have set times to be on a unit or do a group, it will decrease patient anxiety and maximize your time. • Having a set time will help the staff as they will be able to reassure patients that someone will see them and address their concerns. It also gives them an opportunity to ask questions on rights issues. • Even a 20 minute group will have a positive impact with a small additional investment of your time on a unit.

27. Education • Make time to provide Patients’ Rights CEU classes, it pays off. • Make education fun and people will come. That’s why we use the game for a post test. We give anyone who raises a question a piece of gum or a pencil to encourage participation. • Educating everyone provides the largest safety net for the patients. • Use the patient groups to educate the patients and they will learn to speak up for themselves and for others.

28. Consultation • The staff must be willing to show you their vulnerabilities when they ask for your expertise. If they are afraid of your response, they will never share what they are really doing or thinking. • You need to offer information in a manner that supports the person for asking and provides an answer they can put into use without feeling wrong for not knowing the answer. • Every opportunity to answer a question is a chance to teach someone to think like a Patients’ Rights Advocate. Teach the staff, and the staff will start to teach the patients about their rights.

29. Praise Good Examples • This has been our most powerful tool to create a change in attitude and culture on a unit by reinforcing what is dignity and respect. • Start with the best examples available, they may not be perfect, but they will try harder after they are praised; and the rest of the staff will follow. • Start with what you have, you don’t need a card or a key chain, you can put what you observed directly into the letter. This is a lot of good reinforcement for the cost of a stamp (or hand deliver it if your budget is that tight).

30. Praise What You Want • When you send a letter make sure you have all the names and titles straight, especially if there have been changes. • Look for at least one or two staff a month from your facilities to keep the momentum going. Remember; you want to create change and they want to be praised. • Ask the patients about who has been doing a good job and to give you an example, if the same name keeps coming up make sure that person gets acknowledged. It’s OK to say that the praise comes from the patients.

31. Relentless Follow Up • Any plan for a correction you make, however informal, needs formal follow-up. If you have commented on the lack of translation on one case, check for translation on every case of monolingual patients. Discuss your findings, use a formal chart audit to keep the focus on what needs to be done. • Expect improvement, if you don’t see it, take it to the next level of formal correction. • Never let even small things slide; because you are a constant observer on the unit, expect more not less.

32. Utilize your Counties’ Resources • Make linkages with the department that oversees Inpatient Services or monitors inpatient beds. • Find out who reviews the designated facilities in your county, work with them if you don’t already. • Network with the Public Defender, Outpatient Services, Community Care Licensing and other groups and agencies working to provide services to the Mentally Ill.

33. Voice Clear Expectations about Patients’ Rights • In your groups educate staff and patients about patients rights and what are rights violations and that you will follow up each and every complaint. • Track complaints so you can speak to the nature and kind of complaints you have been getting so you can identify trends or problem areas. • Follow up, encourage and praise positive change and efforts toward excellence. • Be helpful but insistent. Remember Patients’ Rights is everyone’s job.

34. “I rate enthusiasm even above professional skill.” Sir Edward Appleton

35. Resources • “You Make a Difference” small cards • “Above and Beyond” key chain • Baudville.com • Pencils, Key rings; prizes for CEU class • Oriental Trading Company orientaltrading.com

36. Barb’s Rules • Be kind (every one you speak to is in a crisis) • Be polite to staff and patients • Be professional • Be firm • Be relentless • Think first, speak second and never lose your temper.

37. DNA • Decide what you want more of • Notice each little instance of it’s presence • Acknowledge and celebrate each time you notice it.

38. Questions? Demonstration of Patients’ Rights Jeopardy Game