Remarks by HHC President Alan D. Aviles Announcing Completed and Future Reforms to Improve Quality of Care for Mental Health Patients at Kings County Hospital Center
Feb 05, 2009
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Good morning. We are standing in the new behavioral health pavilion here at Kings County Hospital Center, which opened just last week and will be fully occupied by the middle of next week.
This very substantial infrastructure investment is among a number of major improvements we have now achieved in the first phase of a comprehensive eight point plan to transform mental health services, improve quality of care and radically change the patient experience for the children, adolescents and adults of Central Brooklyn who depend on the mental health services we provide here at Kings County.
During the past year we have been focused on the design and implementation of sweeping and radical change in the delivery of behavioral health services at Kings County. Those efforts took on even greater urgency with the tragic, inexcusable neglect and death of Esmin Green in this hospital’s psychiatric emergency department seven months ago.
Today we unveil a dramatically transformed physical environment, but perhaps more importantly we report on our progress in fundamentally redesigning the way we have delivered mental health services here for decades. Today, we turn a page as we move forward an agenda focused on instilling and supporting a culture of patient-centered care for mentally ill patients at Kings County, a culture anchored in compassion, respect and an emphasis on sustainable recovery so that patients can re-integrate with their community.
The first phase of our completed reforms includes this long overdue replacement of the antiquated “G” building. The planning for this building began over five years ago and reflected a clear sense back then that behavioral health services here at Kings County needed to be brought into the 21st century. With this spectacular new facility, our patients and our staff are no longer relegated to a physical environment dating back to the 1930’s that often resembled a penal institution in its construction, limited space and appearance.
This 300,000 square foot pavilion allows us to consolidate under one roof all behavioral health inpatient, outpatient and emergency services that have been dispersed across seven buildings on this campus. It doubles the space available in our old psychiatric emergency department. And, more importantly, the state-of-the-art design supports more effective treatment in a much more therapeutic environment for the more than 12,000 children, adolescents and adults served here each year.
Just as you need talented architects to create state-of-the-art physical space, you need leaders who possess talent and vision to dramatically improve the manner in which care is delivered to patients. I am pleased to introduce you to the new senior leadership here at Kings County Hospital.
First, Antonio Martin is the new Executive Director of this hospital. Mr. Martin has an exemplary track record as a hospital leader within our system, having served as the Executive Director of Queens Hospital Center for the last six years.
Second, Dr. Joseph Merlino is the new Administrator of Behavioral Health Services. Dr. Merlino is a respected psychiatrist who has served in various leadership roles and most recently served as Director of Psychiatry for Queens Hospital Center. Mr. Martin and Dr. Merlino have shown themselves to be outstanding leaders and they both have a solid track record of successfully driving culture change and organizational performance improvement in their previous positions.
We are joined by a number of other HHC staff, but I want to single out and acknowledge Dr. Ann Sullivan who I appointed as the interim administrator of behavioral health services here immediately after the Esmin Green tragedy. Dr. Sullivan has been a respected leader in psychiatric services for nearly 25 years. She temporarily stepped out of her role as one of our network senior vice presidents and has spent the last seven months here implementing our reform agenda. I am very grateful to her for helping staff to accomplish so much positive change in such a relatively short period of time.
Over the course of the last decade, Kings County had found itself deluged with patients who presented with very severe mental illness. The pressure on our three psychiatric emergency departments here in Brooklyn has significantly increased over the years. Last year, there were 12,000 more emergency visits compared to just eight years ago. And the result was severe overcrowding, difficulty placing patients who needed inpatient admission, and extended stays for many patients in our Comprehensive Psychiatric Emergency Program (CPEP).
Kings County runs one of only two CPEPs in the borough. CPEPs are this City’s equivalent of a level one trauma center for the most seriously mentally ill — patients who often present in extreme crisis, who often suffer from co-occurring substance abuse that complicates both diagnosis and treatment, patients who too often have records of incarceration, patients who often come here after acting violently towards themselves or others. In fact, here, as in most CPEPs in our City, more than 70% of the patients who end up as psychiatric inpatients are admitted involuntarily because they are assessed to be a danger to themselves or to others.
That’s why a new approach to safety and security – for both patients and staff – has been and continues to be a priority of our reform agenda.
While our work is far from complete, we have already radically reduced overcrowded conditions in the psychiatric emergency room which often contribute to patient agitation and assaultive behavior. Through better coordination with EMS and other parts of our City’s mental health system, as well as more adequate staffing ratios, and more expeditious triage, assessment and treatment, we no longer hit spikes of 50 or more patients in the emergency department as we did at times just one year ago. Now our patient census in the emergency department seldom exceeds 25 patients at any one time.
Where one year ago the average time that a patient spent in the CPEP before discharge or admission was 27 hours, today the average is less than 8 hours.
This dramatic improvement in keeping our emergency department staff from being overwhelmed has been aided greatly by an agreement negotiated several months ago with Kingsborough Psychiatric Center, a state facility. We now jointly staff 24 crisis beds at Kingsborough, and in return, Kings County has priority access to those 24 beds for our patients, as needed, to relieve pressure on both our CPEP and our inpatient units during spikes in volume.
Another major transformation in our approach to safety and security involves the withdrawal of hospital police from our CPEP. Over time we have found that there was too much reliance on hospital police to manage patients in crisis. We have now deployed specially trained personnel with crisis intervention skills, as well as security-related experience. These new staff – called Behavioral Health Associates – are part of the clinical team and focus first on de-escalation techniques in dealing with agitated or aggressive patients. Hospital police continue to serve the hospital and can be called to assist when appropriate.
In completely overhauling the decades-old staffing model, we have added more than 200 new doctors, nurses, psychologists, social workers and other staff across our emergency and inpatient services. The new model of care is intended to ensure that every patient gets the focused attention they deserve – from the minute they enter the emergency room, throughout their stay in a hospital inpatient unit, and to their outpatient follow-up.
Let me describe the second phase of our reform initiatives that will be implemented over the coming year.
We will invest new resources in care coordination to better manage the chronic medical conditions like asthma, diabetes and heart disease, which too often go untreated in mentally ill patients. Because certain psychotropic drugs can contribute to weight gain, or adversely impact diabetes and other chronic conditions, we will assign a senior clinician to assess the medication regimen of patients at risk and ensure that we are making the right pharmaceutical choices for the treatment of a patient’s mental illness without worsening other existing medical conditions wherever possible.
We will create a more patient-centered environment on our inpatient units by expanding the use of Peer Counselors –full time staff who have been psychiatric patients themselves – and who will now serve as navigators, mentors and patient advocates in our CPEP. We recently added Peer Counselors to all tours in our CPEP and they have proved to be invaluable in providing the reassurance and comfort needed to assist patients in crisis.
We will also ensure that the voices and concerns of our patients, their families and mental health advocates are integrated into our program of care. To do so, we will create a new Consumer and Family Behavioral Health Advisory Council to formally engage mental health advocates, patients and their families, as well as concerned members of the Central Brooklyn community.
We also will expand and strengthen case management services and social work support for patients as they make the transition back into the community. We will continue to help prioritize access to available supportive housing, community crisis beds, and specialized community-based programs to help patients sustain their recovery and re-integrate into their community.
I have touched upon some important reforms that we have instituted and some that are in progress. I refer you to the highlights document included in your briefing packet which references these and other innovations organized under the eight major principles of our reform agenda.
During the course of the construction of this building, it became increasingly clear that we too often failed our mental health patients here at Kings County in serious ways. Various regulatory agencies found shortcomings over time, a lawsuit was filed by mental health advocates alleging a wide range of deficiencies, and most recently, at the end of last week, the Department of Justice completed a year long investigation and issued a 58 page report with serious criticisms. DOJ has highlighted, among other things, past incidents that have placed our patients’ safety at risk, including incidents of patient-on-patient violence that arguably constitute civil rights violations.
Inevitably, we will continue to struggle with the daunting challenge of accurately identifying and most appropriately treating patients who are prone to assaultive behavior. Although the measures taken to date have reduced the number of incidents of patient-on-patient and patient-on-staff violence in recent months, we had a serious incident just this past weekend where a male patient suddenly struck a female patient in the face, causing significant injury. Given the aggressive behavior exhibited by many of our most seriously mentally ill patients, it would be disingenuous of me to suggest that we could prevent all such future incidents, but we can do better.
However, we do not run a correctional facility, we run a healthcare institution. It is neither possible nor humane to place restrictions on all patients to curb the violent behavior of the few. We must make considered judgments about which patients present a risk of violence sufficient to treat them more restrictively, but those judgments will sometimes be wrong. Because of the complexity that often accompanies severe mental illness, the treatment of the mentally ill continues to be based on both science and informed intuition.
Given the gravity of some of our admitted failures to meet the needs of patients, and given the horrendous and inexcusable neglect of Esmin Green this past summer, some may ask: why are you tackling reform in the midst of the daily pressures of serving so many seriously ill patients? Why not just shut psych services down, take the time required to make the necessary changes – to programs, to protocols, to personnel — and then start up anew?
The answer is simple. To do so would be to abandon our patients. Ongoing access to psychiatric services here at Kings County is indispensable. Without that alternative, thousands of patients in acute crisis would have nowhere to turn. There is only one other CPEP in all of Brooklyn, and it would be hopelessly overwhelmed if the Kings County program were shut down for even a few days. We do not have the option of an extended pit stop for repairs, we must make the necessary reforms while continuing to meet the pressing needs of our patients.
I believe the steps taken over the course of the last year and the plan we have outlined today address the most significant failings of the past in a responsible way. Our reform agenda is far-reaching and ambitious. It is also feasible.
HHC has demonstrated in recent years that it has the capacity to raise its quality of care to levels that exceed national and regional benchmarks. For the most part, our staff are deeply committed to our mission of rendering care to the most vulnerable among us, to those who, in all likelihood, would otherwise have no access to urgently needed care. Our staff take pride in the role they play in the communities they serve, and by and large, our staff are members of those communities. Current staff who are unwilling to embrace what we have pledged to accomplish today will not remain in our employ.
We will continue to work collaboratively with the plaintiffs toward a settlement of the pending lawsuit. And now we will work with the Department of Justice toward that same end. We appreciate that they have expressed confidence that an amicable resolution of their concerns is possible.
Let me stress that the reforms I have announced today are far-reaching. Indeed, our agenda speaks to a comprehensive program far more ambitious than a mere expectation of adequate care. Our vision is to create and implement a model of patient-centered psychiatric healthcare that is compassionate, respectful, and safe.
Kings County Hospital failed Esmin Green. We cannot undo the past. But we can and will continue to learn from our mistakes. We have already taken bold steps to dramatically improve the delivery of psychiatric services at Kings County Hospital. Much, however, remains to be done and we at HHC vow to redouble our efforts to render the best possible care to each and every patient who comes through the doors of this new Behavioral Health Pavilion.
For anyone interested in seeing more of this facility, we will offer a brief tour at the conclusion of the press conference. Before I take questions, let me first ask Tony Martin and Dr. Merlino to say a few words.
Contact: Ian Michaels (HHC) (212) 788-3339.