Program design paper: Brentwood Hospital

Brentwood Hospital
Analysis of Brentwood Hospitals patient advocate program: Goal of
program improvement
Final report for Judy Mares-Dixon: Designing Dispute Resolution Systems
for Organizations, SMU Plano Texas
Bill Dockett
10-1-2013

Analysis of Brentwood Hospitals patient advocate program: Goal of program improvement
The purpose of this report is to assess the patient advocacy program of Brentwood
Psychiatric Hospital in Shreveport Louisiana as a dispute resolution system. The data gathered
for this report come from a variety of sources including staff interviews, hospital policies, and
hospital internal reports.
Currently there are twelve best practices principles of a successful dispute resolution system
which will be utilized as evaluation criteria.
• The organization needs to engage in an inclusive process to define both dispute resolution
goals and practices.
• The design process should diagnose causes of recurring conflicts and evaluate the
effectiveness of existing dispute resolution procedures.
• The system should be compatible with the organization mission and culture.
• The optimal system should be capable of changing with the organization over time.
• The system should seek to offload, not replace the legal system.
• The dispute system should provide multiple access points for users, to increase the
likelihood that conflicts are addressed early and constructively.
• The dispute system should provide multiple options of handling conflict, including
options for prevention as well as resolution.
• The system should strive to keep decisions in hands closest to the problem.
• Dispute resolution procedures should be designed to address the causes of disputes.
• The system should encourage people to solve problems by satisfying interests, rather than
capitulating to positions.
pg. 1
Copyright 2013 Bill Dockett and Dockett and Associates LLC
www.Dockettandassociates.com

• The system should encourage people to seek psychological and procedural satisfaction, as
well as substantive satisfaction from solutions.
• The dispute system is most robust if people are trained and encouraged to resolve their
own conflicts.
Typically, the rational for evaluation focuses on four major questions. 1. What are you
actually doing compared to what you hoped to be doing? 2. How are you doing at managing the
problems or disputes the system was designed to address? 3. What evidence is there that fewer
problems or disputes are emerging after systemic changes? Within an organizational setting, the
fourth question becomes: 4. How has the dispute management system effected the organization
overall, and how is it perceived and utilized. Furthermore, to what degree is the design
achieving the stated goals? (Rogers, Bordone, Sander, & McEwen, March 14, 2013)
From the outset an important distinction needs to be explained with regards to a dispute
resolution system verses a mediation program since the two are often confused. A simple
definition of a system would be: when an organization has multiple options for resolving a
dispute through choice or options driven for responding to an issue. A mediation program is the
utilization of a subset of tools, typically mediation and/or arbitration, of either a binding or
nonbinding nature for alternative dispute resolution process (ADR) designed to assist parties in
resolving disputes.
A comprehensive conflict management system (CCMS) includes independent and neutral
third party options that allow for informality and anonymity/confidentiality and minimizes the
risk for retaliation.
pg. 2

A well designed CCMS:
1. Encourages people to come forward and express issues
2. Encourages collaborative options
3. Allows choice (voluntary ) from available options
4. Prohibits retaliation for use of system and punishes those who violate the program
when exposed
5. Establishes policy
6. Is linked to organizational values and goals
7. Provides policies, procedures, standards of system which are integrated and found in
relevant documents and resource materials
8. Has clear job descriptions, performance assessment process, criteria and instruments
9. Allows all employees to receive information ( & training) to understand system
operations and responsibilities & privileges
10. Establishes a system for collecting and reporting data
Historical context
Brentwood hospital in its current state is a 200 bed acute care psychiatric hospital, plus an
adult and adolescent partial hospital outpatient program (PHP). Brentwood is a recent
acquisition of UHS, Inc. which formally belonged to PsyCorp who was acquired by UHS Inc.
Prior to and subsequently since the transition to UHS Inc. the facility has consistently outpaced
corporate averages on both their inpatient and outpatient treatment satisfaction discharge
surveys. The transition to UHS Inc. governance has brought with it a new employee and patient
relations culture called “Service Excellence” to be implemented.
pg. 3

During the ten years that Brentwood Hospital has had a patient advocate program, one
individual has been in the position of the patient advocate. The facility conversely has
experienced a great deal of transition with the corporate ownership change, along with four
CFO’s and four CEO’s. The Brentwood program has evolved from a JCAHO 2002 direct
finding for patient care improvement as part of the National Patient Safety Goals. The National
Patient Safety Goals (NPSGs) were established in 2002 with an effective date of January 1,
2003 to help accredited organizations address specific areas of concern with regard to patient
safety (Commission, 2013).
The NPSG’s are developed by The Patient Safety Advisory Group which advises The Joint
Commission on the development and updating of NPSGs. The advisory group advises The Joint
Commission how to address emerging patient safety issues in NPSGs, Sentinel Event Alerts,
standards and survey processes, performance measures, educational materials, and Center for
Transforming Healthcare projects. The advisory group is comprised of a panel of widely
recognized patient safety experts including nurses, physicians, pharmacists, risk managers,
clinical engineers, and other professionals with hands-on experience in addressing patient safety
issues in a wide variety of health care settings. (Commission, 2013). The Substance Abuse and
Mental Health Services Administration (SAMHSA) has also issues its own set of guidelines for
patient advocacy and identification of stakeholders called Protection and Advocacy for
Individuals With Mental Illness (PAIMI) (SAMHSA, 2011).
Current stake holders of the hospital include:
• Management
• Patients/families
• UHS Inc. corporate/shareholders
pg. 4

• Employees
• Insurance payers/contracts
• JCAHO
• State/governmental agencies
Current implementation
Given the programs current state of evolution, structurally it is comprised of a department
of one individual that responds directly to the CEO. The other hospital departments respond via
regular management and committee meetings. This structure also resembles a classical
ombudsman type of structure with authority to conduct both formal and informal investigation of
issues with a divergence point of having management responsibility. The program, according to
policy, is focused on patient/family issues and complaints. Employee related concerns are
referred to human resources, and follow their procedures.
In terms of current design, the patient advocate is not independent due to additional
compliance and management duties. This program design also combines the management and
compliance positions of quality assurance and risk management with one individual. Current
industry practice separates the patient advocate from compliance related positions. This I
customarily done to provide a degree of neutrality, impartiality and discretion to resolve issues
either formally or informally.
Based on hospital policy there are several methods of lodging an issue or
complaint/grievance internally and externally. Written issues in the form of patient/employee
comment/grievance cards are accessible on every floor and on all patient units. Verbal
pg. 5

comments/grievances are also addressed by requesting to speak to the patient advocate. Written
grievances have a 72 hour time frame for investigation and response from date of receipt.
Written comments are collected and reviewed daily by the patient advocate along with the CEO
and directors of Nursing and Clinical Services Monday through Friday. Any grievance resulting
in the violation of a patent’s rights will have a written response generated by grievance
committee within seven days of its review. This response detailing the issue and actions taken
by the hospital. An exception to the above policy is with regard to complaints against the
medical staff. In this situation the patient advocate is to notify the President of the medical staff
who then is to directly address the issue with the patient in a written manner. The
correspondence is to include the contact information for the Louisiana State Board of Medical
Examiners.
External means of filing a complaint/grievance entail contacting the Louisiana
Department Health and Hospitals (LaDHH) or The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO).
Modes of Data Collection
There are three primary methods of data collection utilized by the patient advocate. 1.
Verbal expression of an issue (non-tabulated). 2. Written statements. 3. Discharge satisfaction
surveys. All formal and informal options are utilized to assess the state of the hospital in near
real time processing speed.
The hospital averages 15-20 written issues per month from the adult, children’s and
adolescent populations. Reportedly, most of the patient’s comments/issues fall into two primary
categories. For the adult units, there appears to be a focus on number smoke breaks and
pg. 6

scheduling. With regard to the child and adolescent units, patient and family complaints tend to
focus on a lack of contact/communication with their treating physician.
The second mode of data collection are patient satisfaction surveys that are administered
and collected at the time of patient discharge. This survey is sent to the corporate office for
companywide tabulation. The facility consistently ranks above company average for both
inpatient and outpatient data metrics from satisfaction surveys. The satisfaction surveys are
designed utilizing 16 Likert scale questions with two open ended feedback questions on patient
care and experience in the hospital for all patent contact departments. Positive statements from
surveys are printed in the employee monthly newsletter as a means of positive employee
feedback.
Preliminary Recommendations:
Based on the above referenced report a number of preliminary recommendations have been
formulated and submitted with the goal of improving the process. The goal is to move beyond
compliance, which the program was borne out of, to “Service Excellence”. Furthermore the
recommendations would represent a move to best practices and allow Brentwood to assert a
leadership role in the region and UHS Inc. This report opened by listing a set of best practice
criteria, many of which the current patient advocate program complies with; however, there is
always room for growth and improvement.
• The organization needs to engage in an inclusive process to define both dispute resolution
goals and practices.
pg. 7

Currently the program is insular in nature meaning that only hospital staff is involved. A
step toward inclusion would be to invite a former patient representative or a “Prosumer”
(individual with a clinical background and mental health issues) to join the committee.
Another option could be to invite a noncompeting organization such as the North Louisiana
chapter of the National Alliance for Mental Illness. This would assert leadership and provide
a sense of transparency in the hospital’s patient care.
• The design process should diagnose causes of recurring conflicts and evaluate the
effectiveness of existing dispute resolution procedures.
The current program is reactionary by design. While it provides a mechanism for addressing
future similar issues, it does not lend itself to forecasting zero day issues.
• The system should be compatible with the organization’s mission and culture.
The design structure of the program represents the organizational culture of past corporate
governance, and not the current “Service Excellence” model that the hospital operates under.
• The optimal system should be capable of changing with the organization over time.
By moving toward embracing the “Service Excellence” model and implementing
recommendations a more flexible system could be created.
• The system should seek to offload, not replace the legal system.
As designed, the current system addresses this by attempting to internally address presenting
issues, and then referring when appropriate.
pg. 8

• The dispute system should provide multiple access points for users, to increase the
likelihood that conflicts are addressed early and constructively.
The current system affords two primary methods of access: written/verbal statements and
discharge surveys. Additionally, due to the reduced lengths of stay for most of the patients
the 7 to 9 work day response window is no longer appropriate. This results in patients being
notified of the hospitals response to their issues post discharge. This unintentionally
potentially sabotages the treatment process and does not foster development of appropriate
coping skills.
Patient progress tracking post discharge could be done on a 30, 60 and or 90 day interval for
tracking aftercare/readmission issues. This allows for the identification of weak points in
aftercare planning and an additional data collection mechanism for marketing/advocacy.
• The dispute system should provide multiple options of handling conflict, including
options for prevention as well as resolution.
The current model affords 2 options. As previously stated, the creation of additional
mechanisms for patient and or family reporting/communication via a secure web portal
utilizing the patient identification number to log in could be an option.
Due to HIPAA and confidentiality laws/regulations engaging in social media platforms to
address issues would not be appropriate.
Patient progress tracking post discharge could be done on a 30, 60 and or 90 day interval for
aftercare/readmission issues.
• The system should strive to keep decisions in hands closest to the problem.
pg. 9

The models current investigation process address and encourages this.
• Dispute resolution procedures should be designed to address the causes of disputes.
The current model addresses this, but on a reactionary basis. The recommendation would be
to integrate a more proactive stance of educating the patents and staff about the patient
advocate role and duties.
The current model combines the patient advocate with compliance positions, all of which
require a singular focus. The recommendation for increased accessibility would be to
remove additional compliance roles to allow for a singular focus.
• The system should encourage people to solve problems by satisfying interests, rather than
capitulating to positions.
The current model seeks to achieve this.
Recommendations on improving this would be to implement conflict management skills
development as part of new hire orientation and employee annual reorientation.
• The system should encourage people to seek psychological and procedural satisfaction, as
well as substantive satisfaction from solutions.
The current model seeks to achieve this, but the 7 to 9 business days as previously mentioned
is no longer adequate given the reduced lengths of stay. Possible solutions would be to
reduce the processing time frame to reflect current lengths of stay so that patients can receive
resolution while they are hospitalized. This also encourages a sense of good will and
transparency with fellow patients (I had an issue, told the patient advocate, and I had a
response before I was discharged).
pg. 10

Other possible solutions would be to create an actual patient advocate department and
expand staff to accommodate new timelines.
Another option is to remove compliance and management duties to have position reflective
of industry standards.
• The dispute system is most robust if people are trained and encouraged to resolve their
own conflicts.
The current model lends itself to this but there is not an emphases on coaching patients to
utilize and develop coping skills.
Possible recommendations would be to consult with clinical staff to add presenting issues to
the treatment plan.
During new employee orientation and annual reorientation the staff could be educated on
what the patient advocate program is and be provided with training on conflict management.
Utilizing the opening framework of the twelve best practices principles, a series of
recommendations for growth and improvement have been presented. The proposed time line for
implementation and upgrade of the program would depend on management’s willingness to
adopt the recommendations and include any additional changes. The timeline for full
implementation should not exceed 120 days.
pg. 11

References:
Commission, T. J. (2013). 2013 National Patient Safety Goals Slide Presentation.
Rogers, N. H., Bordone, R. C., Sander, F. E. A., & McEwen, C. A. (March 14, 2013). Designing Systems and
Processes for Managing Disputes (Pap/DVD ed.): Aspen Publishers.
SAMHSA, S. A. a. M. H. S. A. (2011). Evaluation of the Protection and Advocacy for Individuals With
Mental Illness (PAIMI) Program, Phase III. Final Report. HHS (S. A. a. M. H. S. Administration,
Trans.). Rockville, MD:: Center for Mental Health Services, Substance Abuse and Mental Health
Services Administration.
pg. 12

Program design paper: Brentwood Hospital

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Program design paper: Brentwood Hospital