The Action Plan:
- By July 2025, research Occupational/Vocational treatment programming options and draft a proposal and funding request to provide these services within BHA facilities.
- By July 2025, research Sex Offender treatment programming options and draft a proposal and funding request to provide these services within BHA facilities.
- Increase ancillary supports at SCC such as point of care labs and x-ray to improve urgent care capabilities.
Success Measure:
By July 2025, BHA facilities will increase the rate of treatment hours provided per patient days by 10%.
The Action Plan:
- By July 2024, research SUD treatment programming options and draft a proposal and funding request to provide these services with BHA Facilities.
- By July 2025, formalize a Substance Use Disorder treatment program incorporating The Joint Commission enhanced substance use disorder standards.
- Hire a SUD director credentialed as a Substance Use Disorder professional based on WAC 246-811-049. Determine and hire current and additional Substance Use Disorder professionals based on RCW 18.205.
Success Measure:
Increase the ratio of Substance Use Disorder professionals to patients by 25% from FY2023 to FY2025 at ESH, WSH, and CSTC.
|
|
Strategic Objective #2: Promote a culture of safety for staff and patients.
|
The Action Plan:
- Implement and expand Trauma-Informed Care across BHA operations.
OFMHS:
- Incorporate trauma-informed care practices into crisis response situations.
- All staff that work within a ward or residential treatment facility receive yearly verbal deescalation refresher trainings.
- Develop additional areas of reduced stimulation for the patients on the wards and in the Residential Treatment Facilities.
CSTC:
- Enhance and expand training for all staff on safety practices and interventions, with quarterly refreshers and mock drills on CPI/NCI and advanced crisis intervention skills and techniques.
- Annual analysis of workplace violence prevention program and proactive risk assessment.
WSH- Civil and Gage:
- Implement a new admission (or pre-admission) violence risk assessment tool.
- Ensure adequate staffing is available to support the split of the two centers.
- Create additional admission capacity.
- Conduct post-incident reviews and incorporate findings into policy, procedures, and training as appropriate.
ESH:
- Collaborate with WSH to implement a new admission (or pre-admission) violence risk assessment
- Use the Broset on-going risk assessment to score the patient at agreed upon time on every shift for a specific number of days (determined by patient's behavior/ treatment team)
- Build a new admissions team.
- Conduct post-incident reviews and incorporate findings into policy, procedures, and training as appropriate.
Success Measure:
Decrease the rate of staff assault claims and severe assault-related patient injuries by 10% from FY2023 to FY2025.
The Action Plan:
OFMHS:
- Incorporate trauma-informed care practices into crisis response situations.
- All staff that work within a ward or residential treatment facility receive yearly verbal de-escalation refresher trainings.
- Develop additional areas of reduced stimulation for the patients on the wards and in the Residential Treatment Facilities.
CSTC:
- Reduce patient agitation through use of low-stimulation areas.
- Analyze data to determine core causes of violence to support, enhance and expand training initiatives for direct care staff regarding safety practices and early intervention.
- Complete post-incident debriefings.
- Improve strategy to retain and hire direct care staff and nursing personnel.
ESH:
- Analyze data to determine core causes of violence to support, enhance and expand training initiatives for direct care staff regarding safety practices and early intervention.
- Provide a new incident report system to complete Electronic Unusual Occurrence Reports.
- For safety of staff and patients, add a seclusion room on B ward at the Westlake campus for patients.
Success Measure:
Reduce the use of patient seclusion and patient restraint by 10% from FY2023 to FY2025.
The Action Plan:
- Staff responsible for training will complete a train-the-trainer course.
- Provide ACIT to new hires during NEO.
- Schedule existing staff into ACIT during NEO until all staff are trained.
Success Measure:
By July 2025, 100% of BHA facility staff will complete and maintain Advanced Crisis Intervention Training.
The Action Plan:
ESH & WSH:
- Use Consult Liaison Team staff to train new and existing staff on how to properly conduct violence risk assessments and design violence reduction plans. ESH and WSH collaborate on training and implementation.
- Use standard violence risk assessments and violence reduction plans during the admission and treatment plan development process for all patients.
- Track the completion and timeliness of violence reduction plans and review quarterly to identify and address gaps or bottlenecks in the process.
Success Measure:
By July of 2025, 100% of patients who have demonstrated violent behavior in the past 2 weeks will have a violence reduction plan completed within 14 days of admission or transfer.
|
|
Strategic Objective #3: Reduce the demand for and provide timely competency evaluation and restoration services to forensic behavioral health patients.
|
The Action Plan:
OFMHS:
- Identify additional sites where successful Prosecutorial Diversion Programs could be launched in alignment with settlement agreement requirements and request funding to implement.
- Study and, if supported, implement earlier community-based interventions prior to our potential client’s judicial system involvement.
- Seek additional funding based on pay per enrollment and contract.
- Seek ongoing funding sources for Trueblood fine-funded diversion programs.
Success Measure:
Increase the number of yearly participants in state-funded Prosecutorial Diversion Programs by 10% from FY2023 to FY2025.
The Action Plan:
OFMHS:
- Implement a periodic review to identify patients who can be transitioned to a less acute level of care.
- Refer 29-day restoration orders to the existing Outpatient Competency Restoration Programs.
- BHA will work with partners to develop a system whereby restoration individuals are able to receive medication treatment upon arrival to the facility.
- Refer second and third 90-day orders to the existing Outpatient Competency Restoration Programs to free up space at the RTFs and state hospitals for clients waiting in jail.
Success Measure:
Decrease the time from court order to admission for inpatient competency restoration to 14 days by July 2025.
The Action Plan:
OFMHS:
- Create a proactive process for periodic review of competency for individuals who are admitted to any level of care within the competency restoration network (Hospital, RTF, Outpatient).
- Identify local and systemic challenges in the evaluation process through increases in data monitoring and analysis and proactively responding to challenges through outreach, process changes and other appropriate measures.
Success Measure:
Increase the number of jail- based evaluations completed within 14 days to 95% in FY2025.
The Action Plan:
OFMHS:
- Seek funding to hire additional evaluators and administrative support staff to support evaluations for personal recognizance/community-based clients.
- Seek funding to hire additional evaluators to support expected increase in Outpatient Competency Restoration Program post-treatment competency evaluations.
- Collaborate with the criminal courts to ensure consistent understanding and application of personal recognizance and community-based evaluations.
Success Measure:
Decrease the number of days to complete personal recognizance/community-based evaluations to 45 days in FY2025.
|
|
Strategic Objective #4: Develop and provide culturally appropriate services and programming for Native American patients within BHA facilities.
|
The Action Plan:
- Create workgroups within each BHA facility by July 2024 to navigate the contracting process.
- Collaborate with BHA employees to coordinate tribal services and programs within each facility.
- Develop and provide Native American cultural competency training to BHA staff in accordance with BHA policy 10.22.
- If resources allow, hire a BHA Tribal Affairs advocate to work with Native American patients within BHA facilities.
Success Measure:
Offer contracted cultural services to 100% of Native American patients within each BHA facility by July 2025
|
|
Strategic Objective #5: Standardize and upgrade IT resources and processes across BHA and our facilities in alignment with DSHS enterprise IT strategies.
|
The Action Plan:
- Move from federated to enterprise, which includes help desk, desktop support, telephone, tools, application development for BHA usage not per facility, project management (discharge planning, budgeting, management) across all facilities.
- IT resources alignment to meet business needs and bring BHA up to industry standards for IT support models
- Increased Security Posture through the purchase and implementation of modern tools.
- Align security staffing levels with evolving national standards.
- Promote safety standards and reporting processes within the facilities through an Information Security Media Campaign.
Success Measure:
Develop a standard IT Enterprise Support Model and Software Development life cycle by July 2025.
|
| |
|
Strategic Objective #6: Create a culture that weaves equity, diversity, access and inclusion into the fabric of leadership, processes and employee development.
|
The Action Plan:
- The BHA EDI Manager will track management services vacancies across BHA and subscribe to careers.wa.gov job alerts to track job postings.
- Hiring managers for these positions will post a recruitment for a minimum of one week.
- Interview panels will be a diverse representation of staff and external subject matter experts as appropriate.
- Each quarter the BHA EDI Manager will report the percentage of vacant permanent positions filled via competitive process.
Success Measure:
By July 2025, 80% of BHA leadership vacancies will be filled via a competitive recruitment process and this rate will be maintained through the end of the biennium.
The Action Plan:
- Each program will work with the BHA EDI and Organizational Development Manager to establish or reallocate an existing position to do EDAI work.
- If a position is established or a vacant position is repurposed, a competitive recruitment will be held to hire the best candidate.
Success Measure:
Establish a full-time position, or at least a portion of one position, in each BHA program that is allocated to serve as a subject matter expert in equity, diversity, access and inclusion by July, 2025.
|
|
Strategic Objective #7: Provide site-specific hazard vulnerability mitigation through identification of vulnerabilities that pose the greatest risk to interruption of daily operations.
|
The Action Plan:
- Identify significant risks to facility infrastructure and develop a corrective action plan. (Physical plant, technological etc.)
- Identify gaps in facilities internal response capabilities and develop a corrective action plan. (Resources on site i.e. snow plows, supplies, staff etc.)
- Explore and implement applicable external response capabilities such as MOUs with the surrounding communities, mutual aid opportunities and external supply resources.
- Train and maintain a BHA HQ level team to serve in future BHA Emergency Operations Center activations.
Success Measure:
By July 2025, hazards identified with a risk/relative threat above 50% in any of the hazard vulnerability assessment categories (natural, technological, human, hazardous materials) will be assigned a corrective action plan to identify and mitigate risk.
|
|
Strategic Objective #8: Continue our efforts to be an employer of choice – recruiting and retaining individuals committed to a career in public service.
|
The Action Plan:
- Develop and implement a standard exit interview process across BHA.
- Analyze exit interview data and provide recommendations to leadership quarterly.
- Align with and implement recommendations from the DSHS employer of choice workgroup.
Success Measure:
Exit interviews will be offered to all exiting staff within 14 days of notice of termination by July 2025.
The Action Plan:
- Develop and use stay interviews as part of the staff annual review process across BHA.
- Analyze stay interview data and provide recommendations to leadership quarterly.
- Align with and implement recommendations from the DSHS employer of choice workgroup.
- Provide a Spokane Transit Employer sponsored bus pass for staff.
- Explore the feasibility of providing on-site affordable childcare at ESH and WSH.
- Develop and implement monthly employee pulse surveys to collect real-time data on employee satisfaction.
Success Measure:
Stay Interviews will be completed as part of annual reviews for 25% of staff by July 2025.
|
