RONALD SHANSKY, M.D., S.C. 1441-G North Cleveland Chicago, IL 60610 Phone: 312-919-9757 Fax: 312-787-3472 E-mail: rshansky@rshanskymd.com MEDICAL CONSULTANT CORRECTIONS CONTINUOUS Q UALITY IMPROVEMENT December 12, 2011 SENT BY E-MAIL Richard Schmidt, Inspector Milwaukee County Jail 949 North 9th Street Milwaukee, WI 53233 Dear Inspector Schmidt: As you are aware, I received information from plaintiff attorneys which prompted me to meet with a variety of stakeholders in late summer. They raised several concerns about care issues of which they had been informed relatively recently. In a letter I had written, in September, I had indicated that no major changes should be implemented until I had a chance to review the medical and mental health programs. In later October, plaintiff attorneys met with approximately 60 inmates, both at the north facility and the south facility and asked them about any problems with the health care program. As a result of that visit, I received a letter and you have received a copy of it and it details allegations by a variety of inmates but at the beginning summarizes categories of problems. I had indicated to you that I would attempt to review the records of patients whose allegations were described in the November 23rd letter. Last week, on December 1 & 2, I spent two days mostly reviewing records but also having discussions with staff. I sampled about 30% of the records of patients whose allegations are listed in the November 23rd letter. Several of the allegations from patients bore no relationship to what was documented in the records. This may be either because the patient was confused, the attorney misunderstood or some other reason. But in addition, we did find some systemic problems that clearly need to be addressed. 1. Historically, after the implementation of the TIER system, staff were able to work with an assigned IT person who was able to create reports that allowed daily monitoring, particularly with regard to timeliness of access to required services. Unfortunately, apparently due to cutbacks in the IMSD budget, the person who is the TIER administrator has been given other additional assignments and is, in essence, inaccessible. Therefore, there is no electronic method to closely monitor the timeliness of access and several other issues. In the absence of an ability to run reports on a daily basis which indicate patients not being seen within the required timeframe, it is not surprising that some of the delays alleged by plaintiff attorney were, in fact, confirmed during my record review. Therefore, I am strongly urging that IMSD provide the jail health program with a software administrator who will dedicate approximately 20 hours per week to the program or the County hire an outside contractor to provide that much time and the necessary services. In a discussion with the Director of Nursing, we listed the following reports which should be and have been available but are no longer accessible. 1. Patients with positive booking screens who have not had an advanced level clinician assessment despite being housed in the jail for 72 hours. 2. Patients with positive booking screens who have not at a minimum had their records reviewed by an advanced level clinician within 24 hours. 3. Patients with positive booking screens and a chronic disease who have been in the jail for 30 days who have no initial chronic disease visit. 4. Inmates with diabetes who have been in the jail 30 days and have no order for a hemoglobin A1c test in the record. 5. Patients with positive mental health screens with no initial mental health assessment within 24 hours of their arrival. 6. Inmates housed in the jail for 14 days or longer with no mental health assessment, whether or not they have had a positive screen. 7. Sick call triage requests that have not been seen by a nurse within three days. 8. Referrals from a nurse to a nurse practitioner or physician that are not seen within seven days. 9. Patients housed in special needs that have not had a mental health assessment note within 30 days. 10. Patients housed in special needs who have not had a mental health note within a week. 11. The number of inmates housed in special needs that have no mental health note on Day 1, Day 2, Day 3, etc. These reports are part of a system for insuring timely care that is dependent on the availability of an electronic record and the associated report writing capability. In addition, we found a case in which the screening history missed a critical element, which fortunately was picked up several days later and serious complications were avoided. The electronic screen used for the nursing screen lacks a question with regard to history of major surgery. It is not clear how this could have been left out, but nonetheless it has been and there are other ways in which it would be beneficial to have a software administrator continue to modify existing screens. Thus, there is no doubt in my mind that the jail electronic medical record software will require approximately 20 hours per week of dedicated time. Another task for the software administrator would be addressing the problem of an individual patient who has multiple electronic records. These records should be merged whenever they are identified so that in searching for an individual patient, one has access to all of the clinical information by accessing a single record. The last thing I'll say with regard to the TIER system, it is not supported as far as I am aware, by the company. I know that the County was having discussions and was close to replacing this inadequately designed and unsupported system. I strongly urge the County reestablish its plan to replace the TIER system with a more effective medical record system. 2. In addition to access delays for medical services, the record review verified that there were significant delays in access to psychiatric services. This comes as no surprise, as the downtown facility has not had a psychiatrist for the better part of six months. I am aware that there are plans to begin utilizing senior psychiatric residents to provide as much as 20-40 hours per week onsite, which should be a valuable addition. However, this does not in any way mitigate the need for a psychiatric director to take ownership of the psychiatric program, most especially at the north facility, which by design houses the most disturbed patients. In my very brief discussions with representatives from the behavioral health department, they conveyed to me a concern that any attention and/or resource that they made available to the jail would likely detract from their existing program. I am hoping that I misinterpreted the discussions but I did not walk away optimistic that they were able to facilitate a solution, particularly with regard to a chief psychiatrist. If the Medical Director position is successfully addressed, clearly the next two priorities must be a Chief Psychiatrist and a Health Service Administrator. With these key positions filled I believe the program, both medical and mental health, can achieve a degree of quality and responsiveness we all wish to see. 3. We also identified problems in delayed access to medications, particularly with regard to patients transferred between facilities. In a lengthy discussion with staff, we were told that there is a process to insure that patients are transferred with their medications between facilities and that this process works quite well. However, on a daily basis, custody will add or delete inmates from the transfer list literally within minutes of the transfer and it is these add ons or deletions at the last minute whose medication continuity is likely to be disrupted. Therefore, it is critically important that both custody and medical establish a task force to solve the problem of medication discontinuity resulting from last minute changes to the transfer list. 4. We also discovered a problem related to request of information from outside health service providers. Not only were some providers slow to respond, and this was verified in some records, but additionally we learned that when the outside records arrived, they may be reviewed by a clinician but not necessarily immediately forwarded to the appropriate clinician that will use the information as a basis for initiating a treatment regimen. This is a fairly simple problem to correct and I am hoping the Director of Nursing has already fixed this. 5. We found one record in which there was poor clinical decision making with regard to the timeliness of referral to nurse practitioner. This can happen, but hopefully with a comprehensive review program this will be corrected, as nurses will have a sample of their records reviewed and, where indicated, feedback with regard to areas that require improvement. 6. We also learned that there are significant problems that remain with the responsiveness of the grievance process. We reviewed a grievance described by plaintiff attorney and we found a delay by custody in getting the grievance to medical and a further delay by medical staff in responding. Both custody and medical performance must improve. If grievances are entered into the grievance system daily, then they can be turned over to medical within 48 hours of receipt. If medical responds to the patient within a week, the patient will have a response in less than two weeks. We also discussed the need for face-to-face discussion with grievants depending on the nature of the area of grievance. The QI program should monitor the percent of grievance responses in which a discussion occurs. Clearly, if the grievance is an informational issue a discussion may not be necessary. But for many clinical concerns the only way of achieving some resolution is by having a straightforward discussion. 7. I am especially concerned about the allegations related to a clear change in the professionalism of correctional officers. I have been working with this jail for several years and it appears that for reasons unknown to me professionalism among some of the officers is deteriorating. This is an issue of which I am not an expert. On the other hand, it can and does impact health services; for instance, the allegation that correctional officers are not responding to patients coming to them with symptoms is a serious breakdown, if confirmed. This area will require further discussion with regard to systems to monitor these types of problems. 8. I will be requesting a report from the psychiatric social worker supervisor on a monthly basis with regard to the issue of severely mentally ill patients being inappropriately placed in disciplinary cells. Even if the mental health unit is overcrowded, Milwaukee County Jail cannot punish patients for being mentally ill. This is another area we will be addressing. 9. On one of my next visits I will be specifically looking at the treatment of patients undergoing withdrawal and the implementation of the co-pay system. I am extremely familiar with and helped establish the position statement of the National Commission with regard to co-pay systems and will look to see whether the practice at Milwaukee County Jail is consistent with the recommendations of the National Commission. In summary, the jail must have an electronic software administrator available on a regular basis and should also look to a replacement software. The Medical Director, Chief Psychiatrist and Health Service Administrator positions must be filled as expeditiously as possible. Custody and medical must work together to insure avoiding medication discontinuity at times of transfers between facilities. I want to thank plaintiff attorneys for providing the letter and expect that this will begin a new process for improving the health service programs. Respectfully submitted, R. Shansky, MD cc: John Schapekahm Peter Koneazny Larry Dupuis