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WSH Systems Improvement Agreement (SIA)

The news agencies are now reporting that DSHS has entered into an SIA (Systems Improvement Agreement).  This type of agreement is NOT common and represents the equivalent of a “Hail Mary Pass.”  DSHS released the following announcement yesterday to the media:

DSHS and CMS negotiating an agreement to fix systemic issues at state hospital 

OLYMPIA – The state Department of Social and Health Services and the Center for Medicare and Medicaid Services (CMS) will work together to negotiate a Systems Improvement Agreement (SIA) – a structured agreement that safeguards patients while providing time for Western State Hospital to implement systemic improvements to hospital operations. 

Successful negotiation and completion of an SIA will return WSH to substantial compliance with all Medicare Conditions of Participation. 

“WSH provides critical services to Washington citizens, and we are pleased that CMS has agreed to consider an SIA. This is an opportunity to focus the energy of our new leadership toward making the sustainable, long-term changes needed to ensure we provide safe, quality care,” said Carla Reyes, assistant secretary for the DSHS Behavioral Health Administration. 

An SIA negotiated with CMS will stipulate the terms under which the hospital agrees to: 

 Obtain independent consultative review (at its expense and with CMS approval); 

Acquire expertise in the development and implementation of an effective hospital operations improvement plan and quality assessment and performance improvement program; 

Engage the services of an independent, full-time, on-site compliance officer for the duration of the agreement; and 

Other terms specified by CMS, including a resurvey by CMS within six to 12 months. 

CMS will suspend the hospital’s termination order and maintain federal funding pending its fulfilment of the agreement. The SIA specifies the qualifications and responsibilities of the independent consultant and stipulates the content and frequency of reports that are to be submitted to CMS. 

“This is our opportunity to make the right changes,” Reyes said. “With the continued surveys and complaint investigations – which are absolutely legitimate in holding us accountable for operating a safe and quality hospital – we have been applying Band-Aid fixes to address symptoms rather than solutions that address the underlying root causes of serious repeat violations. 

“There are so many dedicated and hard-working professionals at the hospital. We just don’t have a functional organizational model in place to help them be more successful. The independent review and guidance provided under an SIA will help us remedy these gaps and attract additional high-quality staff.” 

Under the SIA, once the hospital is resurveyed and demonstrates substantial compliance with all of the CoPs, the pending termination is stopped. CMS then restores the deemed status and dismisses the SIA. 

To understand what an SIA is, please read the linked article produced by Becker’s Hospital Review.  The cost of entering into an SIA and initiating the required changes will cost hundreds of thousands of tax payer dollars.  

The systems improvement agreement process is a true last ditch effort to correct the extensive damage that was caused by the last CEO and DSHS Administration that supported him.  In my last blog entry I outlined that the Western State Hospital root cause of failure (besides administrative incompetence) was the lack of oversight that was directly attributable to Western State “Hospital” not being a “hospital” under Washington law.  If Western State became a “hospital” under the law, it would have to comply with laws that apply to all other Washington hospitals.  This would change everything.

What an SIA does is FORCE Western State to actually BECOME a “hospital” during the time the SIA is in effect.  It is the Legislator’s job to make Western State a “hospital” under Washington law during the period that Western State is under the SIA.  

When Western State becomes a “hospital” under Washington law, abuse of licensed staff will immediately become illegal because mandatory overtime laws will apply for the first time to WSH RN’s and LPN’s.  Western State Hospital will experience the inability to operate unless competitive wages are initiated to fill the numerous vacancies…  Unfortunately, State procedures require a demonstration of the inability to fill vacant positions before the Office of Governor (OFM) can recommend market wage increases…  This was a process that was prevented from occurring when the previous CEO told Legislators that there was ZERO need for additional staffing.  Under normal processes, funding for additional staffing and market wage adjustments would take two years or more at a minimum.  Due to the incompetence that occurred in the past two years, normal processes cannot be allowed to apply or Western State Hospital will fail.  The current situation is extraordinary, sixty-five million dollars a year in federal funding will be lost unless a fix is initiated in a short period of time.  The fix is a small fraction of that figure.  The fix is the following:

  1. Follow the SIA guidelines to buy more time to allow the Legislature and Governor to bypass normal processes to provide the required funding and SAVINGS to pull off the transition. 
  2. Initiate market adjustments to psychiatrists, registered nurses, and licensed practical nurses THIS year, bypassing normal collective bargaining processes by creating a memorandum of understanding with each union stating that immediate market adjusted wages will be omitted as a subject of negotiation for the next contract as a unique none precedent setting circumstance.  The market adjustment of wages amend the previous labor agreements with regard to wages.  This is what is needed for recruitment and retention.  WSH would become a competitive employer even if the wages are SLIGHTLY lower than in the public sector. 
  3. During the SIA period it will be pointed out that WSH has EXTENSIVE, unnecessary, and redundant chain of command structures that can be thinned (delayered) for extensive savings.  The initiation of modern timekeeping systems to compensate employees for ACTUAL time worked would save WSH millions of dollars a year in unnecessary payment of unearned wages.  Elimination of unnecessary and redundant paperwork will also produce great savings.  Levels of productivity would explode while great savings were created. 
  4. (Added 4/30/14) WSH has hired hundreds of on-call personnel for which it is NOT budgeted to curb (cover up) the MASSIVE need for overtime required for daily operation.  DSHS never requested additional staffing (it requested staff reductions while expanding administrative positions) when DSHS knew that that at minimum it needed an additional 170 to 200 full time positions of which 114 were RN2’s, 10 LPN’s, and the rest nurse aide positions (MHT, PSA, IC).  When those computations were made, we also had a recruitment and retention problem with RN’s and LPN’s.  WSH currently has permanent “institutional” levels of full time staffing and can only sustain 5 staff per ward on day and evening shift while on night shift can only sustain 4 staff per ward for seven days per week…  Minimum staffing levels have risen to between six to twelve staff per ward as a minimum safe staffing level.  With the additional staffing, overtime will almost completely be eliminated and there will be no need for hundreds of on-call personnel. 
  5. The Legislature must fix antiquated laws to make Western State a “hospital” under Washington law to give WSH the protections, reporting processes, and oversight procedures that apply to ALL other hospitals within Washington.  DSHS will no longer be able to state that they are exempt from State laws that protect patients and employees.

There is much work to do in a SHORT period of time.  Will the Governor rise to the occasion to fix what HIS selected DSHS administration created at WSH?  It is interesting to note that the fix must occur just PRIOR to the election of the next Governor.   

I remind you that as a voter, you have the power to create change.  Your two candidates for Governor are the following:

Bill Bryant - FaceBook Page,  Web Site.

Jay Inslee - FaceBook Page,  Web Site.

WSH Root Cause of Failure and Solution

A document was created by Deputy Assistant Secretary of DSHS (and interim WSH CEO) on 4/14/16 which  illustrates why Western State Hospital requires an oversight body (overseeing all DSHS actions) and why DSHS can never be trusted to operate “hospitals” without having its “hospitals” meet the definition of hospital under Washington Administrative Code.  If Western State Hospital was audited, it would become known that DSHS is adept at suppressing information from being presented to the legislature, public, and accreditation and regulating bodies.  The creation of this document actually points out the root cause of the current quality problems at Western State Hospital. 


Protections and laws which have been passed to create transparency, safety, and oversight to Washington hospitals do not apply to Western State Hospital or Eastern State Hospital because under Washington law neither is a “hospital” and DSHS actually takes proactive actions (like 16-04-001) to prevent meeting basic standards that would apply in any other hospital, from applying at state hospitals.   


In her document, the interim CEO states:


  • Note: Per WAC 246-360-010(27), State Hospitals do not meet the definition of hospitals and are not required to report Adverse Events to DOH.  The hospitals may determine an event should be reported as curtesy to DOH.


WAC 246-320-010


For the purposes of this chapter and chapter 70.41 RCW, the following words and phrases will have the following meanings unless the context clearly indicates otherwise:

(27) "Hospital" means any institution, place, building, or agency providing accommodations, facilities, and services over a continuous period of twenty-four hours or more, for observation, diagnosis, or care of two or more individuals not related to the operator who are suffering from illness, injury, deformity, or abnormality, or from any other condition for which obstetrical, medical, or surgical services would be appropriate for care or diagnosis. "Hospital" as used in this chapter does not include:

(a) Hospice care centers which come within the scope of chapter 70.127 RCW;

(b) Hotels, or similar places, furnishing only food and lodging, or simply domiciliary care;

(c) Clinics or physicians' offices, where patients are not regularly kept as bed patients for twenty-four hours or more;

(d) Nursing homes, as defined in and which come within the scope of chapter 18.51 RCW;

(e) Birthing centers, which come within the scope of chapter 18.46 RCW;

(f) Psychiatric or alcoholism hospitals, which come within the scope of chapter 71.12 RCW; nor

(g) Any other hospital or institution specifically intended for use in the diagnosis and care of those suffering from mental illness, mental retardation, convulsive disorders, or other abnormal mental conditions.

Furthermore, nothing in this chapter will be construed as authorizing the supervision, regulation, or control of the remedial care or treatment of residents or patients in any hospital conducted for those who rely primarily upon treatment by prayer or spiritual means in accordance with the creed or tenets of any well-recognized church or religious denominations.


Please note that the definition of “hospital” in this antiquated law compares psychiatric hospitals as being in the same class as “any hospital conducted for those who rely primarily upon treatment by prayer or spiritual means in accordance with the creed or tenets of any well-recognized church or religious denominations.”  This dates back to institution / asylum days.  


Psychiatric care has evolved greatly in the past twenty years from an institutional warehouse to a true modern accredited hospital with modern medications and full active treatment, positive outcomes, as well as transitions back into the community.  Western State Hospital and Eastern State Hospital have been accredited by The Joint Commission and CMS as meeting the criteria for “hospital” nationwide.   Unfortunately Washington law has failed to evolve and DSHS Administration intends to keep it that way.  DSHS mismanagement and abuses will become common knowledge if the legislature strikes out WAC 246-360-010 subsection 27 part “g.”   If the Legislature was to make Western State Hospital and Eastern State Hospital a “hospital” under Washington Administrative Code and the Revised Code of Washington, numerous levels of oversight and accountability would apply AUTOMATICALLY.   Document 16-04-001 was intended to eliminate transparency, accountability, and notification of credentialing authorities such as DOH and CMS.  That document specifically states:


  • State Hospitals are not required to report adverse events to the Department of Health.  State Hospitals do not meet the definition of “hospital” under WAC 246-320-010(27).

  • The State Hospital my choose to report an adverse event…   


This is an action that was taken to prevent oversight, accountability, and transparency which would automatically apply to any hospital under Washington law.  Rather than DSHS reporting to the Legislature that WAC 246-360-010(27) was antiquated and recommended for removal and modification to make Western State Hospital and Eastern State Hospital into a “hospital” under Washington law, DSHS moved to cover up events rather than going through the process to improve care and learn from the errors.


The initiation of Document 16-04-001 also signifies an assumption that Western State Hospital will “choose” not to report events to the Department of Health as no person would be held accountable for “not” reporting.  The document is actually intended to discourage reporting of a Facilities Complaint to the Department of Health by employees as such reporting is no longer mandatory as a duty of the employees’ licensure (according to DSHS).  Thus reporting a Facilities Complaint to the Department of Health requires an employee to be a whistleblower, thus opening the possibility of the employee being subject to retaliation by DSHS…   As has occurred on many occasions and is occurring now.



Once the Legislature makes Western State Hospital and Eastern State Hospital a “hospital” under State Law…  The following will occur:


  • Eastern and Western State Hospital would be licensed to operate by the Department of Health (rather than DSHS itself under its own oversight) and be mandated to operate under Department of Health oversight and mandatory reporting criteria like ALL other hospitals within Washington.

  • DSHS cover ups would become an artifact of past institutional practices and WSH & ESH would become modern hospitals under Washington law, as they already ARE as accredited hospitals.

  • RCW 49.28.130 will apply to Western and Eastern State Hospital.  Mandatory overtime protection laws will apply to WSH/ESH for the first time.  Finding—2002 c 112: "Washington state is experiencing a critical shortage of qualified, competent health care workers. To safeguard the health, efficiency, and general well-being of health care workers and promote patient safety and quality of care, the legislature finds, as a matter of public policy, that required overtime work should be limited with reasonable safeguards in order to ensure that the public will continue to receive safe, quality care." [ 2002 c 112 § 1.]


  • Medicare certification would work the same way as with all other Washington hospitals at WSH/ESH.  Federal Medicare pays for services in acute care and psychiatric hospitals that voluntarily seek certification and are approved by the Centers for Medicare & Medicaid Services (CMS). CMS contracts with the Department of Health to evaluate compliance with the federal regulations by periodically conducting on-site surveys in these hospitals.  But in this case there is a mandatory reporting requirement.  Western State Hospital/DSHS by its recent actions is attempting to PREVENT reporting to DOH and CMS, this is the root of the current problem at WSH.


  • Food preparation is NOT currently in compliance with State law at WSH.  There is no mandatory oversight of food preparation for over half the meals served at WSH when food is prepared (bulk delivered foods are proportioned and plated) by nursing personnel on each ward.  This practice would come into compliance with State law, drastically enhancing the care that is provided at WSH.  Food handler training requirements would be more expensive at WSH/ESH if normal laws applied and were not actively suppressed by DSHS. 


  • Although DSHS would license WSH/ESH through Department of Health processes, DSHS would be under constant DOH/CMS oversight through mandatory reporting processes and in ENFORCED compliance with laws that apply to all hospitals in Washington.  There would be no need for a legislative oversight body over WSH, this would cause great savings.


  • DSHS had to DUPLICATE numerous layers of bureaucracy to emulate DOH licensure processes and quality control which would have otherwise been governed by the same laws pertaining to all hospitals within Washington.  If DSHS licensed WSH/ESH through DOH, all laws would apply as would oversight thereby ELIMINATING the need for numerous redundant structures within each hospital and DSHS itself.  This would bring about great savings by dismantling duplicate structures within DSHS.


  • Through compliance with existing hospital laws that would now apply to WSH/ESH for the first time, timekeeping issues could be addressed for the first time and employees would be compensated for actual time worked…  Saving the State millions of dollars a year in unearned wages.  See transition time issue and listen to broadcast: 20140509_JR_WesternState.mp3


  • When Western and Eastern State Hospital are licensed to operate as a true hospital under Washington law through the Department of Health, laws will apply causing great savings to DSHS.  It is these savings that would be used to fund competitive wages and sufficient staffing.


In closing, the single key to fixing the State Hospital issues is for the Legislature to make DSHS State Hospitals become a “hospital” under Washington law, therefore licensed to operate via the Department of Health like all other hospitals in Washington.  This act alone will bring the oversight mechanisms that DSHS has prevented from occurring for so many years.  Yes, the solution IS that simple.  


A Long Strange Week

It seems that that the current Washington State Governor and his appointed Western State Hospital and DSHS Administrations have reached a new apex of incompetence.  By the CEO eliminating competent personnel in key positions and replacing them with his own incompetent selections and personal friends (rather than hiring panel recommendations), Western State Hospital has collapsed internally and WILL most likely lose $65 million in Federal Funding because the current Governor did NOTHING to intervene or replace the problem.

Since the current CEO was the first CEO to ever be hired to a multiyear contract, WSH has reached the lowest point I have observed in my 31 year history at WSH.  Certain individuals were KEY to keeping WSH productive and accountable…  Most were eliminated by the CEO.  The CEO had eliminated the Medical Director for an extended period until he was FORCED to replace the position…  Again and again…  The CEO is now trying to eliminate the Chief of Staff position (an elected position).  This CEO does not listen to committee recommendations and has taken steps to assure that care providers and patients remain working in dangerous conditions where less restrictive measures remain unavailable.  There can be no culture of safety at WSH while this CEO and Administration remain.  When the CEO is present at a meeting, we know that any presentation that is made would be pointless, as his fixed points of view never waver though presentation of facts or reason (but we carry on anyway with the presentations).  This is consistent with the fact that the CEO has never to my knowledge hired any key administrative employee that was recommended by a hiring panel consensus.  Note that DSHS and Olympia do not allow the CEO to speak to the media so as to let his brilliance shine (for all to see).  

This week has been difficult to observe…  I can remark about some of the data because it has already been reported in the media…  The following occurred over the past week:

  • One extremely dangerous patient escaped by opening a window, walking fifty yards to the bus stop.
  • Two additional patients with criminal histories also escaped.
  • A patient was found dead on another ward on the same day, I do not know about the medical examiner results.
  • A patient was allegedly raped in HMH within the past week.
  • A staff member on a “two staff to one patient” assignment was beaten up and hospitalized within the past week.
  • On East Campus the heating system one morning switched to FULL ON heating and could not be controlled, sending the temperatures in many rooms to close to 100 degrees unit wide…  The troubleshooter had to wait for day shift maintenance to come in and figure out what was going on…  The heat was so severe that items melted and an electrical fire could have erupted at any time.  Literally nobody knew what to do.  Exit doors had to be propped open in non-secure areas and ward patio (secure area) doors had to be propped open on all wards.  
  • The flu continues to circulate within the hospital due to the Medical Director keeping the initial flu outbreak top secret.  I will report on this issue later.  The spread continues…  
  • Employee survey results indicate that since implementation of the current CEO, the hospital has fallen on its face and may be unrecoverable with regard to safety and morale.  See blog entry.
  • The Joint Nurse Staffing Committee was told that if the funded 51 Registered Nurse positions are not filled by July, the funding will return to Olympia.  This would be tough to do as RN’s are now 25% behind in pay with the public sector and WSH is about to lose CMS funding through administrative incompetence.  The very first action of the CEO was to eliminate an RN position, even though he was briefed of the SEVERE RN shortage at WSH.  I look forward to publishing the meeting minutes of the Joint Nurse Staffing Committee meeting.
  • The WSH Security Department Head created its own escort procedures resulting in myself having to file complaints with the Department of Health to assure that the Security Department was mandated to escort patients to criminal arraignment hearings and criminal court proceedings… The Security Manager wanted UNTRAINED nursing personnel to perform the transport/escort task (instead of security) using caged cars that nursing personnel were never trained to use.   Administrative appointed nurse managers were going to go along with this nonsense before they were stopped by the open complaint filing.  Something like this could have never happened in any other CEO administration.  It was kind of a prophetic situation due to the civil patient escapes. 
  • Staffing has consistently been insufficient, resulting in frequent mandatory overtime.  Records will indicate that minimum base safe staffing could not be provided daily due to the MASSIVE staffing shortage that the CEO denies exists.  We have all noted that staffing is DRASTICALLY better when CMS and Joint Commission inspectors are present.  A note to CMS and TJC surveyors…  PLEASE COME AND STAY!!!

I was surprised to learn that C4, the ward where criminal past civil patients (HB 1114 patients) were assigned, was NOT considered an acute care ward by WSH administration.  I checked into the Central Safety Committee and Central Campus Safety Subcommittee (meeting minutes) records to determine why acute status was not applied to that ward.  Monthly meetings are required by the Safety Committee Charter.  I came to find that zero meetings or minutes were filed for the Central Campus Safety Subcommittee since February of 2015…  Meaning that C4 was not vetted by its own Safety Subcommittee.  This violates accreditation requirements at every level.  The Safety Committee Charter can be found here. 

Facts speak for themselves…  The buck stops with the Governor who took no action to change a dysfunctional and incompetent administration at Western State Hospital and DSHS.  WSH will most likely lose $65 million in federal funding on May 3, 2016…  Unless we continue to receive (what seems to be) endless short term extensions during an election year.  

But since this IS an election year, all of us can exert influence over a change in leadership through the election process.  A drastic change needs to occur to improve mental health care.  BE SURE TO VOTE!  


Your two choices for Governor will be:

2015 DSHS Employee Survey

DSHS has just released the Western State Hospital 2015 Employee Survey.  The report does not include employee comments…  This is the first indication of a major coverup.   

First lets look at the “Major Comment Themes” section:

screenshot 146

Note that the survey indicates that almost all areas fall under “needs work.”   Note the “Management” and “Genera/Other” (what the hell is that?) numbers.  I find it interesting that comments were not provided so as to give the “needs work” heading more meaning in each area, especially “other."  Those of us that work at WSH, understand this meaning well.  Numerous requests for changes in WSH Administration will not be published in an election year.

The next section of the survey has been compiled in an obscure and obfuscation attempted way…  It breaks down change in views from 2013 when the new CEO and his Administration were appointed until 2015.  Pay particular attention to the section entitled “Change 13-15.”  This indicates almost zero positive changes and a devastating reduction in work productivity point of view.  Note that NOT all negative numbers were redlined, view this as part of the Administrative cover-up of the true meaning of this survey.  It is my opinion that if this was not an election year, the true level of failure of the current DSHS Administration would have been published rather than covered up.

screenshot 147

The way this survey was published is problematic at best.  Unless the truth is plainly presented, it cannot be addressed.  

The CEO of WSH gave the following response:

screenshot 149

© Paul Vilja 2017