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.

© Paul Vilja 2017