Report 2003-114 Summary - July 2004
Department of Mental Health:
State and Federal Regulations Have Hampered Its Implementation of Legislation Meant to Strengthen the Status of Psychologists at Its Hospitals
Our review of the Department of Mental Health's (department) implementation of Chapter 717, Statutes of 1998 (Chapter 717), commonly known as Assembly Bill 947, revealed that:
- Even though the department has acted to implement Chapter 717 at its four hospitals, a key issue—whether psychologists have the authority to serve as attending clinicians in patient care and treatment—remains unresolved.
- State regulations specifically allow only physicians to order the restraint and seclusion of patients, an action that psychologists at the hospitals contend is within their scope of license.
- No significant change occurred either to psychologists' membership on certain key committees or in the privileges available to them after Chapter 717 was enacted.
- Although California is considered one of the more progressive states with regard to the status of psychologists in state hospitals, some other states' statutes allow more privileges for their psychologists but the psychologists are not always performing these activities in practice.
RESULTS IN BRIEF
Legislation was passed in 1998 to strengthen the status of psychologists at state-operated health facilities by requiring these facilities to establish medical staff bylaws permitting psychologists to become members of their medical staff and allowing them clinical privileges, such as providing psychological assessments to patients. This legislation, Chapter 717, Statutes of 1998 (Chapter 717), commonly referred to as Assembly Bill 947, amended Health and Safety Code, Section 1316.5.
Even though the Department of Mental Health (department) has acted to implement Chapter 717 at its four hospitals, a key issue—whether psychologists have the authority to serve as attending clinicians in patient care and treatment—remains unresolved. In addition, state regulations specifically allow only physicians to order the restraint and seclusion of patients, an action that staff psychologists contend is within their scope of license. Further, we did not identify significant changes either to psychologists' membership on key committees or in the clinical privileges available to them after the enactment of Chapter 717. Finally, although California is considered one of the more progressive states with regard to the status that psychologists hold in state hospitals, other states' statutes allow them more privileges.
State and federal regulations governing the care and treatment of patients in its hospitals have constrained the department's ability to fully implement the requirements of Chapter 717. The department's hospitals provide inpatient mental health services primarily to patients who are involuntarily committed for care. State regulations set forth by the Department of Health Services (Health Services) restrict to physicians the overall medical care and treatment of patients in two of the three types of health facilities within these hospitals. As of April 2004, these two types of facilities accounted for 76 percent of the patients in the department's hospitals. In addition, Health Services' regulations governing all three types of facilities allow only physicians to order the restraint and seclusion of patients. Further, federal regulations generally restrict to physicians the overall care and treatment of Medicare and Medicaid patients at these facilities. Medicare patients accounted for 20 percent and Medicaid patients for 2 percent of the department's hospital population as of April 2004.
The department's hospitals have allowed psychologists to be included on their medical staff, but psychologists still are neither allowed to serve as attending clinicians nor to order the restraint and seclusion of patients. The department, using reports it requested from a psychology subcommittee and its hospital chiefs of staff, issued a special order in January 2003 enumerating 27 activities that psychologists could perform under their scope of license. However, these activities included neither the authority to act as an attending clinician nor the ability to order the restraint and seclusion of patients. As a result, staff psychologists still contend that the department has not fully implemented Chapter 717. Nonetheless, the department's view is that it has implemented the intent of Chapter 717 and has addressed the psychologists' contentions to the extent possible within the framework that governs patient care in its hospitals. In 2003 the department requested medical staff at its hospitals to develop pilot projects for psychologists to serve as attending clinicians. According to the department, it is currently promoting solutions to satisfy its psychologists, psychiatrists, legal requirements, and standards of care for its patients.
A court has concluded that psychologists are permitted to take primary responsibility for the care and treatment of patients in acute psychiatric hospitals; however, Health Services' attempt to amend the regulations to permit psychologists to order their restraint and seclusion in the department's health facilities was voided by the Office of Administrative Law. The department contends that the psychologists' authority to be primarily responsible for patient care and treatment is limited by their lack of authority to prescribe medication, and as of April 2004, 98 percent of the patients in the department's hospitals received medication.
With few exceptions, psychiatrists hold more positions than psychologists on three key committees—medical executive, credentials, and bylaws—at department hospitals, with the ratio of psychiatrists to psychologists as high as 9-to-1. We also found that the composition of the medical executive committees at the hospitals did not change appreciably after the passage of Chapter 717 in 1998. Moreover, psychologists are generally underrepresented on these key committees in terms of their proportion of the medical staffs. For example, psychologists at one of the hospitals currently represent 36 percent of the medical staff, yet they make up only 10 percent of the medical executive committee.
Similarly, medical staff privileges for psychologists have remained relatively unchanged since the enactment of Chapter 717. The hospitals approved all 182 medical staff and privilege applications from the psychologists and psychiatrists we reviewed. However, psychologists could not apply to act as attending clinicians and to order seclusion and restraint because the approved application form for psychologists does not list these privileges. We focused on the application form because it lists all the privileges the hospital allows psychologists to apply for.
California is one of only 17 states to allow psychologists to practice in a hospital setting. Thus, the State is considered progressive in the status psychologists hold at state hospitals. Nevertheless, some private hospitals within California and some other states' statutes allow their psychologists more privileges. For instance, psychologists in two of the three private hospitals we contacted are allowed to serve as attending clinicians. In addition, state law in Louisiana expressly allows psychologists to order the seclusion and restraint of patients. However, the psychologists and administrators we contacted at individual hospitals in certain of those states indicated they were not performing such activities in practice.
The department should work to resolve the continuing issue regarding whether psychologists can serve as attending clinicians in its four hospitals. This effort should include providing leadership and guidance to the administrators, psychiatrists, and psychologists at each hospital to find reasonable solutions to satisfy the statutory and regulatory requirements governing patient care.
To ensure the appropriate level of representation for psychologists on committees, the department should direct the hospitals to annually review the composition of their medical staffs and the proportion of psychologists, psychiatrists, and other medical staff on their medical executive, credentials, and, if applicable, bylaws committees. Each hospital should modify, to the extent possible, the membership of these committees to more closely reflect the composition of its medical staff.
The department agreed with our findings and recommendations and stated that it plans to continue working with the medical staff at its hospitals to resolve any remaining issues of concern. In addition, where appropriate, the department stated it will direct its hospitals to make the membership of medical staff committees more proportionate with the overall medical staff membership.