A Shameful DSHS Data Dump (Amended 9/30/16)

AMMENDED BLOG (9/30/16)  In my haste to respond to the release of the secret CSM Consultant report I missed a few stitches…  I will address the difference between RN3 and Ward Administrator position descriptions and correct false data within the report itself which claims that Non-RN4 Unit Managers were a factor at WSH historically when they were not.  Also of note is that Ward Program Managers only existed for a couple of years within WSH history.  Ammended input is in red. 

Today (9/29/16) the secret CSM Consultant report was released to the public for the first time as a result of numerous information requests.   The following email was sent as the information was released to news agencies:

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Note that DSHS states that the report “may” be exempt from disclosure under the Public Records Act…  The State apparently had no intention of releasing this data… In fact the report contains the following data on every page:

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Not subject to discovery pursuant to RCW 43.70.510?  I see nothing in that provision that would prevent discovery as we are not talking about patient records or possible HIPPA violations.  Very strange… 

But news agencies had ALSO filed Freedom of Information Act paperwork with the Federal Government, therefore giving news agencies access to the report through CMS via the Federal Government.  As the data was going to be released anyway, the CSM Consultant report was released today by DSHS.  That report is available for viewing below:  

Please note that the report does NOT mandate the implementation of $2.6 million massive expansion of administration in the form of “Ward Administrators" (Washington Management Service positions).   In short, DSHS openly lied to get an additional $2.6 million per year in unnecessary funding (in lieu of using these funds for additional direct patient care provider positions) blaming this report DSHS thought would be kept secret from the public and Legislature.  A severe Unfair Labor Practice has occurred as DSHS Administration forced rapid adoption and funding of 28 administrative positions prior to any form of proper disclosure and demand to bargain processes taking place. 

Submitted with the CSM Consultant report was the following fictional document… It is DSHS’s spin of the report.

In that fictional DSHS spin document it stated the following:

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I must remind you that until today, only a select few administrators had any form of access OR INPUT into the CSM Consultant report outcomes.  Note that they have EXPANDED the number of Ward Administrators to 30 from 28 that was described in the WPA FAQ document (now more than $2.6 million per year).  The report did NOT identify the need for additional ward program administrators, this was a lie.  The only mention of anything in the report similar to “ward managers” were the following:

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In addition the following components were present in the CSM Consultant report:

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Nothing that is stated above implies the following which was provided to all personnel by the CEO in the WPA FAQ document:

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The above statement which was provided to all personnel and all Labor Unions was a complete fabrication.  It was a fabrication based on the belief that nobody would ever be allowed to see the CSM Consultant Report.  The Legislature should immediately eliminate the funding it has already approved for Ward Administrators.  It was a cognitive leap to not openly discuss the report with all personnel because the above data presents a more simple solution than the costly one that was proposed.  Why did DSHS not IMMEDIATELY present the Ward Administrator concept a month ago to the labor unions as the concept represented a radical change in work conditions?  Perhaps they did not want the following information to be presented to CMS prior to THEIR plan approval and funding. 

A ward based leadership model already exists on each ward.  The Psychiatrist is the team leader and prescribes medications and approves treatment team recommendations for behavioral treatment based within their scope of practice under the Uniform Disciplinary Act.  Nursing personnel (Charge RN2’s, LPN’s, PSN’s, MHT’s, PSN’s, and IC’s) are under the direct supervision of a Registered Nurse 3 who has interdependent role and oversees specific functions of clinical care through the delegated authority of the ward Psychiatrist.  It has been the normal delegated role of the Registered Nurse 3 to perform routine audits of care and ward quality care processes, and assures standards are maintained through completion of employee performance evaluations taking input from other members of the treatment team.  RN3’s coordinated training schedules when WSH still had yearly competency training.  Under the current structure, the RN3 is the middle level ward manager.  Accountability is built into the ward structure through the Uniform Disciplinary Act.  Other members of the treatment team are the Psychologist and Social Worker who are both licensed and perform their duties also pursuant to their scope of practice under the Uniform Disciplinary Act. 

Why has this structure failed in the recent past?  Western State Hospital did not have enough charge nurses (Registered Nurse 2’s) to provide seven days of coverage through three shifts, thus WSH Administration often used RN3’s to cover as charge nurses (RN2’s) instead of allowing them to regularly perform their primary supervisory job function.  By having RN3’s serve frequently as RN2’s, the normal supervisory roles of the RN3 were fractured as work relationships frequently moved from peer lead worker to supervisor and back creating an undefined and ever changing supervisory relationship.   While some unit RN3’s performed RN2 jobs on various wards, the other unit RN3’s often covered from three to six wards preventing true supervisory oversight.  By never requesting the minimal level of staffing required to null out overtime and provide full coverage for a three year period, DSHS Administration found itself unable to allow yearly training to continue.  Competency training for all nursing personnel was eliminated in early 2015 and has NOT be reinstated to this day.  RN3’s continue to be frequently assigned to RN2 duties due to the past acts of an incompetent administration.  Rather than creating a $2.6 million per year additional administrative layer, additional full time RN2’s can be funded to allow RN3’s to perform their normal functions as delegated ward managers.  RN3’s perform all of the functions described for Ward Administrators exempt for the fact that there is one RN3 for each shift rather than an ineffective 24 hour coverage unreasonable expectation.  The Joint Nurse Staffing Committee requested 114 additional full time RN2’s, but DSHS only funded 51.  Had the CSM Report been provided to direct patient care providers for input, the recommendation would be to allow RN3’s to act as delegated ward managers during their assigned shift thus utilizing existing supervisory structures without creating yet another additional layer of administration.  The reporting hierarchy would be optimized and the ward based leadership model would be strengthened while remaining within the parameters of scope of practice and Uniform Disciplinary Act.  

A quote from WAC 246-840-705 (Functions of a Registered Nurse):  In an interdependent role as a member of a health care team, the registered nurse functions to coordinate and evaluate the care of the client and independently revises the plan and delivery of nursing care.  The registered nurse functions in an interdependent role when executing a medical regimen under the direction of an advanced registered nurse practitioner, licensed physician

Historically speaking, for a majority of the past 32 years I have worked at Western State Hospital, the Unit RN4 was the sole Unit Manager for each unit.  Only within the Phillips Administration and Adler Administrations were SEPARATE additional unit manager concepts implemented.  The RN3 was the ward manager who performed quality assurance checks, scheduled training, performed TJC Accreditation preparation, performed CMS inspection preparation,  performed all nursing timekeeping and scheduling, hired all nursing personnel, was responsible for corrective action, completed evaluations, and participated in the patient transfer process representing the entire treatment team of the ward.  For a majority of the past 32 years, it was common for an RN3 to be the ward manager of two wards rather than one.  For a majority of the past 32 years, there was a simple chain of command in which important information would go directly from the RN3 to the Director of Nursing without any additional layers of administrative personnel.  There was no such thing as “upper administration” or lateral duplicate administration positions as exist at this time. 

In the Phillips and Adler Administrations, numerous new layers of administration were initiated which essentially destroyed all previous communication structures.  The Unit Manager name was taken from the RN4 and given to another Administrator who may or may not be a licensed clinician, this Administrator was now the main communication contact with “upper administration,” when previously there was NO FORM of “upper administration” as exists now.  In the Phillips Administration for a few year period, Ward Program Managers were implemented.  Ward Program Managers replaced the traditional role of the RN3 on each ward as it related to coordinating care with the treatment team and nursing personnel.  Thus Ward Program Managers become the chief communicator of ward needs to the newly formed Unit Manager that was not an RN4.  That Administrative Unit Manager become the main communicator to “upper administration” which consisted of yet another layer for administration which was then headed by Rae Simpson, the same person that is now advocating for the return of this concept.  She was one of the few persons that was allowed to see the CSM Report prior to its release yesterday.  For many reasons, the Ward Administrator is a flawed and failed concept which creates additional and unnecessary layers of administration, destroying clear lines of communication and feedback.  When the massive expansion of administration was implemented, suddenly paperwork and forms become unmanageable as the persons that were charged with competing those clinical forms were no longer in the true communication loop.  Simple structures produce supervisor communications over complex ones.  In fact during the Phillips administration, the structures were so complex at even external agencies were unable to trace accountability to anyone as Ward Program Managers were NOT active practicing clinicians, the blame always went to the Psychiatrist, Psychologist, Social Worker, or Nursing Personal.  Further, the Ward Program Manager provided input into employee evaluations blindly as corrective or other action was confidential and not subject to an external administrators knowledge.  It was a nightmare scenario.  Luckily the nightmare did not last long.  

Unfortunately, when the Ward Program Managers were eliminated, shards of numerous additional layers of administration had remained intact creating numerous “upper administrative” structures (silos).  Those structures must be delayered in order to create appropriate and simple structures.  The buck stopped nowhere…  

Now lets look at the position descriptions for Registered Nurse 3 and Ward Administrator.  You will note that the Ward Administrator concept is a redundancy that is not required on any ward.  I point out to the following components of the Registered Nurse 3 position description:

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Ward Administrator Description:  A WPM has no authority to delegate nursing care under the law and is not held accountable by the Uniform Disciplinary Act as the job class has no defined scope of practice under the law as well as no particular required licensure.  A WPM cannot modify clinical assignments of care or modify  assignments of care.  A WPM may not issue a seclusion or restraint order nor can a WPM override a restraint or seclusion when that clinical decision is made.  (An RN3 can.)  Yet the following is the WPM job description:

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In the job description above, what you are seeing is DSHS attempting to place a square peg into a round hole.  Even though they CANNOT legally delegate or clinical care assignments or modify assignments, the appearance must be made that they have some form of supervisory/administrative duty or they cannot meet the criteria for being a Washington Management Services Employee.  This is due to the Washington Management Service Laws.  To be a Washington Management Services employee, one must meet the definition of manager or managerial employee under WAC 357-58-035.  

WAC 357-58-035 

What is the definition of a manager or managerial employee?

In accordance with RCW 41.06.022, a manager or managerial employee is defined as the incumbent of a position that:

(1) Formulates statewide policy or directs the work of an agency or agency subdivision; 

(2) Administers one or more statewide policies or programs of an agency or agency subdivision;

(3) Manages, administers, and controls a local branch office of an agency or an agency subdivision, including the physical, financial, or personnel resources;  

(4) Has substantial responsibility in personnel administration, legislative relations, public information, or the preparation and administration of budgets; and/or

(5) Functions above the first level of supervision and exercises authority that is not merely routine or clerical in nature and requires the consistent use of independent judgment.

[Statutory Authority: Chapter  41.06 RCW. WSR 05-12-068, § 357-58-035, filed 5/27/05, effective 7/1/05.]

I would argue that a Ward Administrator cannot legally meet the above criteria because of the clinical setting and scope of practice issue.  A Ward Administrator COULD meet the criteria if they were a Psychiatrist or Registered Nurse who have authority to modify clinical delegated duties or assignments.  Also, there is mention of term “Administratively Supervises,”  which is not defined under Washington law…  Actually I was unable to find a definition of the term Administratively Supervises, what does it mean?

I suggest that every person review the report in detail.  Based on the reports' contents, I have no confidence in the current DSHS Administration.  It is clear that it was their intent to fraudulently obtain millions of dollars of funding per year based on what they thought was a SECRET report that NEVER recommended such action be taken.  This event shows why transparent government is essential.  The Governor and Legislature should de-fund the “Ward Administrator” concept and utilize that funding to provide sufficient permanent full time direct patient care personnel, food aides, and custodial (environmental) care employees to null out routine overtime use.  This would eliminate the need to retain expensive non-perm on-call personnel and agency personnel that are not part of the basic staffing budget.  

Additionally, license Western State through the Department of Health to turn it into a true “hospital” under Washington Law.  This act would create mandatory reporting relationships (thus preventing routine DSHS cover-ups) and routine inspections through the Department of Health to assure compliance with all State hospital laws, this is something that has never been done in the past.  As stated in past blog entries, DSHS has issued directives to prevent disclosure of serious events.  Becoming a licensed true hospital will prevent the administrative abuses that resulted in Western State losing its accreditation and possibly CMS funding.  Further, all protections that apply under Washington law would apply for the first time for Western State employees, it would be illegal to implement mandatory overtime on certain classifications of personnel and additional food aide personnel would be required to meet safe food laws and standards.  This will require DSHS to discontinue covering up the staffing shortage that DSHS had denied for the past three years.  Request the overtime, agency personnel use, and on-call personnel use numbers for the past year.  DSHS must never be allowed to have direct facility license oversight of itself again. 

I note that communication and reporting relationships is a key issue throughout the consultant report, but in this case the consultants missed the root cause that Western State is NOT a hospital under Washington Law. 

© Paul Vilja 2017