dent and a vice-president of the United States resign from office because of questionable behavior. We have seen federal officials hauled into court and found guilty of illegal acts. Today we see federal agencies summoned before Congress and questioned as to whether their actions are legal and ethical. But there are also the Archibald Coxes and the Elliot Richardsons, who refused to cross the line of ethical and legal accountability to themselves. They removed themselves from the situation and preserved their personal integrity. Others, less wise, suffered personal and familial distress of a high order. The lesson to be learned is that one has a high degree of accountability to one’s self and one’s beliefs and convictions, as well as to the constitutional structure within which one functions. A failure to be accountable to one’s self in these areas can lead to enormous personal disaster, as well as disaster for others. In spite of all the discussion of program accountability, fiscal accountability, process accountability, constitu-

tional and legal accountability, management quality, and ethical accountability, when the chips are down there is one issue of accountability that stands far above the others. That is for the quality of the services provided the patient. The Texas Department of Mental Health and Mental Retardation or any other mental health agency exists for only one reason-to provide good quality care, treatment, and training to mentally ill and mentally retarded people. If we don’t achieve that, then nothing else counts. If we don’t give adequate care, treatment, and training, if we don’t protect the constitutional and legal rights of the people we serve, then nothing else matters and we shouldn’t even be in the business. Fancy statistics, pretty publications, lovely pictures, suave presentations, attractive buildings, tight financial reports-all of these mean nothing if the patient or resident does not receive the help we are obliged to provide him and for which we are accountable. That is the crux of accountability. Without that, all else is a sham.S

State Hospital Review Boards in Minnesota MIRIAM KARLINS Mental Health Consultant Minneapolis, Minnesota MARILYN St.

Paul,

For

visits the commitment

KNUDSEN Minnesota

the

past

eight

years

Minnesota

has

had

a review

ill board consists of at least three individuals appointed by the commissioner of the department of public welfare. The board is an external review body in that members are not associated with the department or with the state hospital. It board

and

for

the

each

mentally

state

hospital

retarded.

serving

the

hospital papers

as frequently and processes,

as

required assess the

to review propriety

of treatment procedures, ensure that each patient has an individualized treatment plan, interview patients and record their concerns, conduct a random review of patients’ records, and meet with hospital staff. The board reports its findings to the commissioner, and to the head of the hospital.

mentally

Each

Ms. Karlins formerly was director of education and manpower development for the Minnesota Department of Public Welfare. She is currently doing private consultation and is chairperson of the Willmar (Minn.) State Hospital review board. Her address is 6450 York Avenue South, Minneapolis, Minnesota 55435. Ms. Knudsen is in the private practice of law in St. Paul and is on the Willmar State Hospital review board. She and Ms. Karlins are also co-chairpersons of the statewide review board committee.

The Minnesota Hospitalization and Commitment Act, passed by the state legislature in 1967, contains a number of important provisions dealing with the admission, retention, treatment, and discharge of patients. It also delineates specific rights of patients and establishes a review board for each state hospital serving the mentally ill and the mentally retarded. The boards are a combination of an internal and external review body, and that makes them somewhat unique. They are internal in that board members are appointed by the commissioner of the department of public welfare, members report their findings and recommendations to the commissioner and to the head of U

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Review board members must assess the

propriety of treatment procedures, ensure

that each patient has an individualized treatment plan, review patients’ records, and meet with hospital staff. the hospital, and members each receive their fee of $50 per day, plus expenses, from the department of public welfare. They are external in that no member can be associated with the department of public welfare or with the state hospitals. Review board members, therefore, are not dependent on the system for their livelihood and can approach their tasks of interviewing patients, reviewing records, and meeting with staff and others with complete independence. The law requires that each state hospital be visited at least once every six months by a review board and that each board consist of three or more persons, one of whom shall be qualified in the diagnosis of mental illness or mental deficiency, and one who shall be learned in the law. The third member is not defined by law but is usually an interested, informed citizen. In practice the review boards meet more often than once every six months. The meetings are held as infrequently as once every three months and as frequently as twice a month. The majority of the review boards meet monthly, however, and the board members set the times for the hospital visits. They report their findings to the head of the hospital and to the commissioner of the department of public welfare. On admission the patients must be advised of the existence of the review board and of their right to appear before the board. The dates of the review board visits must be posted on bulletin boards on the wards where patients can see them. Patients may make an oral request to appear before the review board to any staff member, who must relay the request to the head of the hospital. The patient’s request does not need to be in writing. Originally the review boards were set up specifically to review the admission and retention of patients to ensure that their legal rights had not been violated, alternatives to hospitalization had been explored, no patient was being inappropriately retained in the hospital, and provisions of the Hospitalization and Commitment Act regarding the various methods of hospitalization were being carried out. In 1973 the legislature amended the act to allow review boards to examine the records of all patients admitted to state hospitals and to examine personally, at their own instigation, all patients for whom there appears to be a reasonable doubt as to their continued ‘ ‘



642

HOSPITAL

& COMMUNITY

PSYCHIATRY

need of confinement in a mental hospital. Board responsibilities were further expanded to allow members to receive reports from patients and interested persons, including but not limited to hospital employees, on conditions affecting the humane and dignified care of patients. The board also was authorized to examine such conditions. The statutes allow the review boards considerable freedom to carry out their responsibilities; however, it is clear to review board members that their function is not a clinical one. Their role is to assess the propriety of the procedures involved in treatment, to ensure that each patient has an individualized treatment plan, to listen to any patient who wants to appear before them and to record his concerns, to do a random review of patients’ records, and to meet with hospital staff and others. INVOLUNTARY

TREATMENT

In addition to those functions set forth in the statutes, review boards also carry out regulations promulgated by the department of public welfare. One such policy gives the review board the specific duty of inquiry and recommendations regarding any involuntary treatment of patients committed to the hospital under a court order. Occasionally involuntary treatment of other patients occurs when the hospital physician exercises his statutory authority to impose an emergency hold order on a patient who, in his opinion, is mentally ill or inebriate and is in imminent danger of causing injury to himself or others if not immediately restrained and that an order of the court cannot be obtained in time to prevent such an anticipated injury. Since such an order can be in effect for only 72 hours and a succession would be difficult to justify in view of the availability of court orders, the physician’s emergency order cannot be used for a long-term involuntary treatment program. When involuntary treatment is rendered it is of two kinds; a clinical emergency or a clinically pressing situation. In a clinical emergency treatment may be administered and then reported for review at the next review board meeting. Treatment in these instances usually involves an injection having short-term effects, or the use of restraints or seclusion to prevent injury or a threatening situation. At the review board meeting deficiencies can be noted for future reference and also for the protection of hospital staff and patients. In a clinically pressing situation treatment is withheld until the review board has met; however, the hospital is authorized to require the review board to meet within 14 days. In such cases, the review board is to examine the treatment proposal made by the staff, interview the patient, and review the patient’s medical records. If there are any irregularities or if there are questions or areas of disagreement about treatment, the treatment is to be withheld until the review board makes its report to the commissioner of public welfare and his office has investigated the situation. In many instances the function of the review board, “

‘ ‘

in the course of holding the hearing and examining the facts, is to serve as an arbiter between the hospital and the patient to correct deficiencies in the record. The standard of review is clearly enunciated in the policy and involves, at a minimum, six considerations: the legality of the commitment itself, that is, whether the hospital has any authority to hold and treat the patient; the exercise of concerted efforts to develop a professionally sound treatment program that involves the patient; reasonable efforts to explain the plan, risks, and benefits of the proposed treatment to the patient and to interested others; consideration of alternative treatments, specifically including a change of the treatment team; a clear and sympathetic presentation of the patient’s point of view; and the patient’s awareness of his legal rights. The last category is very important because of specific rights of the patient enumerated under the act. Patients have a right to receive and write uncensored letters, have visitors, practice their religion, be free from restraints, and have periodic mental and physical examinations. In addition, there are specific requirements for treatment. One of the goals of treatment is to avoid further hospitalization. To make sure that goal is met, the board’s review must be in conjunction with the patient and with the appropriate county welfare department. There are also definite terms that must be included in a written program plan which shall describe in behavioral terms the case problems, and the precise goals, including the expected period for hospitalization, and the specific measures to be employed in the solution or easement of said problems. Under the statute, these program requirements are designated as rights of the patients themselves, and are not merely standards for the hospital. Additionally, in reviewing whether the patients’ rights have been protected, the review board must decide whether the patient has been accorded his right to treatment as defined in the decision in O’Connor v. Donaldson, and his right to be free from involuntary intrusive therapy articulated in February 1976 by the Minnesota Supreme Court in Price v. Shepard. ‘ ‘

‘ ‘

STAFF

AND

BOARD

RELATIONSHIPS

The Minnesota review board system is not perfect. Like so many statutes and regulations, its success depends largely on the degree of cooperation and dedication of those individuals involved in the treatment program. Staff’s willingness to hear what patients are saying and the credibility they are willing to give to patients’ statements and concerns, their ability to look at situations with some objectivity, their defensiveness when their practices are questioned, and their attitude toward patients and review boards all have an impact on the effectiveness of the boards. Staff members are encouraged to see the review board members whenever the boards visit the hospital. Often the board seeks information or clarification from

the are

staff. However, staff are seen only after the patients interviewed, never before. Review board members always ask the patients who request to see them if they have already discussed their concerns or questions with staff, if such discussion seems appropriate. If patients have not, and if it is appropriate, the board advises them to talk with staff. Patients are also reminded that review boards do not determine treatment or take over staff functions. For the most part, staff and review board members are able to work quite well together. In those cases where strictly legal issues are involved, the staff and review board relationships are not likely to be in conflict because the law is quite clear. If the patient’s commitment papers are not in order or if certain procedures required by law were not followed, the situation can be documented, leaving little room for argument or dispute. In the area of treatment, however, staff and review board relationships can be more easily upset and conflicts can occur. For example, there can be problems between the board and the staff if the patient’s treatment plan is not individualized, if the goals are vague, or if the patient has not been involved in making his treatment plan. Additional problems occur if the patients complain about their treatment, if there appears to be no treatment based either on the record or on what the patient reports, or if the patient states that he perceives his treatment as punishment. In 1973 a directive from the department of public welfare established the position of patient advocate at each hospital. The patient advocate’s job is clearly defined, with safeguards established so that he is able to carry out the advocacy responsibilities. The advocate works closely with the hospital review board members by providing follow-up on certain recommendations made by the board, obtaining additional background information when it is requested by the board, and serving as a liaison between the board, hospital staff, and patients. In addition, the advocate is responsible for educating staff about functions of the review board in the area of patients’ rights, and for informing patients of their rights and of the dates of visits by the review board. Approximately three years ago all the state hospital review board members voted to meet together as a statewide committee to share ideas, concerns, and recommendations. The department of public welfare has assisted this statewide effort by providing workshops for board members in the fall and in the spring for the purpose of training, education, and coordination. Although review boards are now in their eighth year of operation in Minnesota, they continue to find areas that need changing, and are constantly seeking ways to improve their operational procedures and effectiveness. The boards continue to provide feedback from the patients into the system, and carry out the important function of an outside review body that is available to the patients and that is knowledgeable about patients’ rights and individualized treatment programs.

VOLUME

27

NUMBER

9 SEPTEMBER

1976

643

State hospital review boards in Minnesota.

dent and a vice-president of the United States resign from office because of questionable behavior. We have seen federal officials hauled into court a...
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