Draft for A Corrective Action Plan


Prepared for 

Riverside County Mental Health


Author:  Kathi Stringer

Drawn:   June 24, 2000

Revised: July 10, 2000 [Rev. D] 


  • Paul Shirley MSW

  • Pat Risser (Patient Rights' Expert)


Corrective Active Number One


ISO 9000 / 9002 Certification

Contract for hire a qualified agency to work with top management to prepare and implement a quality system, manual, operating procedures, and work instructions per ISO-9000 [ISO 9002], family standards (Ref-2).  ISO 9000 standards are fairly easy and allows organizations to assess quality in a comprehensive manner.  The attraction of this approach is primarily due to the idea of “getting geared-up for excellence” rather than settling for minimum level. ISO 9000 quality system can help:

  •  gain cost savings and improve profitability 

  •  increase the organization’s focus on quality improvement

  • provide an objective evaluation of the organization’s performance

  • provide a report card for the public and so strengthen confidence 

  • improve documentation and record practices

  • partnership with JCAHO standards.


Corrective Active Number Two

Design and implement within the current system a corrective action mechanism that would require appropriate outside consultants to review a treatment plan when a patient fails to respond to treatment within a maximum period of 10 days.


Corrective Action Number Three



This article was given considerable thought and planning for practicality and feasibility to integrate into the current system.  Corrective Action is based on selected ideas from Linehan’s program (Ref-1) and structured within the framework of ISO-9000 standards (Ref-2) for adaptability.


  • The purpose of this proposal is to act as a mechanism to help block patient mistreatment and more importantly to strive for the achievement of excellence for patient mental health.  This plan is formulated for workable service standards between professionals and administrators.  This plan addresses program monitoring, evaluation, and control.

  • Hire or contract for services, a Program In-service Facilitator, who’s responsibility would focus primarily on introducing and reviewing therapeutic skills for the nursing staff.  Goals would be to construct or ameliorate the therapeutic alliance aimed toward patient participation and trust. 

  • The required facilitator strengths must focus on a close, direct familiarity with clinical concerns, especially as they exist within a broader organizational context, an individual who will resolve problems and not who will ally, protect, and collude with the agency.
    (Bruce L. Gates, Social Program Administration) ”The constraints imposed must still be translated into some effective means for ensuring that the behavior of individual service providers is made predictable and accountable, for it is here - in the user-provider transactions - that social policy is truly implemented”.

  • Additional emphasis on Corrective Action to a) protect patients,  b) staff and administrators against ill-advised or unjustified criticisms.

  • The facilitator’s function would consist of five components.  1.) coordinate and conduct in-service training, and 2.) review the participation of nursing staff, and 3.) identify and review problem areas affecting the quality of patient treatment (staff or administration), and 4.) review problem areas as requested by Patient’s Rights and use the findings for in-service training, and /or recommendation for corrective action, and 5.) provide quarterly and yearly reports to the selected departments of the County.



Given the tools, a Facilitator will act as a coach to lay the foundation for synergistic teamwork with nursing staff.  The Facilitator will act as a guide to define strategy for attaining objectives, and communication and the value it creates, and how each member of staff fits into the purpose of the patient’s mental health wellness.  The Facilitator will strive to awaken the potential that each member of staff possesses, to energize interest and enthusiasm, and create motivation. 


Section I.
Program In-service Facilitator

I.                     Program In-service Facilitator

A.         Program In-service Facilitator will be referred to as Facilitator for the convenience of this article. 

B.       This Plan under Corrective Action Number Three will be referred to as Program for the convenience of this article.

II.                   Facilitator

A.       The Director of Mental Health for the County of Riverside will hire or contract for hire a Facilitator that meets the minimum following requirements;

1.          Minimum education and experience:

a)       Education: Graduation from an accredited college with an M.S., M.A., MSW or MSN and knowledge of human rights and patient advocacy issues. A minimum of 5  hours of organizational / industrial psychology or equivalent in previous job history .

b)       Experience: Experience performing mental health and organizational related duties; at least two years direct clinical experience with adults in inpatient settings.  Demonstrated knowledge of human rights and patient advocacy issues.

2.          Knowledge and abilities:

a)       Knowledge of : Comprehensive knowledge of various treatment modalities.  This shall include knowledge of how to choose the most appropriate theoretical frameworks to address the needs of a given disorder, also knowledge of how to match specific types of interventions to individual patient needs so as to maximize benefits to the patient's mental health and minimize the potential for harm to the patient.;

b)       Knowledge of : A comprehensive understanding various treatment modalities and including how specific treatments would enhance or impair a patient’s mental health; and,

c)       Knowledge of: psychosocial rehabilitation, client-directed services, trauma-based services, empowerment and recovery principles, strengths based approaches; and,

d)       Ability to: Plan, organize, and direct, or coordinate a specialized in-service program involving members of various treatment disciplines; provide professional consultation and program leadership; teach and participate in professional training; recognize situations requiring the creative application of technical skills; develop and evaluate creative approaches to the therapeutic alliance and treatment of the patients toward the rehabilitation of mental disorders, to plan, organize, and review data for program evaluation; identify the more difficult problem areas in relationship to patient sensitivity and psychological treatment procedures; secure the cooperation of professional and lay groups; analyze situations accurately and take effective action; speak and write effectively; effectively contribute to the department's corrective action objectives.

3.          Special personal characteristics: 

a)       Professional integrity, patience, alertness and tact, demonstrated leadership ability.

B.         The Facilitator shall in relation to its function as described in Section II;

1.          coordinate and conduct in-service nursing training;

2.          target a specific staff person or persons with training that addresses a problem;

3.          investigate and report unusual occurrences out of in-service training discussions;

4.          under the request of the Department of Patient’s Rights review material; and,

5.          recommend corrective action as necessary.

C.        The Facilitator responsibility will operate independently of the Medical Director of Mental Health.

III.                 Funding

A.         will fall under the budget of Riverside County Mental Health;

B.         provide for the fees or wages of the Facilitator; and,

C.         provide for the materials related to the function of the Facilitator.

IV.                Facilitator Termination and Appeal

A.        The Facilitator is subject to periodic reappraisals for reappointment by the Director of Mental Health;

B.        the Facilitator may be replaced when job performance falls below expected levels; and,

C.        the Facilitator may appeal to the County Executive Office for review of the County Board of Supervisors for job termination if the Facilitator suspects termination was the result of derogatory statements filed within the Quarterly or Annual Reports.


Section II.
Facilitator Function

I.               In-service Training shall be conducted every 14 days in consecutive sessions for maximum attendance, and a for a minimum duration of 70 minutes, and tripartite functions to consist of;

A.         [30 minutes] Lecture / Strategies and Continuing Education

1.          Comprehensive knowledge of the fundamentals of mental mechanisms.

2.          Adaptation styles.

3.          Coping strategies and therapeutic intervention skills.

a)        Coping strategy example: Teach and facilitate adaptive coping behaviors for life-style balance and management, relaxation training, tension-reduction strategies, and anger management.

b)        Therapeutic intervention example: A patient's stressor is another person in the immediate environment. To facilitate ventilation, emphasis is on support with the use of an empathic, nondirective, concerned technique.  The nurse speaks in calm, clear, simple statements, avoiding any challenge to the patient (Grinspoon, 199b).  Aggressive, confrontational, threatening approaches at this time usually result in escalation of the aggression.

4.          Improved, goal oriented, therapeutic nurse-patient relationship.

5.          An understanding of communication skills, respect, desire to help.

a)         Giving information: "My reason for speaking with you is..."

b)         Seeking clarification: "Did you say you were upset with Janet because she said that?"

c)          Encourage description and exploration: "How did you feel when Rick said that to you?"

d)          Presenting reality:  "Why do you think you are unstable for a Job?  You don't appear shaky to me."

e)        Seeking consensual validation: "Did I understand you to say that you feel better now than you did last week?"

f)          Focusing: "Maybe we could identify one problem you have and talk more about that."

g)        Encouraging comparison:  "How do you think another person might handle this?"

h)        Making observation: You look like you are more relaxed now then when we first started talking."

i)          Giving recognition or acknowledging: Sue, I see you are making progress."

j)          Accepting: (not necessarily agreeing with but receiving communication with openness): " Yes, I hear you say that you don't know if you want to be in the group or not."

k)        Encouraging evaluation: "When Jim gives you support do you feel better?" or "How did we do with helping with your problem?"

l)           Summarizing: "What we talked about today are several issues that..."

6.          Help facilitate and redefine the patient’s interpersonal world

a)         Example: In many cases the patient has mistaken beliefs that “the world is bad”.   Through good countertransference management, increased interaction, and decreased retaliation, a patient’s internal objects can be modified through positive introjection indentification (Glen Gabbard) (or more simply, golden-rule).

7.         Sensitivity and validation as a therapeutic tool.

8.         Emphasis on psychological concerns should be addressed in the least restrictive setting.

B.         [20 minutes] Discussion / Interaction / Exchanges of Ideas

C.         [20 minutes] Production of Assignments

1.         Nursing staff to give examples for strategies and skills used from one in-service session to the next, for example:

a)         RN interacts with a severely agitated patient.

b)         RN to give actual strategy for defusing situation while building the therapeutic alliance.

2.         Peers to discuss, coach, support, feedback, scrutinize, and consider alternative methods.   

II.              Training

A.       Target a specific staff person or persons with training that addresses a problem as required per Corrective Action Order through CARB.

III.            Reviews

A.       Reviews of nursing staff participating in in-service training will be recorded and added to the employee file.

IV.           Corrective Action

A.        The Facilitator shall identify and document any recommendations for corrective action designed to address a problem.  The documentation of corrective action shall include:

1.         measurable objectives for each action, including the degree of expected change in persons or situations;

2.         time frames for corrective action; and,

3.         persons responsible for implementation of corrective action.

B.        The Facilitator shall submit recommendations for corrective action to the Corrective Action Review Board (Section III) as necessary.

V.             Reports

A.         Quarterly reports shall;

1.          be provided to the office of the Director of Mental Health;

2.          contain a progress report;

3.          critical or on-going problems as related to rejected corrective action; and,

4.          goals for the next quarter

B.         Annual Report shall;

1.          be provided to the Riverside County Board of Supervisors;

2.          to the Executive Office of Riverside County;

3.          to the office of the Director of Mental Health;

4.          shall contain a 12 month progress report;

5.          critical or on-going problems as related to rejected corrective action;

6.          recommendations for solving specific problems; and,

7.          goals for the next 12 months


Section III.
Corrective Action Review Board (CARB)

I.                     CARB will review recommendation for corrective action as requested by the Facilitator.

II.                   The CARB committee shall consist of:

A.         Head of Patient Rights

B.         Head Nurse

C.         Medical Director

D.         Program In-service Facilitator

III.                 Within set time constraints CARB shall;

A.         Approve  recommendations

1.         The result of a successful conclusion through all the CARB members

2.         The board shall prepare and submit a Corrective Action Order to the appropriate department entity and the order shall include;

a)         Measurable objectives for each action, including the degree of expected change in persons or situations;

b)         Time frame for corrective action; and

c)          Persons responsible for implementation of corrective action

3.         Each member of CARB shall retain a copy of the Corrective Action Order for their records and data analysis.

B.         Reject recommendations

1.         The result of a disagreement through unsuccessful negotiations by any one member of CARB.

2.         CARB shall document and record each members reason for approving or rejecting the recommendation for corrective action.

3.         Each member of CARB shall retain a copy of the Corrective Action Order for their records and data analysis.


Section IV.
Quality Assurance

I.                     Evaluation of corrective action

A.       The quality assurance entity shall monitor the effectiveness of corrective action until problem resolution occurs.  Results of the implemented corrective action must be documented and communicated to the appropriate departments.



Reference: The Press-Enterprise Published: Tuesday, October 26, 1993
There is a certain degree of concern whether The Department of Mental Health would report accurately any various derogatory information which would reflect legal liabilities against the County which would trigger management termination. 


A probe (1993~) conducted by the Department Mental Health Task Force concerning allegations by addicts and former employees of abuse, harassment and racism.  Disconcerting was The Mental Health Director’s response in a summary to County Board of Supervisors which “smoothed” over the findings, giving the appearance of covering up the raw findings from the investigative report.  Records also show that County Board Supervisors Patricia Larson and Bob Buster stated that the Department Director’s report only scratched the surface of problems.


Considering the 1993 report above, and that the Medical Director ignored a Corrective Action Request from Kathi Stringer in 1997 and Department’s apparent continued neglect for Corrective Action from the events of Kathi Stringer’s admit in 1998, this plan incorporates an Annual Report to entities (Section II (IV), (B), (1-2)) outside the Department of Mental Health for an added measure of monitoring.  




·        Simon Slavin posed the following question, in  regards to the problem of accountability: "What are the means by which social services programs might be monitored, evaluated, and controlled?" (p. 303) He then discussed the inherent problems in creating a system of accountability in human service agencies.  In his conclusion, he offered a generic suggestion that is like the plan we are proposing, "Accountability systems [need to be] less devices through which supervisors monitor employees than the means through which staff members at all levels learn how well they are doing their jobs, how to cope with change in constructive ways, and how to plan for future change" (p.308).

·     Gates also quotes William Shonick, as follows: "Either the consumer is to be educated to utilize the professionally determined needs or the professional will have to take in account consumer wants that were overlooked in the formulation of the needs standard." (St. Louis: C.V. Mosby, 1976, p, 9n)

·     The requirement of in-service training as a supportive and ongoing educational tool under the direction of a Facilitator would serve as a corrective action measure.  To simply “try harder” will not act as a mechanism as required by the family of ISO-9000 standards.  This plan is presented in good faith and designed to be a win-win situation for all involved.



(1)   Marsha M. Linehan, Ph.D., ABPP 

Professor, Department of Psychology    
Director, Behavioral Research & Therapy Clinics (BRTC)    
University of Washington                                                                  
Seattle, Washington 98195-1525

(2)   ISO-9000
ISO is the
International Organization for Standardization
ISO 9002:1994 Quality system-model for quality assurance in production, installation and servicing.

Med-Data Management, Inc.
2270 7th Street, Suite 7
Mandeville, LA 70471
Phone (toll free): 800-434-5142
Phone (local): 504-674-2217
Fax: 504-674-2265

It's in every healthcare provider's best interest to earn accreditation from and to comply with industry standards organizations, such as HCFA and JCAHO. Now a new industry standard on the global block is gaining acceptance as the international quality standard. It is ISO-9000.  Quickly becoming the only recognized as set of quality management standards.

Certified ISO-9000 providers have seen:

·    Decreases in operational costs

·    Reductions in customer complaints

·    Increases in quality

·    Heightened favorable public image of integrity, quality, and trust

·    Increases in demand for products and services

·    Easier entry into the global marketplace

TQM Systems / Consulting Company / ISO-9000

Principal Consultant is Marvin M. "Mickey" Christensen, P.E., BS, MS
12382 Mollylea Drive
Baton Rouge, LA 70815
Phone: 225-273-4972
Fax: 225-273-4979


TQM Systems is able to provide the consulting help a company needs to implement "results focused" Total Quality Management and/or ISO 9000/QS9000/14000 compliance.

Mickey served as the prime consultant for getting the first and third acute care hospitals certified to ISO 9002 in North America. He is certified by the Registrar Accreditation Board (RAB) in the U.S.A. as a Quality Systems Lead Auditor.

Karen M. Longlade of Sigma Quality Solutions states “It's in every healthcare provider's best interest to earn accreditation from and to comply with industry standards organizations, such as HCFA and JCAHO. Now a new industry standard on the global block is gaining acceptance as the international quality standard.

ISO Members

·     American National Standards Institute (ANSI)
11 West 42nd Street
13th floor
US-New York, N.Y. 10036

·    American Society for Quality (ASQ)
Telephone: 800-248-1946 / 800-248-1946

·    NASA

Pulaski Community Hospital

2400 Lee Highway
Pulaski, VA 24301 540/994-8100 

PULASKI, VIRGINIA, June 15, 1998 -- Pulaski Community Hospital is the first and only hospital in the United States to receive ISO 9000 certification for quality performance and JCAHO Accreditation with Commendation.

Daniel Katz and Robert L. Kahn, "The Social Psychology of Organizations (New York:  John Wiley, 1966) 

Jeffrey Pfeffer and Gerald Salancik, "The External Control of Organizations (New York, Harper and Row, Pub., 1979).

Bruce L. Gates, Social Program Administration (Englewood Cliffs, New Jersey, 1980) 

Glen O. Gabbard, M.D.,  Treatment of Psychiatric Disorders / Videotape Series / Integrated Treatment of Borderline Personality Disorder / Pharmacotherapy and Psychotherapy
Sponsored by the American Psychiatric Association

Keltner, Schwecke and Bostrom , Psychiatric Nursing Second Edition Textbook on Nurse-Patient Relationship, Milieu Management and Psychopharmacology

Shonick, William, "Elements of Planning for Area-Wide Personal Health Services" (St. Louis: C.V. Mosby, 1976, p, 9n).

Simon Slavin, "Social Administration," (New York:  The Haworth Press, 1979)