Oklahoma City — Gov. Brad Henry today released an independent review of the State Medical Examiner’s Office, saying the report’s recommendations will assist the agency as it attempts to regain national accreditation and get back on track.
Last month, the governor tasked Oklahoma Commissioner of Health Terry Cline to conduct a top-to-bottom review of the agency after a series of controversies culminated with the dismissal of the chief medical examiner after less than a year on the job.
Among other things, Cline has recommended additional resources and improved facilities for the ME’s office along with structural changes to strengthen the agency’s governing board and empower a full-time administrator to run the agency’s day-to-day business while the chief medical officer focuses on the office’s medical and clinical work.
“I believe this review will serve as a roadmap for regaining national accreditation and enhancing public trust in the Medical Examiner’s Office,” said Gov. Henry. “As expected, Commissioner Cline was very thorough and deliberative in his review and has produced an excellent report. I want to thank Commissioner Cline, ME board members and agency staff who assisted with the review process.
“As I have said before, and as Commissioner Cline’s report confirms, the governing board and frontline staff are doing a very difficult and important job under challenging conditions, and I have no doubt they will improve their agency and regain national accreditation with appropriate state support.”
The key recommendations in the Cline report include:
-Statutory changes increasing the board’s authority;
-Adoption of an organizational model with a chief medical examiner who reports to an administrative agency head;
-Increased funding for critical positions and equipment;
-Appropriate and ongoing training;
-Development and implementation of appropriate policies and procedures; and
-A new facility.
To compile his report, Cline reviewed past agency audits and reports, toured agency facilities and interviewed board members, agency staff and outside stakeholders.
Cline, who has led health agencies at both the state and federal level, commended the governing board and staff members at the ME’s Office, saying they are already taking steps to improve their agency.
“The board members and staff all want what is best for the people of Oklahoma and have already started implementing improvements at the Office of the Chief Medical Examiner. With the appropriate management structure and adequate resources and facilities, the agency can and will succeed,” said Cline.
Gov. Henry said he has forwarded the report to legislative leaders for review and will work with them to implement the changes necessary to address its recommendations.
“Legislative leaders are committed to getting the ME’s Office back on track, and I am certain we will reach a consensus on the changes that accomplish that goal,” said the governor.
REPORT
Review of the Office of the Chief Medical Examiner
And Recommendations
Prepared for Governor Brad Henry
By Terry Cline, Ph.D.
March, 2010
Background
This report is intended to provide short-term and long-term recommendations for an implementation plan to stabilize the Office of the Chief Medical Examiner and to place it on a path toward reaccreditation from the National Association of Medical Examiners (NAME). It should be noted that the Office of the Chief Medical Examiner toxicology laboratory is currently accredited through the American Board of Forensic Toxicology (ABFT). This report is a summary and is in no way exhaustive nor is it intended to substitute for recommendations made by other bodies.
The mission of the Office of the Chief Medical Examiner is to protect the public health and safety of Oklahomans through the scientific investigation of deaths as defined by state statutes.
During an audit by NAME in April, 2009, a number of deficiencies were noted and the agency lost its accreditation. In a letter from the NAME Chairman to the Chief Medical Examiner (CME) on June 8, 2009, it was noted “that the majority of the deficiencies were related to the facility and staffing. The inspector recognized the quality of work done by your dedicated staff, when death investigations and autopsy pathology are performed, despite the deficiencies.” The NAME inspector noted “?the office does quality investigations?The causes and manners of death in all of these cases was well documented. There is a core dedicated staff working extremely hard to continue to deliver quality postmortem examinations without sufficient support structure. Due to the above described deficiencies, I recommend non-accreditation.”
In December, 2009, the Board of Medicolegal Investigations completed an Assessment and Revitalization Plan. The Plan provides a Problem Statement which includes:
Recent problems center around the failure of the Agency to secure reaccreditation through the National Association of Medical Examiners (NAME) due to shortages in personnel, antiquated equipment, and an inadequate and aging headquarters facility. This was followed by revelations prompting a Grand Jury indictment of the Agency’s former Chief Investigator?
Since the writing of that report, the Chief Medical Examiner was also removed from his position.
The Assessment and Revitalization Plan provides a detailed history as well as recommendations to be followed which would lead to the Office of the Chief Medical Examiner regaining its accreditation from the National Association of Medical Examiners. The recommendations, some of which were already in the implementation phase, appear well grounded and are consistent with the conclusions drawn from the numerous documents reviewed for this report as well as the interviews noted below. While timing and priorities highlighted in this report may differ from the Revitalization and Assessment Plan, the Plan provides solid recommendations and should be implemented over time.
Points of Reference
Documents reviewed include:
1) A Special Audit from the Oklahoma State Auditor and Inspector for the period January 1, 2003 through January 1, 2008 (provided March 12, 2008),
2) An Operational Audit from the Oklahoma State Auditor and Inspector for the period January 1, 2006 through June 30, 2008 (provided January 13, 2009),
3) The Inspection Report on the Office of the Chief Medical Examiner in Oklahoma from the National Association of Medical Examiners (inspection April 13 — 16, 2009),
4) An Assessment and Revitalization Plan submitted by the Board of Medicolegal Investigations, Subcommittee for Assessment and Revitalization, December 2009,
5) Oklahoma Statutes under Title 63 related to the Board of Medicolegal Investigations/Office of the Chief Medical Examiner, and
6) Administrative Rules associated with the Board of Medicolegal Investigations.
In addition, the Chief Medical Examiner’s central office in Oklahoma City and the Eastern District office in Tulsa were fully toured, one special meeting of the Board of Medicolegal Investigations was attended on February 22, 2009, all members of the Board of Medicolegal Investigations were interviewed, and individual meetings were held with 22 Office of the Chief Medical Examiner staff from across the state. Additionally, interviews with a small sampling of external stakeholders, including some previous board members, law enforcement and the Child Death Review Board, were completed.
Summary and Recommendations:
The fact that the Office of the Chief Medical Examiner lost its accreditation from the National Association of Medical Examiners, combined with the fact that the Office is currently without a permanent chief medical examiner presents significant challenges. The Board, through its development and implementation of the Assessment and Revitalization Plan, along with several personnel changes at the agency, a shift of financial management to the Office of State Finance and a request for an audit, all demonstrate a clear commitment on the part of the board and Office of the Chief Medical Examiner to regain accreditation.
Given all of the challenges, recruiting a Chief Medical Examiner will most likely be difficult. However, a recurring theme from the interviews and also noted in the NAME inspection report, is the presence of a strong core of committed and dedicated staff at the Office who are its strength through this period of difficult transition. Given the changes that have been made recently at the Office, combined with a demonstration of increased funding and a commitment for implementation of the Assessment and Revitalization Plan, prioritization and implementation of recommendations as outlined below, the agency is well positioned to build on the numerous strengths noted in the accreditation inspection and to enter a new era as a top-notch medical examiner’s office which instills trust and the confidence of the public. The opportunity for a new Chief Medical Examiner, working with the Chief Administrative Officer and staff at the Office, is to build on these strengths and to take advantage of the momentum for improvement to provide a remarkable turn-around for the agency.
Backlog of Completed Reports:
Aside from hiring the Chief Medical Examiner, the most pressing and public issue facing the Office appears to be the backlog of incomplete autopsy reports. As of the writing of this report, there were approximately 1,111 reports which were backlogged; 350 completed reports which were awaiting entry, approximately 450 non-autopsy and 300 autopsy cases where all of the laboratory and clinical work was completed but the reports have not been written. The number of backlogged reports has been reduced from a high of 1,500 cases in October, 2009. The Office of the Medical Examiner had reports which were several years in arrears. While the implications of these delays may be lost on many individuals, these delays have serious implications for families seeking information on the death of a relative, on criminal justice proceedings, and on insurance payments and estate settlements among other important considerations.
Deficiencies regarding outdated equipment and facilities and staffing are well documented in the NAME Accreditation Inspection report. While there may be several contributors to the backlog and several potential bottlenecks in terms of a finished report, the backlog appears to be the result of 2 primary factors:
1) A shortage in the overall number of pathologists, and
2) Inefficient management and productivity expectations of the pathologists’ workload.
In essence, the viewings and autopsies and laboratory analyses are being completed; however, several of the pathologists then lack the time to review this information and to then write their reports. Understandably, there is great variability in the amount of time to complete an autopsy based on the complexity of the situation surrounding the death. However, there appear to be few office guidelines and expectations regarding the number of autopsies to be completed and assignment of cases and management scheduling which allows for reports to be written. There is great variability in the number of autopsies completed by various pathologists which appears to go beyond the complexity of the case. The average annual number of autopsies completed per pathologist exceeds the recommended annual number of autopsies performed and this undoubtedly contributes to the backlog in report writing.
Policies and Procedures:
Although there are reportedly small improvements in this area over the last several months, the agency is in dire need of standard policies and procedures throughout the organization.
Training, Education and Staffing Levels:
Most frequently associated with funding constraints, a much repeated concern was the lack of training for individuals throughout the organization and as a result a deficient number of staff who are certified in their respective areas. Training at both the introductory level and continuing educational levels are significantly deficient as noted by multiple individuals as well as previous audits.
Multiple deficiencies were noted due to staffing shortages. The NAME inspection report noted “The quality of investigations and autopsies is excellent, but the personnel have an excessive workload?they routinely accrue overtime?The pathologists also have an excessive workload as delineated below. There is also a case backlog.”
Facility:
Deficiencies of the facility are numerous and are well documented in the NAME inspection report. The report noted “?Though these building (sic) are 28 and 26 years old, they were clean and generally well maintained?these deficiencies primarily involve space and personnel needs.”
Recommendations:
Immediate:
Funding:
Within the last several months, the agency turned over financial management of the Office of the Chief Medical Examiner to the Office of State Finance (OSF). The agency also approached the legislative leadership in February of this year and requested an audit to better understand their budget and fiscal controls. Although no intentional misconduct was alleged, concerns were expressed about the lack of fiscal accountability and management prior to the agency’s involvement with OSF, leaving the agency uncertain of its available resources and ability to manage recent state-wide budget reductions annualized at 7.5%.
While the Assessment and Revitalization Plan recommends 30 newly funded positions over 2 years, it is recommended that new funding for pathologists (3), along with a medical transcriptionist, be a priority to address the backlog and to maintain a timely response with the issuance of reports in the future. Given the immediate shortage of staff, it may be necessary to enter into short-term contracts for some of the work. This requires close management and assignment of work to the pathologists to minimize the probability of a contracted pathologist being required to testify in court. In the absence of hiring a transcriptionist, the agency should consider a contract to manage any potential transcription backlog.
Equipment: The Assessment and Revitalization Plan provides detailed recommendations regarding equipment purchases at $1,022,991 and vehicles at $450,000. It is recommended that the Administrator work closely with Department of Central Services to explore recently improved vehicle leasing options as an alternative to vehicle purchases. In addition, items such as generators were not included in this report’s recommendations because they were listed as low priorities, as was a metal building attached to the existing building in Oklahoma City; with plans for a new facility, these do not appear to be critical investments during a period of revenue shortfall.
Budget Request:
Equipment (one time costs): $500,000
Pathologists (3) at $175,000 each: 525,000
Benefits (3) at $52,000 each: 156,000
Training: 25,000
Medical Transcriptionist: 21,500
Benefits: 21,229
Funding:
One Time: $500,000
Recurring: 748,729
$1,248,729
Funding request includes immediate one-time equipment needs as well as recurring funding for three (3) pathologists, transcriptionist, and dedicated training funds.
The Assessment and Revitalization Plan details funding needs for additional staff over a two year period. Even with temporary detailing of staff to office space in nearby agencies, hiring should be phased to coincide with the building of the new facility, otherwise the current facility simply will not be able to accommodate all of the staff.
Statutory Changes: The most pressing statutory change will be inclusion of language which clearly expands and delineates the authority of the Oklahoma Board of Medicolegal Investigations to provide appropriate oversight of the agency. In overly simplistic terms, the Board has been instructed that their authority is limited to the hiring and firing of the CME and they are not allowed by statute to request direct information from the agency or to direct any other action. While cautions regarding micromanagement by a board or protections against confusion regarding board/staff roles and authority are good practice, it is suggested that statutes be modeled on the statutes for other state agencies which clearly delineate the authority and role of a governing board in relation to the agency director, staff and the agency in an appropriate manner which does not limit or hamper their effectiveness as a governing body. With appropriate statutory authority, the current Board of Medicolegal Investigations, which has demonstrated its commitment to change and improvement over the last several months, appears well positioned to provide appropriate governance to lead the agency to accreditation.
Other statutory changes: Several state legislators have extensive experience with or knowledge of the Office of the Chief Medical Examiner, including but not limited to Senator Leftwich, who worked in the Office of the CME for over 17 years, Representatives Cox and Ritze, both practicing physicians with many interactions with the Office, and Rep. Al McAffree who had experience with the Office as both a police officer and funeral director. It is recommended these members, as well as others with specific and related knowledge and experience, inform the changes to statute. Several bills are currently being considered and it is hoped the legislature will act decisively to address opportunities for increased effectiveness and management of the Office.
Changes in organizational structure: There are basically 3 different organizational structures to be considered in terms of agency leadership:
1) Model #1: The current system has the Chief Medical Examiner as the head of the agency, responsible for all operations, medical, clinical, and administration for the agency.
2) Model #2: A second model, which is proposed under legislation currently being considered, is for joint leadership with a Chief Medical Examiner responsible for clinical and medical procedures and shared leadership with a Chief Administrative Officer who is responsible for other operations in the Office.
3) Model #3: A third model is for an Administrator as the agency head responsible for all operations and a Chief Medical Examiner responsible for medical and clinical operations who reports to the Administrator.
The third model, while definitely in the minority of options espoused by those interviewed, is the recommendation of this reviewer. This model is similar to a hospital CEO model where your hospital director may be a physician who has specific administrative experience, but more often, you have a non-physician as CEO who has overall responsibility for the operation of the facilities, in addition to a chief medical officer who is responsible for medical decisions and operations and who reports to the CEO. Given the magnitude of the administrative policies, procedures, and operational changes which may be needed, it will be important to have a clear line of authority, unlike Model #2 with joint leadership which may lead to confusion and conflict.
Model #3 allows for the Chief Medical Examiner to focus entirely on the medical/forensic aspects of the office, while overall responsibility for the operation of the agency, legislative interactions and many external communications are the responsibility of the Administrator. Appropriate medical oversight continues to be ensured through a qualified CME, as well as appropriate medical representation on the governing board.
Concern regarding Model #1 centers around the very small number of physicians qualified as a CME, further limited by those who would also have expertise in administrating a several million dollar state agency, with the ability and time to also work with the legislature and other stakeholders. Model #3 could require the Administrator to have experience and expertise in a related field without unnecessarily restricting the candidate pool to physicians.
State agencies such as the Oklahoma Department of Mental Health and Substance Abuse Services, as well as the State Department of Health, which were once administered exclusively by physicians, now allow flexibility in having administrators with qualifications in related fields. While still possible to have physicians in these positions, the positions are not limited to physicians; the model allows for appropriate medical expertise throughout the organizations while also requiring appropriate medical representation on the governing boards. Mirroring an organizational structure which is used successfully in thousands of medical facilities, hospitals and clinics, Model #3 maximizes the strengths of both the administrator and the chief medical examiner to the full benefit of the agency.
Consortium of administrative specialists (HR, IT, Legal, Finance, Audit): It is recommended that teams of administrative sister agency specialists are requested through the Chief Administrative Officer immediately. It is common practice for fellow state agencies to provide consultation to one another. The absence of policies and procedures is an extreme vulnerability for the agency identified in several documents and by staff and board members. Teams of experts from fellow state agencies could convene immediately and develop, recommend and support implementation of appropriate policies and procedures for the agency, while simultaneously developing and strengthening this expertise in the agency itself over the next year.
Development of these policies and procedures would build on standard state agency policies and procedures while working in consultation with NAME for content expertise. Every opportunity to work closely with NAME, which has vast expertise and experience from across the country, should be explored and the relationship strengthened as the Office of the Chief Medical Examiner works toward accreditation.
Long-term:
Facility: All reports and the vast majority of individuals interviewed are in agreement that a new facility is needed in Oklahoma City. There was not, however, consensus regarding the appropriate location of a new facility. It is clear there are advantages and disadvantages to both sites which have been explored, with either a new facility being constructed at the OU Medical Center campus or on the campus of the University of Central Oklahoma. The importance of the agency maintaining its independence, especially from law enforcement, was a repeated and strongly espoused theme. Bottom line: a new facility is needed and regardless of the location, the Office of the Chief Medical Examiner needs to be independent. Although independence is critical, opportunities for collaboration, such as academic affiliations and appointments, must be nurtured. These collaborations will grow support for the Office as well as provide a feeder system of interns and fellows and potential employees.
Until a new facility is situated, it is recommended that the possibility of temporary office space in either the State Department of Health or at the OU Medical Center, both within one block of the Office, be explored to relieve pressure of overcrowding at the Oklahoma City site.
A commitment of funding for a new facility may be critical in attracting a new Chief Medical Examiner (regardless of the model employed) and for actually regaining accreditation.
Funding: As outlined in the Assessment and Revitalization Plan, a new facility is obviously the largest segment of a budget request. Whether it be funds to retire a bond, or funds for lease payments, additional funds will be required for the Office of the Chief Medical Examiner to be located in a new facility. Although an estimate of needed funding for a new facility is provided in the Assessment and Revitalization Plan, given changes in the economy and construction costs and the various possibilities being explored, an estimate of the needed funds and a commitment of these funds is best made closer to the time the state is ready to move forward with actual implementation of a plan.
Conclusion:
The Office of the Chief Medical Examiner is an agency which has been mired in controversy over decades. Although the agency had experienced a period of relative calm, long-term neglect of staffing growth and development, inadequate facilities and equipment and an absence of internal policies and procedures have resulted in the loss of accreditation by the National Association of Medical Examiners. In its attempt to correct many of the noted deficiencies, it became clear that statutory changes are needed to provide the Board of Medicolegal Investigations with the authority to appropriately govern the agency.
Changes at the agency over the last several months demonstrate that the agency as a whole is making improvements to move forward, despite the monumental challenges they face. Core staff provide the real bench-strength for the agency. The Board has provided an Assessment and Revitalization Plan which outlines the necessary steps for the agency to regain accreditation.
The conclusions from this review are certainly not inconsistent with that Plan; however, this review provides a prioritization which makes recommendations for immediate implementation. While many of these recommendations require legislative action (funding and statutory changes), others are within the control of the agency and can be implemented immediately, and some are, in fact, in process now. It should be noted that a new facility, while critical, will not in and of itself result in accreditation.
All the following factors, in combination, are recommended to lead the agency to accreditation:
statutory changes increasing the Board’s authority,
adoption of an organizational model with a chief medical examiner who reports to an administrative agency head,
increased funding for critical positions and equipment,
appropriate and ongoing training,
development and implementation of appropriate policies and procedures, and
a new facility.
Even if all of these changes could be made at once, it is unrealistic to believe the agency could absorb the magnitude of these changes simultaneously. Statutory changes providing the Board with expanded authority and specific funding are recommended for immediate action, which can result in critical hiring to address the backlog of reports. Hiring of the Chief Medical Examiner, as well as the additional pathologists is essential. Short-term contracts for pathologists, which would involve logistical complications, may be necessary until full-time staff are hired. The possibility of utilizing temporary office space at neighboring state agencies would relieve some of the overcrowding of staff, and coordinating teams of individuals from fellow state agencies would allow the agency to immediately begin the process of developing and implementing critical policies and procedures.
Quick legislative action, combined with the demonstrated leadership of the Board over the last several months, will lead to immediate improvements. This agency, in a matter of weeks, can look and operate in a substantially improved manner from its present appearance and operations. Staff who were interviewed were eager to identify challenges throughout the agency so those problems can be addressed. After a period of great turmoil, this agency, with proper support and leadership, is poised to provide the level of expertise which is expected of an agency with critical responsibilities to the State of Oklahoma.
