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on the accreditation committee that made the previous decision. The decision of the board is final.

I would like to add a word about the qualifications of the surveyors participating in this process. Surveyors are selected on the basis of experience and knowledge in the areas of mental health. They are psychiatrists, administrators of mental health facilities, or other pe mental health professionals.

They undergo several days of training and orientation with emphasis on the standards and their interpretation. As a part of the training they are sent as observers on surveys along with experienced surveyors. Next they participate as a part of a survey team after which they are considered ready to survey independently.

Mr. McXninch will now present information relevant to our survey al of St. Elizabeths Hospital.

Dr. McAninch?

SURVEY OF ST. ELIZABETHS (1975)

Dr. MCANINCH. Mr. Chairman, based on accreditation procedures, just outlined, a team of four surveyors conducted an on-site visit of St. Elizabeths Hospital on September 8 through 11, 1975. All of the surveyors were psychiatrists by profession.

The survey team compared the existing conditions of the physical plant and service delivery system(s) with the approved AC/PF standards. As is our practice, corrections made in response to recommendations made in conjunction with our 1974 survey were noted as part of this survey.

The survey team based its judgment as to the level of compliance of St. Elizabeths Hospital largely on a multiplicity of items pertaining to the quality of patient treatment as noted in the fundamental principles section of the Accreditation Manual for Psychiatrie Facilities.

This manual contains nine fundamental principles, compliance with which is considered important in order for accreditation to be attained or retained. These are as follows:

Principle 1.–The primary functions of any psychiatric facility shall be to diagnose and treat persons with psychiatric disorders, to restore them to an optimal level of functioning and to return them to the community.

Principle 11.The psychiatric facility shall acknowledge the dignits and protect the rights of all of its patients.

Principle 111.The psychiatric facility shall have a competent staff mbuse members subscribe to ethical and professional standards.

Principle IV.-A psychiatric facility shall not exclude any person from rerujr. ing services, or from membership on the governing body or medical staff, or from employment on the basis of race, creed, sex, or national origin.

Principle V.-The psychiatric facility shall integrate its services with other community resources and shall be responsive to community needs.

Principle VI.—The psychiatric facility shall have clearly delineated purposes and goals reflected in its written policies, procedures and organization plans

Principle VII.The psychiatric facility shall promote a climate that makes possible the establishment of significant relationships among staff, patients and their families.

Principle VIII.The activities of the psychiatric facility shall be conducted in accordance with the law and with accepted standards for clinical practice and human dignity.

Principle IX.—The psychiatric facility shall be organized so as to perform its functions and accomplish its goals.

With the exception of principle IV, varying degrees of noncompliance were found with respect to all.

ADVERSE ACCREDITATION RECOMMENDATION

AC/PF central office review of the survey reports and related supportive materials submitted by the survey team resulted in an adverse accreditation recommendation which was concurred in by the AC/PF accreditation committee and then ratified by the accreditation committee of the board on November 11, 1975. Noncompliance in areas affecting patient safety was instrumental in the nonaccreditation decision.

On January 28, 1976, representatives of St. Elizabeths Hospital met in an informal interview with AC/PF central office staff to discuss any questions raised by the letter of recommendations forwarded to St. Elizabeths Hospital on November 28, 1975.

Corrections were noted subsequent to the onsite visit. There were still major areas of noncompliance, particularly those affecting patient safety and treatment. The accreditation committee of the board reaffirmed its nonaccreditation decision on April 16, 1976.

APPEAL PANEL

On May 5, 1976, St. Elizabeths Hospital formally requested that an appeals hearing panel meet to review the nonaccreditation decision.

The appeals hearing panel was conducted on June 11, 1976. Members of this panel were knowledgeable about the standards and accreditation process and were persons who had had no prior review of these materials or association with the accreditation decisions pertaining to St. Elizabeths Hospital.

The quality of treatment planning and its implementation and the environmental and safety deficiencies affecting the general quality of patient treatment were of major consideration in the appeals hearing panel's recommendation. The panel ratified the decision of the accreditation committee, and subsequently the panel's ratification was itself ratified by the executive committee of the board August 14, 1976.

Mr. Chairman, this concludes the prepared segment of our presentation. As was indicated earlier, however, we would be pleased to respond to the committee's questions.

The CHAIRMAN. Thank you very much.
I yield to the gentleman from the District, Mr. Fauntroy.

REASONS FOR NONACCREDITATION

Mr. FAUNTROY. Thank you, Mr. Chairman. I have several questions for

any member of the panel. In the first instance in your judgment, are the primary deficiencies at St. Elizabeths Hospital those most directly responsible for nonaccreditation, do they relate to budget, or some other factors ?

In other words, would additional funds solve the institution's accreditation problems?

Dr. MCANINCH. The major problems were in areas having to do with environmental, patient safety, patient treatment, particularly as it pertains to documentation of the kinds of treatment rendered, the

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quality of the staff and in terms of the governing body and manage. ment as it pertains to policies and procedures in the entire organizations tional function,

Accordingly, many of these items are in fact affected by budget. Nese But budget in and of itself would not have resolved the problems of Engine St. Elizabeths Hospital.

Mr. FAUNTROY. I believe that the District of Columbia General Hos- atten pital, a District facility, is similar to St. Elizabeths in that it, too. is not accredited by your association. Are the problems of these two institutions, those leading to nonaccreditation, similar? Are they related ? How much does the lack of funds contribute to the problems of both institutions?

Mr. COLDEWEY. I am fearful that we did not come prepared to distou cuss any of the details of the District of Columbia General. We have the impression that they are at the present time nonaccredited. I think to it is reasonable to say that it is probable that part of the reason for the that, at least, is a financing problem.

That has been our experience with many similar institutions.

Mr. FAUNTROY. On that point, are there many mental institutions almal of the size and budget of St. Elizabeths Hospital that are not accredited by your institution ?

Dr. MCANINCH. Well, there are a variety of State hospitals who ha! receive nonaccreditation that are similar in size such as Pilgrim Statema Hospital in New York, St. Lawrence in New York.

There are several others that we might mention. Again budget as it pertains to the remodeling of many of the older buildings is a major item. But beyond that, it also has to do with the deployment of staff and the provision of quality care and an evaluation system, a system to determine the nature of the care and treatment that is rendered that we are also very concerned about.

Mr. FAUNTROY. We are concerned with whether or not an institution has to be of a certain size in order to be accredited. We expect to hear testimony later that St. Elizabeths is too large and should be scaled down and deinstitutionalized. I wondered if you would care to comment on that concern?

Dr. WOLMAN. There is no limitation as far as our eligibility requirements for accreditation survey is concerned. In regard to whether they are eligible for survey, it does not pertain to how small or how large they are.

Nr. FAUNTROY. I wonder if you would care to expand on your identification of the policymaking structure and management as being a problem?

Dr. MCANINCII. Well

Mr. FAUNTROY. This is related to an alternative suggestion that an independent corporation might be a way of more effectively addressing these problems. I just wondered how this draft legislation might have, if any, effect on your ability to judge the institution.

Dr. McANINCH. I could say that in review of it, there seems to be no inconsistencies in the draft legislation and the standards contained within the green manual. In terms of the problems that St. Elizabeths is presently experiencing in terms of the governing body, there are a number of recommendations that we have made during our 1975, 1974,

and 1975 surveys that do directly pertain to the organization of its governing body and the ability to provide adequate physical resources so that there would be appropriate care of psychiatric treatment rendered at St. Elizabeths.

We are also very concerned in terms of our standards pertaining to their written goals and policies and procedures and an organizational plan whereby there is a delivery system evident.

This has been a problem with the present structure.

HOSPITAL SIZE

Mr. FAUNTROY. On the basis of your information and experience, would you say that large State-owned and operated mental hospitals are a thing of the

past ? Dr. WOLMAN. I think at one time about 15 years ago, about the time that the Joint Commission on Mental Illness and Health made its report to the Congress, there was the great hope that the large institutions for the mentally ill could be if not eliminated at least reduced considerably.

It is on that premise that there has been an attempt for the patients: to be released to small units in the communities. Unfortunately, this has not always worked out. The quality of care and the treatment in those small units has not been as it should be and there has been a great deal of concern about the environment of some of these small homes.

As a consequence, there is still a great need for larger institutions with the recognition that it would be fine if they could be reduced. But they are still with us and probably will be for a long time.

Mr. FAUNTROY. I assume that your organization is divided into geographical areas of some type. I wondered what the States encompassed in this region are and if there are any institutions comparable in size and budget to St. Elizabeths in this region that are not accredited ?

Mr. COLDEWAY. In response to the first part of your question, sir, we do not operate on a regional basis. We are national in scope without geographical breakdown. So far as similar nonaccredited hospitals, Dr. McAninch earlier cited two that came to mind, so to speak,

I would say further that of the currently 7,100 hospitals currently registered in the United States, the joint commission accredits roughly 5.000, leaving one with the conclusion that we do not accredit about 2,100. To generalize about those that are not accredited, however, would be very difficult.

My impression is that they range in size from very small to very large, that they are reasonably distributed geographically across the entire United States, that their ownership characteristics and other characteristics for that matter vary such as to make a characterization almost impossible. Mr. FAUNTROY. Thank you. Mr. Chairman, I will yield at this time. Both Mr. Diggs and I have a funeral to attend.

Mr. HARRIS. Thank you, Mr. Fauntroy.
[At this point Mr. Harris assumed the chair.]
Mr. HARRIS. Mr. Whalen?

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Mr. WHALEN. I presume that the findings of your survey have been transmitted to the committee staff !

Is that correct?

Does the committee have copies of this so we can go into this in more detail at our own pace?

Mr. COLDEWEY. We have indicated to the staff that whatever information is required we will be more than happy to furnish.

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HOSPITAL DEFICIENCIES

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Mr. WHALEN. Perhaps we could get into some of the specific deficiencies to which you have alluded in your comments. You refer to inadequate environment. Could you be a litle more specific as to what this failure is?

Dr. MCANINCH. Mr. Whalen, this has to do with a variety of sitva. tions. Let me give you a few examples. Sleeping facilities should provide appropriate privacy for each patient. This is given in particular reference to Nichols, East Side, Haden, O'Malley, Richardson, and Hoffman buildings. In other words, in terms of environment, one of our major concerns is the protection of human dignity, privacy being one such situation.

The fact that the person is able to have his own personal articles and opportunity to decorate his own room, things of that nature.

Similarly, there were recommendations made about clothing provided by the facility should be appropriate and should not be dehumanizing. There should be areas available

Mr. WHALEN. May I interrupt here?

With respect to the second deficiency, it would seem to me that this could be done without any radical changes or perhaps even any sig. nificant increase in funding. How about the first? Is it possible to correct that deficiency in the existing facilities to which you referred!

Dr. MCANINCH. Yes. Personally I have to indicate that I was not at St. Elizabeths at the time of the survey. But from my past experience with other similar State hospitals, I would assume that this could go down with another one of our recommendations, having to do with every resident having ample closet and drawer space in which to keep his private property.

Frequently, what we are seeing is very large wards, dormitory style. If appropriate drawer space is used as dividers, frequently this will meet both kinds of standards that AC/PF is concerned about.

There are a variety of recommendations along that line having to do with places where the patients can be alone when it is not clinically contraindicated, that they should have proper and adequate lighting daylight, the furniture should be comfortable and in good condition.

These are many of the kinds of th that came up in terms of environment.

Mr. WHALEN. In your commission's surveys throughout the conntry, have you noted recently constructed facilities which are better able to accommodate these recommendations than the old kind?

Dr. MCANINCH. Well, I think there is a general move across the United States to close out, particularly the buildings that were built in the 1800's and are still being used by many of the psychiatric patients and move toward new construction at this point in time.

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