San Benito County 2006-2007 - California Grand Jury Reports

Of SAN Benito County School BUS*

36 pages 4 findings 8 recommendations

Findings & Recommendations 4 findings

F1: Plans, Budgets, and Schedules b. The current office that deals with customer billing and payments is very small and cramped. The two desks a. Detailed plans and schedules exist to implement the and adjacent waiting area are very small. This lack of provisions of Measure L. These include a project sum- space makes it difficult to maintain customer privacy. mary for the comprehensive improvement of a wide range of facilities and services. Emergency room im-

Related Recommendations (1)

R1: Staffing review of the course materials to determine contributing The Grand Jury recommends that the Hollister School causes for this accident. District obtain the services of a qualified safety manager

F2: Operations in Current Facilities a. The Grand Jury recommends HHMH consider alternate According to the quality report of the Joint Commis- procedures to relieve some of the emergency room crowding sion for the period June 2005 to June 2006, HHMH and wait times as interim measures until the new facilities was below the performance of most Joint Commission are available. These could include extending the hours of accredited organizations in the following major areas: the clinic, adding clinic staff, immediate screening and Heart Failure Care ......Nationwide and additional waiting areas for non-emergency cases, or a Statewide combination of all those procedures. Those interim oper- Pneumonia Care ......Nationwide ations might be paid for from the unanticipated interest Surgical Infection income that will accrue from unspent funding, including Protection ................Nationwide contingency funding. For the same period, HHMH was similar to the b. The Grand Jury recommends HHMH develop interim performance of most Joint Commission accredited procedures to relieve the crowding and ensure privacy in organizations in the following three major areas: the customer billing and associated waiting area until the National Patient new facilities are available. This could include a sound Safety Goals ......Nationwide barrier between the two desks, moving the waiting area (statewide is not calculated) to a remote location to be called or paged to the desk, Pneumonia Care ......Statewide and/or taking customers to private offices for interview Surgical Infection or discussion. Protection ......Statewide

Related Recommendations (1)

R2: Management inadequate for supervising the district's school bus a. The Grand Jury recommends that the Hollister School system including the critical safety area. They are more District exercise its contractual rights and place a standing in line with the job of a mid-level dispatcher/route order for all reports, training materials and records from monitor. The position does not even report to the the contractor and review these periodically to ensure the operational side of management, rather to the Chief contractor is in compliance with the safety rules. Business Officer. It appears that much of the trans- portation management has been left to the contractor. b. The Grand Jury recommends that the contractor and This is a clear conflict of interest and abdication of Hollister School District develop a documentation and training management system to ensure that drivers carry responsibility. only current documents and that drivers receive docu- b. The Hollister School District Transportation Safety mented initial training, and training on all new or Plan does not address what to do when there is an revised procedures. accident. The Tiffany Transportation Services Accident/ Incident/Emergency Procedures attached to the plan c. The Grand Jury recommends that the Hollister School and dated 3/24/06 is marked in part "... this is still a District develop and enforce a "near miss" reporting system work in progress! What do you think?" It is entirely to identify possible weaknesses in the safety program. void of an official release date, revision, or signature. d. The Grand Jury recommends that all accidents and near There are two sets of evacuation instructions, but miss events be analyzed for root cause and a corrective they differ. The instructions dated 12-14-06, almost action plan developed with implementation dates and 4 months after the accident, are marked "DRAFT." that the Hollister School District monitor to ensure The instruction sets appear to be a hodgepodge of that the contractor has complied. mbulance Ambulance San Benito Healthcare District Implementation of Measure L and Provision of Quality Healthcare San Benito Healthcare District Implementation of Measure L and Provision of Quality Healthcare Physical Therapy ......2,100-3,400

F3: Quality of Care provements have been given priority. Significant areas a. Medication Errors: Hazel Hawkins Memorial of new construction and space allocation are as follows; Hospital (HHMH) was one of the nine recipients of the 2006 Cheers Award from the Institute for Project ......Planned Area (Sq. Ft.) Safe Medical Practices (ISMP). The Cheers Award Emergency Room .................................. honors organizations that have set a superlative Inpatient Med/Surgery .................................... standard of excellence for others to follow in the ICU ......1,000 prevention of medication errors and adverse drug Women's Center .....8,000-13,000 events. HHMH was cited as being a role model Laboratory .................................... for implementation of medication safety efforts in Pharmacy ......1,600-1,900 a small organization. Imaging ......500-600 San Benito Healthcare District Implementation of Measure L and Provision of Quality Healthcare

Related Recommendations (1)

R3: Management for school bus operations among other duties. This position a. According to the job description and testimony of should report directly to the Superintendent. The incumbent the Superintendent, the Hollister School District should have experience and be able to manage the contractor Transportation Coordinator is responsible for super- effectively to bring them into compliance. The incumbent vising the district's school bus system and coordinating should be qualified to perform risk analysis, inspections, the transportation program including monitoring the and audits and develop procedures to the extent necessary performance of the outside contractor. The only men- to ensure the safety of school bus transportation system for tion of safety in the job description is to "prepare and all users. If qualified staff and/or personnel are not available, enforce safety rules." the technical service portion of the program can be obtained on a contract basis. However, the minimum qualifications, education, and experience requirements for that position are woefully

F4: There are procedures in place for kennel cleaning, but primary mission. Grand Jury visits indicate problems in following those procedures. There are no procedures governing care and METHOD OF REVIEW use of the drop box.

Related Recommendations (1)

R4: Management review of facts causing inability of fueling gration requirements prior to the acquisition of any new or system to support the total contingent of buses. significantly changed technology. The purpose of the review

Additional Recommendations 4

Not linked to specific findings.

R5: Measurements and Management The Grand Jury recommends that the SBCHD aggressively The Grand Jury recommends that the Director, staff, and pursue additional staff on a priority basis using appropriate public input establish measurable performance goals and incentives if necessary. Shortfalls in clinical/case worker staff program schedules and present the department's results have a direct negative impact on case management. In the against those benchmarks to the public in a quarterly report. interim, and within the funding guidelines, the Grand Jury The Grand Jury recommends the establishment of a non- recommends that the SBCBHD investigate applying the political, non-health care professional citizen oversight/ unused staff funding to find more productive solutions for expanding mental health services to mitigate the staff review group especially from the at-risk sectors to act as the interface between the Mental Health Advisory Board, shortage and reduce caseload. consumers, citizens, and the SBCBHD. Their function

R6: An interview with the Hollister Police Department GENERAL REVIEW should be conducted to determine what procedures are The Grand Jury observed several problems in this investiga- in place to ensure proper management of the Shelter. tion, including disarray and disorder in and around the

R7: It is suggested that the 2007-2008 Grand Jury continue Shelter (junk stacked in back of the building and papers investigation to resolve issues not brought to completion strewn about the office), lack of space both in the office and during this term. in the animal areas, understaffing and high staff turnover,

R8: The City of Hollister should acquire the capacity to and difficulty in getting or understanding financial and other generate complete and timely reports. information. A large amount of information was provided, but much of it was too late for the Grand Jury to process in this term. San Benito County Jail San Benito County Jail The TVs and VCRs in the jail are purchased from the profit

* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.