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A small, incomplete step toward accountability.
That’s how we viewed last week’s legislative hearing on recent patient deaths at Oregon State Hospital.
Eight months after 25-year-old Lane County resident Kenneth Hass fell and died in a filthy seclusion room at the state psychiatric hospital, Oregon Health Authority officials acknowledged to a state Senate committee what Lookout Eugene-Springfield’s reporting already revealed: A “culture of complacency” has prevented hospital employees from asking questions or raising concerns when they see something wrong, and that culture has contributed to five unexpected patient deaths in two years.
The brief legislative hearing gave Oregon Health Authority officials a chance to tout progress on two metrics federal inspectors and hospital accreditation surveyors have flagged: the amount of time patients spend in seclusion or under restraint.
But even their figures, which compared October 2024 incidents to last month, raise questions. The health authority pointed to a roughly 80% drop in the average time patients spend in seclusion. But Hass is believed to have spent significant time in seclusion last fall, so it’s unclear how much of the decline is due to the fact that Hass is no longer alive.
And even if the drop is due to concrete policy changes, comparing two metrics across two Octobers is hardly sufficient to improve the cultural issues that investigators say plagued the hospital for years. We need clearer evidence that major changes in the underlying issues are underway.
Here are two ways we can get it:
First, Oregon Health Authority should immediately announce a program to improve the culture at the hospital. The confidential report Lookout obtained detailed a culture where staff don’t ask questions or raise concerns because they assume that nothing will be done, or they fear being ridiculed by their superiors.
The health authority needs to publicly announce what criteria it will monitor to ensure this mentality is eliminated. Whether that’s captured through staff interviews, anonymous surveys or another method, the agency needs to outline measurable goals and what steps it will take to reach them.
Second, lawmakers need to be periodically updated — in a public setting — about the hospital’s progress toward those goals. What improvements have been made six months after starting, one year after starting, two years after starting? What still needs to be done?
These policies should be overseen by the two organizations that oversee accreditation and certification at Oregon State Hospital, not Oregon Health Authority itself. Both of those organizations — the Joint Commission and the Centers for Medicare and Medicaid Services — have previously flagged safety concerns, and are in a better position to objectively evaluate the progress Oregon Health Authority sets out to make.
Improving the culture of any organization is hard work. But the extent of the issues raised by accreditors and Lookout Eugene-Springfield’s investigation demands the state commit to whatever it takes to reduce the unacceptable number of patient deaths. And to do its work in full view of the public, rather than behind closed doors.
We will be paying close attention.
