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Federal Survey Team Finds St. Elizabeths Hospital in Compliance With Medicare/Medicaid for First Time Since 1997

Friday, May 3, 2002

(Washington, DC) For the first time in five years, a federal survey team found St. Elizabeths Hospital in compliance with Medicare/Medicaid standards, announced Martha B. Knisley, director of the Department of Mental Health, which operates the hospital. The survey was conducted between April 29 and May 2 by a team from the US Department of Health and Human Services Centers for Medicare & Medicaid Services that pronounced the hospital an ". . . excellent work in progress."

"We are overjoyed with the survey team's assessment of our operations," she said. "This is a huge accomplishment. I don't know of any other hospital that has overcome as many deficiencies in as short a time as we did."

Being found in compliance restores the hospital to an annual inspection cycle rather than the multiple inspections within a year it has undergone to evaluate progress in correcting deficiencies. "From this point forward, we will be treated just like other hospitals. No more special conditions; now we can focus on continuous improvement," explained Director Knisley who also noted that special praise was given for improvements in the pharmacy, active treatment for patients, and patients' rights.

In December 2001, the most serious deficiency found by the CMS survey team was that the hospital violated regulations governing the use of seclusion and restraint and gave the staff 23 days to turn around its practices, which it did. Additionally, the hospital was cited for lack of active treatment for patients and patients' rights violations. These latter two areas are what the team focused on during its most recent survey.

"The entire hospital staff, led by Chief Executive Officer Joy Holland and Medical Director Craig Krause, is to be commended for the heroic actions taken to correct the deficiencies discovered last December," said Director Knisley. "Of greater significance is that these improvements create the foundation to build for the future. We are a new Department, charged with developing a mental health system that has the interests of consumers of mental health services at its core. This survey's results validate all our work, prove we are on the right track, and show us we have a long way to go."

The surveyors noted that additional progress must be made in the following areas: documentation of mandatory training; and integrating quality improvement processes into hospital operations.

Ms. Holland became CEO in August 2001 and by November had assembled her management team that has chalked up a number of improvements in direct patient care since October:

  • A 90 percent reduction in the use of seclusion and restraint
  • A 700 percent increase in the use of active treatment to engage hospitalized consumers in activities that promote their recovery
  • Reduced use of tranquilizers by eliminating all standard "as required" orders
  • Provided a less restrictive environment by unlocking the units
  • Provided choice in diet by allowing patients to select their own foods

A list of the hospital's accomplishments since October 2001 follows.

Accomplishments at St. Elizabeths Hospital from October 2001 Through April 2002

Direct Patient Care Improvements

  • A 90 percent reduction in use of restraints and seclusion since October 2002
  • Achieved 700 percent increase in active treatment, from 600 hours per month to 4,200 hours per month by enhancing the Treatment Mall program
  • Conduct independent review of all alleged incidents of abuse and/or neglect
  • Reduced use of tranquilizers by eliminating all standard "as required" orders
  • Provided a less restrictive environment by unlocking the units
  • Provided choice in diet by allowing patients to select their own foods
  • Standardized meal times and dining locations
  • Realigned admission services for the acute admissions to provide more intensive services
  • Implemented a choking prevention program

Indirect Patient Care Improvements

  • Remodeled two buildings to allow for active treatment for patients unable to go to the Treatment Mall
  • Improved the grounds and facilities infrastructure, which support patient care
  • Developed and reorganized the medical records for efficiency, accuracy and completeness
  • Supplied medical emergency kits to every unit to bring into compliance with legal and hospital standards
  • Improved housekeeping services by using effective cleansing agents, increasing cleaning frequency of living areas to eliminate odors and prevent the spread of infection
  • Implemented a hospital-wide psychopharmacology consult service to help manage difficult cases

Managerial and Administrative Improvements

  • Developed standard operating procedure for contract monitoring for all building repairs/improvements and equipment maintenance (including biomedical equipment)
  • Initiated core competencies for all departments
  • Established a peer review process for all disciplines
  • Developed department of education and training to provide orientation, required annual training and professional development for all staff
  • Organized an integrated executive staff with all hospital managers to accomplish hospital's annual goals to be tracked using weekly meetings to monitor/review/implement objectives
  • Established protocols for use of overtime in all departments
  • Developed protocol for monitoring abuse of leave
  • Improved response time for filling supply orders and completion of work orders
  • Eliminated down time of equipment repair by requiring contractors to repair equipment on site
  • Quality improvement program (continuous monitoring) for grounds sanitation, housekeeping and supply inventory

For further information, please contact Linda Grant at (202) 673-1937 or email.