State’s MH Inspector General: Watchdog, Detective, Psychiatrist
It is an indigo-blue-sky day in Charlottesville, Va. The sun-dappled magnolia leaves rustle softly in the breeze. A blond, 42-year-old woman in a charcoal turtleneck pullover and slacks opens the front door of her home and welcomes a visitor in for a chat.
Anita Everett, M.D.: “What we do is make unannounced inspections to make sure that patients are safe and receiving appropriate treatment.”
And if that is not enough, Everett holds a position that appears to be unique—inspector general of her state’s public mental health system.
True, there are other inspector generals around the United States, but none of those positions are comparable to that in Virginia, and none is occupied by a psychiatrist. For instance, Everett explains, Illinois has an inspector general for human services, but that person handles mostly abuse and negligence cases and is not a psychiatrist. Florida has an inspector general for its system that falls under child and family services, but the inspector general’s role has more to do with financial auditing. There was some form of inspector general in the District of Columbia who reported on problems in the living quarters of persons with mental retardation, but the person filling that position was not a psychiatrist.
Crisis Prompted Position
The reason that the position of inspector general of Virginia’s public mental health system was created, Everett said, started back in the mid-1990s when “we had a person die while in seclusion and restraint at one of our hospitals.” The U.S. Department of Justice then investigated the public mental health facilities of Virginia and found a number of them woefully lacking in terms of safety and treatment.
Then in 1997, the attorney general of Virginia, James Gilmore, ran for governor and promised that if elected, he would set up a position to serve as a watchdog over Virginia’s public mental health system. He was elected as governor and kept his word: In 1999 the Virginia legislature passed a bill that created the position, and he signed it into law. He then appointed Everett to the position since she had had extensive experience in public mental health—having been medical director of a rural mental health clinic near Staunton, Va., from 1992 to 1999.
Everett has a very small staff—only two people—though she can occasionally hire consultants. “We are focused primarily on Virginia’s 15 state mental health facilities, which care for some 3,600 patients,” Everett explains. “But we also have the authority to review the quality of clinical services in community mental health programs licensed by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services, which are in the hundreds.
“What we do is make unannounced inspections to make sure that patients are safe and receiving appropriate treatment. This includes not just talking with staff, such as aides and night nurses, but with patients themselves.”
Four Years, 700 Recommendations
During the four years that she has been inspector general, Everett and her staff have sent 78 reports containing some 700 recommendations to the governor. “Some of our recommendations are very small things,” she says, “like replacing shredded curtains, and some of our recommendations are quite big—like hiring more nurses so that they don’t have to work overtime and become exhausted and then perhaps neglect or abuse patients.”
The Virginia Department of Mental Health is required by the Code of Virginia to respond with a corrective action plan to each recommendation made by Everett and her staff. If the department is not able to implement the recommendation, it is required to justify its decision in a plan of correction that is released on the Web site of the Office of the Inspector General.
Examples of the kinds of recommendations that have been implemented in one or more facilities include the hiring of new nurses, increasing access to primary care physicians, replacing antiquated equipment that caused injuries, and resolving a fire code violation that placed adolescents at risk.
Still other things that she and her staff have achieved, Everett says, are examining patient discharge plans from state facilities to see whether the plans are appropriate to patients’ reintegration into the community; scrutinizing the causes of deaths in state facilities to make sure that patients did not die because of lack of safety or because of inadequate treatment; and probing the ability of seriously, persistently mentally ill patients to access services in community mental health centers.
Playing Watchdog Not Easy
Nonetheless, playing detective—watchdog if you will—is not always easy, Everett concedes. “I think the biggest challenge is being a physician who sometimes has to question the practice of other professionals. Sometimes the staff members I inspect feel threatened by me, but they really shouldn’t. My interest is the same as theirs, to provide the best patient care possible.”
Another difficulty, she adds, “is questioning public mental health traditions in Virginia, which can really raise the hackles of the state’s citizens.” She adds that being a district branch representative to the APA Assembly has really helped her “learn how community psychiatry is done in other states so that I don’t get stuck in the Virginia way!”
Which leads to several of the things which she would still like to accomplish in the position—for example, to see how many seriously mentally ill Virginians have access to evidence-based services in the community and to take patients along to help with inspections. “When we first started,” she points out, “we actually hired patients to come and work with us, to talk with other patients and with staff about conditions, but because of funding limitations, it’s been a while since we’ve done that.”
“My dream for the office,” she admits, “is to have a few more staff members so that we can do some more thorough evaluations. But the current state budget crisis in Virginia won’t allow it.”
In fact, whether Everett will even be permitted to continue as inspector general is uncertain because her four-year term ended in January, and Gov. Mark Warner has appointed her acting inspector general of the system only until July 1.
Finally, it is even questionable whether the position of inspector general itself will continue to exist, since what the Virignia legislature and governors give, they can also take away.
Whether the position survives for the long haul, however, Everett feels good about what she and her staff have achieved. “I do believe that we have made a difference in patients’ lives,” she says with a smile.
She hopes that the successes that she and her staff have achieved will inspire other states with inadequate public mental health systems to create an inspector general position of their own. ▪
