Committee Chair Calls County Mental Health Quality Improvement Plan "Overly Bureaucratic"

To say committee chairman Dr. George Santos (center) was not impressed would be an understatement.
To say committee chairman Dr. George Santos (center) was not impressed would be an understatement.
Margaret Downing

Presented with a plan for better “quality improvement” for The Harris Center for Mental Health and IDD Tuesday, Dr. George Santos said he had “to be blunt” and characterized it as an “overly bureaucratic” mishmash that he could make little sense of and that would do little to improve quality at the former Mental Health Mental Retardation Authority.

With Chief Operating Officer Dr. Scott Strang to his left, Quality Committee chairman Santos urged the trio of presenters – Dr. Daryl Knox, Chief Medical Officer for the Harris Center; Tamara Coy, the new Compliance Officer; and especially Joel L. Carr, Director of Quality Improvement – to go back to the drawing board and start all over with a new concept.

Santos, the chief medical officer and executive medical director for Houston Behavioral Healthcare Hospital (and previously medical director for West Oaks Hospital), took issue with committees proposed by the administrators that in several cases had no front line members, physicians, nurses or caseworkers who have direct contact with patients but instead relied upon department heads to funnel/filter concerns to the board.

Faced with selecting their first new executive director in almost 24 years by September 1, with the departure of retiring executive director Steven Schnee, the agency, which acts as a broker as well as a provider of mental health care services throughout the Houston area, is apparently ready for some board-directed retrofitting. [The agency renamed itself — the IDD stands for Intellectual and Developmental Disabilities — to get away from the word "retardation."]

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As seen at Tuesday morning’s meeting, though, the desire for “culture change” has a ways to go. Jon Kenney, chairman of the Harris Center’s board, commented on this, observing: “Organizations are perfectly designed to achieve the outcomes that exist. You guys are perfectly designed to get the outcomes that you’ve been getting. What you have to do is drop back and say how will we redesign our organization to achieve a different set of outcomes?”

Santos said in general he wants clinicians, physicians and nurses to have a more direct access to the board. Committee member Lois Moore, a registered nurse and former chief administrator of the University of Texas Harris County Psychiatric Center, of the Harris County Hospital District, said that the “traditional” approach is to have lower-level staff pass their concerns on to their department heads and it is the directors who attend meetings with the board. She warned that including others might mean meetings would get too big.

Several board members used the term “siloed organization,” meaning the Harris Center, as large as it is, hasn’t necessarily done a very good job of blending its operations or informing one part what another is doing.

Carr said when he accepted his new job eight months ago, he was told by Knox that the agency “had been focused on productivity in terms of numbers and compliance. ‘I need you to shift the culture from that to quality improvement,’” he says he was told.

He broke down the proposed new operation into three groups: compliance, which would be regulatory-oriented, following the law, and deal with contractual requirements; outcomes management under Dr. J. Scott Hickey, which would measure the agency's effectiveness in how it dealt with patients; and his own quality improvement group, which would use information from the other groups to make improvements. He pointed out that to be successful, all of the agency’s 64 programs would have to be dedicated to quality improvement.

Santos’s reaction was immediate:

“It’s hard for me to kind of understand how these three different departments exist. It’s almost like we’re rationalizing a bureaucracy. Right now I don’t understand the three parts. The last two seem to be what’s normally subsumed under PI, performance improvement, and compliance tends to be exactly that, looking at regulatory compliance – are we billing properly, were patients seen that we’re billing for, are we meeting codes, are we violating some rules in places that might get somebody in trouble,” Santos said.

He called the approach laid out by the trio “reactive” and “very disorganized,” saying it seemed designed to have procedures in place to respond when something goes wrong but not necessarily to stop something from going wrong in the first place. “You avoid that by having a robust plan in place to avoid those adverse findings.”

In an apparent attempt to be more conciliatory, he said, “There’s obviously a lot of work and thinking. The feeling is we’re trying to maintain a system that is not a really good system. How do we reorganize this in a way that’s workable? This needs to be integrated in some way. PI cannot be separated from outcomes.”

Toward the end of the meeting, which lasted about an hour and a half, Kenney underscored Santos’s comments with a charge to senior management, breaking the tension somewhat:

“You have got to go through the process of coming up with a different structure. I have never in my history seen as much segmentation as you guys have in this organization. And I can tell you one thing you’re not designed for: Speed.”

That drew a laugh from the crowd, which Kenney acknowledged, telling the room: “We all of us have to figure out a better way of doing business.”


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