quality of the staff and in terms of the governing body and management as it pertains to policies and procedures in the entire organizational function.

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

Mr. FAUNTROY. I believe that the District of Columbia General Hospital, 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 discuss any of the details of the District of Columbia General. We have the impression that they are at the present time nonaccredited. I think it is reasonable to say that it is probable that part of the reason for 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 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 receive nonaccreditation that are similar in size such as Pilgrim State 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.

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

Dr. MCANINCH. 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 institutionswith 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?

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.

HOSPITAL DEFICIENCIES

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 situations. 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 significant 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 things that came up in terms of environment.

Mr. WHALEN. In your commission's surveys throughout the country, 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.

Obviously, they would be more in keeping with the life safety code as it applies to the 1973 code and they would also be more in keeping with environmental standards.

Mr. WHALEN. You refer to noncompliance of patient safety criteria. Is this due primarily to the facilities that exist?

Can they be upgraded?

Dr. MCANINCH. A good number of them have been upgraded. I think part of it, in terms of St. Elizabeths Hospital, is also the confusion as to the fire marshall, who is really legally responsible for that particular set of buildings, things of this type, that have never really been clear cut, plus the problems that are existing within the buildings. Both of these have compounded the problems in terms of patient safety.

PERSONNEL

Mr. WHALEN. You mentioned patient treatment. What are some of the examples of failures there? Lack of staff? Lack of qualified personnel or a combination of the two?

Dr. MCANINCH. It would be a combination of the two and it would also be noted in terms of patient records. In other words, we are concerned that there are identifiable admission criteria whereby patients are selected for treatment and that it is deemed appropriate for them to be provided this treatment within St. Elizabeths Hospital. Second, there should be an adequate diagnostic assessment and we can clearly find indications of this in the medical record.

Next we would be concerned that there are indications in their records that there has been implementation of such.

Mr. WHALEN. In other words, you are talking about recordkeeping. I think you referred to documentation earlier and it seems to me this is more of a management problem than a strictly medical problem. Is that correct?

Dr. MCANINCH. I think it goes together because we are concerned that there is multiple discipline input into this entire treatment planning situation and that we can find situations-indications that the treatment per se has been rendered and is appropriate.

Going along with that, there should be an evaluation system involving utilization review of patient care evaluation studies to guarantee the quality of this care.

Part of it is documentation, part of it is staff and part of it is having written goals to indicate the nature of the treatments to be rendered. Mr. WHALEN. From the commission's experience, is this situation fairly widespread throughout the country?

Let me explain the question by stating, from my own limited observation, it seems to me that in our public facilities, mental and psychiatric, we are suffering from an acute shortage of doctors, qualified physicians and psychiatrists.

Dr. MCANINCH. I am thinking of how I would like to really respond to that best. It seems to me that the problem of documentation is fairly widespread in terms of the level of sophistication of many hospitals. However, I do believe that we are not putting the emphasis entirely on the physicians as carrying the complete burden of psychiatric care and treatment.

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We are looking at a multiple discipline team approach. I think many State hospitals have been quite successful in finding this kind of a combination.

EFFECTS OF NONCERTIFICATION

Mr. WHALEN. Just one final question: What are the practical effects of decertification? The institution would continue to operate. But what are the effects on the patient in terms of medicare, medicaid, and so forth? Would this ultimately cause the closing down of the institution?

Dr. WOLMAN. I think the chairman with his opening remarks hit upon a very crucial point with respect to the effects and that is the nonavailability of medicaid and medicare funds which has considerable consequences.

More than that, there is an effect upon the training of professional people, professionals who come for their training to various institutions of this type. They are reluctant to come to one that is not accredited.

I think that is obvious. I think there is a third aspect. If an institution or the people that govern it have any self-respect, self-esteem, or professional pride about taking care of the mentally ill, I believe that in itself has a devastating effect.

I think the professional pride in not just the professionals but everybody concerned with the institution is an important aspect of it. Mr. WHALEN. Thank you, Mr. Chairman.

Mr. HARRIS. Thank you, Mr. Whalen.

I have one very quick question. I noted with regard to your statement on the second to the last page, you state that:

The AC/PA 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.

That is concurred in:

Noncompliance in areas affecting patient safety was instrumental in the nonaccreditation decision.

PATIENT SAFETY

You also say that upon review there were still major areas of noncompliance particularly those affecting patient safety and treatment. As to the final decision of failure to accredit, would you say that the major problem was safety?

Dr. MCANINCH. Within all of our manuals, Mr. Harris, patient safety can be a sole factor determining nonaccreditation. It is the only such factor that can stand on its own.

That is why there is that indication in our testimony of today. Obviously there were other problems dealing with patient treatment that were also indicated that were a part of the total decision of nonaccreditation.

Mr. HARRIS. In any review, I presume, with respect to accreditation, you are going to find with regard to your nine principles different degrees of noncompliance. The corners of the steps are dirty and that kind of thing all goes into the report.