California’s Prison Crisis 2006: Is the System Beyond Help?

I find some of Ms. Christie's recommendations amusing at best.

I remember the movement by "progressives" to change the involuntary mental health commitment laws back in the 1960's and 70's. The end result? More mentally ill people allowed to decompensate until their behavior crosses the threshold into the criminal justice system, where they're sentenced to state prison. State prisons are not the place for these people, everyone agrees.

I also appreciate Ms. Christie's embracing Dr. Petersilia's indeterminate
sentencing structure. Unfortunately progressive Governor Jerry Brown was the father of the current determinate sentencing laws as a result of the outcry from liberal factions that claimed that indeterminate sentencing resulted in "people of color" spending a disproportionate amount of time behind bars vs. their white counter parts. Dr. Petersilia offers no evidence of a successful indeterminate sentencing program in California (which there are several), and other than shortening sentences for receiving a G.E.D. she offers no other example of behavior that should be rewarded, or disincentives for misbehavior.

The whole focal point of the "progressive movement" has shifted to the prison system and offers no cure for what leads people into CDCR. Why are there no drug treatment programs at the community level? Wouldn't the community be better served by concentrating it's resources in the counties?

Mental Health Court pilot programs in Marin and Riverside Counties have shown great results, reducing the number of mentally ill offenders committed to CDCR while maintaining their family and community ties, as well as reducing costs associated with incarceration. No one in the "progressive movement" addresses these issues.

Bottom line? Are we better served by concentrating our resources at the community level BEFORE the offender enters CDCR? I think regular contributers to this site should explore the possibilities.

Thanks for your comments, Joe. I am glad we are having this discussion.

I don't think the whole focal point of the progressive movement has shifted to the prison system. Many fine folks are trying to implement Prop 63, the measure the voters passed to provide funding for exactly what you are talking about--mental health treatment at the front end so incarceration can be avoided in many cases. There is a very interesting article I recommend to our readers in today's SF Chronicle that discusses the cuts in mental health dollars and how this is impacting treatment that many Californians need. It can be found in the news summary on this site.

I think we need to do both. It is pennywise and pound foolish to not do it at the front end, as you state. But I am sure you will agree that much needs to be done with those who are in our state's prison system and getting absolutely terrible medical care--and that much more needs to be done with follow up after they are released.

I remember the problems we had (and actually still have with our state mental hospitals) that led to the Lanterman-Petris-Short Act and the release of many of the former patients from these facilities. The problem with the deinstitutionalization of these former patients is that we did not follow through with funding and resources for them once they were out and wandering around the streets. The problem is that Ronald Reagan, who was our governor at the time did not want to commit those resources to helping the former patients. That is a problem that we, as progressives, must address. Many of us are. But that doesn't take away from the problems of the prisons that need solutions--and that may come about as a result of the Federal Courts if our elected officials don't or can't act.

Dealing with the county jail bed shortage would resolve the prison overcrowding problem and “rebalance” the correctional system.

It is reported that the State intends to build additional prison without evidence of a normal planning process. Construction of correctional facilities involves a commitment of 30-40 years or longer and requires careful total system analysis and planning. Additional correctional capacity may very well be needed, but it is not rational to construct additional correctional beds without conducting a normal planning process to determine how much additional capacity, if any, is needed, and where it may be needed. This has not been done.

Prisons are intended and designed to house and program offenders serving sentences of a year or longer – county jails are designed to house offenders serving sentences of a year or less. Historically, about 50% of all offenders were held in a county jail and 50% were held in prison. The current ratio is about 1/3rd (80,000) in county jail and 2/3rds (160,000) in prison.

There are now more “county jail inmates” serving their short terms in prison and being paroled than there are felons serving more than a year in prison and being paroled. In CY 2005, about 77% of all releases from prison to parole served less than 12 months in prison. Only 23% of all releases served more than 12 months in prison . These short term offenders occupy 20,000 to 30,000 prison beds. County Jails are required to release of over 18,000 inmates monthly due to lack of bed space. This jail bed shortage is the major cause of the shift of so many less serious offenders serving short terms to the State Prison System. It is also the prime cause of the extraordinary parolee return to prison rate which adds about $500,000,000 to annual prison costs.

If sufficient county jail beds were available, there would probably be a smaller prison system with about 125,000 inmates and a larger county jail system with about 125,000 inmates, reflecting the historical “normal”, balanced correctional system 50%/50% inmate split. There appear to no benefits and significant drawbacks, including higher costs, to allowing a de facto, informal policy change of sending short term offenders to prison.

Analysis of a correctional system has to start at the front end of the system, the point of arrest and the county jail system [. To quote from a Michigan Task Force on Jail and Prison Overcrowding ][ ”there is a relationship between jail and prison overcrowding: the actions taken by one system ultimately affect the other; they are not mutually exclusive.” Failure to take note of this obvious fact is a major cause for many of the current really serious California correctional system problems. The lack of correctional system leadership remains a crippling impediment to dealing with the system deficiencies.

The State needs to develop and maintain a strategic plan for the total statewide correctional system, a critical guide for the design and development of the correctional system. A strategic plan would be an independent resource for the Legislature, Governor and local officials and provide guidance for the orderly growth and functioning of the statewide correctional system. At the least, the State needs to take steps to gradually return responsibility for housing less serious offenders from the State Prison System back to the County Jail System. It appears to be far more rational to invest in local corrections at the front end of the system than to compound current structural problems by continuing to expand the State prison system without a sound basis for doing so.

Thank you Barbara for your great article. There are cetainly individuals who belong behind bars for the protection of the general public. I believe the politicians in California have played right into the hands of the prison machine of the guards union. When simply put to a politician it means do it our way or we have enough money to get you out of office. If this type of mentality is allowed to continue in the Sacramento Capitol it won't be much longer until the entire prison system crumbles from the ground up. Because the taxpayers will not be able to foot the bill for warehousing every petty criminal in the State.

The mentally ill should be housed in mental hospitals run by psychiatrist, doctors and nurses NOT by prison guards. These faciities should NOT be under the control of the CDC or the prison Mental Health Department.

Rehabilitation can only occur when there is treatment of the sickness, and NOT punishment of the mind. Long term solitary confinment of the mentally ill only make then worse and has no place in the healing process. The very sick prisoners should be released to their families when there is no threat to the general public. The prison complex has become an industrial complex of human waste. We do not need any new prisons. We have far too many prisons already with a rope around the necks of the politicians who are too weak to stand up to the prison guards union who call their power "job security."

Well I have read these posts along with the original story and I have to say there are some positive ideas along with some very naive ones. Mentally handicapped people do not belong in state prisons, for there safety and for the safety of staff and other inmates who may cross their abnormal behavior. Now we must decide what makes a person mentally incapable of going to prison. A person who commits murder, mayhem or rapes women or children could be described as being mentally incopitent, because their actions are not ordinary or normal. The prison guard union is not to blame here, the blame belongs with the administration that refuses to police their own. I don't mean the guards, I mean those people who work out of Sacramento who make all these ridiculous policies that seem to backfire as soon as they are enforced. Paroles is another area that needs adjusting, stop sending parolees back for 1-15 day stays for ridiculous violations. Rehabilitation, have you looked up this word in the dictionary? It means to return a person to the good person they were before they got in trouble; what if the person was never good to start with? I agree, more job training for the inmates, more training in self respect, and less B.S. education plans that look good on paper, but deliver nothing to the inmate or to society.

One huge reform that is needed is that people in law enforcement such as police and prison guards need to have an AA degree at the very minimum. It often isn't a case of good vs. evil people but of sick vs. well people.

Some people need to be removed from society but this could be done in a much more healing manner. The Scandanavian countries have been very successful at rehabilitating even the worst criminals.

The US is way behind many countries on prison reform. Why isn't there a work project so that the inmates can find employment when they are first released instead of being cast to the streets with only $200 in their pockets.

Sometimes they don't even get the $200 and after their traumatic experiences in prison can't survive the outside world.

Lockdown is destroying the body, mind and spirits of people. Stress causes physical diseases, and so do filthy conditions poor nutrition and too much of this is intentional.

An AA for prison guards with classes in psychology, sociology, nutrition and stress management, not to mention basic first aid courses would be a good starting place.

People are being sent back to prison for showing up l/2 hour late to their parole appointments even when they were riding a bus that failed to get them there.

It's almost as if someone is giving brownie points or cash bonueses for re-arrests. Nothing would surprise me.

Nice editorial.

...."New upcoming awareness of social understanding guided by scientists from Schools of Social Sciences (perhaps in future supported by church’s representatives) can give a better outlook to man on Man’s Earth, our Global World. These new guidelines shall be given to a recalcitrant Justice System unless there is economic incentive to do adopt them. The judicial system and its affects on society are dictated by economic interest rather than common sense and what may be beneficial to society....."
Reforming Statements
Letter to My Friends
View from abroad

The prisons are beyond repair !!!
We all deserve to know the truth. Mr. Hagar is determined to continue his investigation, and to compel the governor’s staff to testify.
If they have nothing to hide, let the real story be told.
The Department of Corrections and the guards union have been playing patty cake, for a very long time. Hagar said, the worst thing that can happen to a person is to be an inmate in a California prison, or a guard.
We the people need to know, the real reason as to, why reform has not taken place.
Why guards who beat and kill prisoners are not held responsible(only transferred to other prisons.)
Why the guards union protect these abusers.
Why aren't the guards union,impoving conditions for the honest and humane guards,who are trying to work around rouge abusive guards,who make their job miserable. They pay union dues,where is their protection.
Why are doctors not getting paid, many leave, then they hire more quack, expensive outside doctors.
Whose going to rescue the terminally ill, aging and dying prisoners, and place them in hospitals, they can’t wait until the year of 2011.
The mentally ill should not be in prisons, guards are not medical professionals.
CDCR should not be in-charge of any healing facility, look at how they are handling it now, its horrific !!!The money trail needs to be followed thoroughly !!
A new agency needs to be created now,to house the mentally ill,with a real professional healing staff.
The administrative segregation units need to be shut down,these units cause a sane man to become insane.The mentally ill who are placed in these units for punishment,deteriorate and commit suicide very quickly !!
Lives need to be saved, and a real chance to recover!!!
The state agencies have proved to be incapable and are complete failures,their neglectful and disruptive powers needs to be taken down !!

A very important point missed is sentencing reform. one of every four inmates is a striker,serving double time or 25 years to life.Sixtyfive percent are non-violent offenders such as drug users.Most past priors which can be decades old were for burglary.Would it not make more sense and cost less to treat the addiction at a fraction of the cost of incarceration about 36,000 dollars for each inmate? Let's look at the root of the problems.New prisons would only add to the crisis and the financial burden to the taxpayers. We have too many inmates serving too long of sentences period.

I DO AGREE WITH THIS LADY...PEOPE NEED TO OVER COME THE LIVE OR THOUGHT OF DANGROUS HUMAN AND REMEMBER THE LONGER THEY STAY IN PRISONS THE MORE EACH OF THM GET A CHANCE TO TEACH A FIRST FELON THE ROPES OF A TOUGH MAN BHIND BARS. ALL THE JUDGES AND GOVENERS NEED TO OPEN THEIR EYE AND SEE WHAT THEY ARE DOING AND ADDMIT THAT THEY ARE HELP THE WORLD OF VIOLNCE.

Here is an essay I wrote about 18 months ago. I won't even begin to comment about the retaliation that was launched against me for speaking frankly - and truthfully. I have "pasted" it here - but the footnotes didn't make it for some reason.
Here you go: * A PORTRAIT OF ORGANIZATIONAL DYSFUNCTION
*(This version supercedes any previous version and is the only one approved by the author.)
MLF
Monterey, Ca.
April 18, 2005

I INTRODUCTION:

AS I write this the physicians employed by the California Department of Corrections (CDC) are, after being unfairly maligned as a class, under fire and absorbing the blame for failures of Central Office policy makers. The Institution’s Chief Medical Officers (CMOs) are being systematically “picked off” by the same management at Health Care Service Division (HCSD), HQ. And, unorchestrated - and for all practical purposes leaderless - the entire system of health care delivery in California’s 32 disparate prisons is on the cusp of total meltdown.

BUT what should not be happening is this unprincipled and irresponsible assault on CDC physicians. It is egregious enough that they have been singled out to scapegoat for failures higher up but now our leadership proposes to compound the calumny by forcing them to endure “testing” without cause or due process - and summary dismissal if they resist. The whole horrifying thing is unconscionable – at least.

MOST of the problems plaguing the CDCs efforts to deliver adequate health care and recently to “improve” it spring from unresolved classic conflicts. It was inevitable that we would find ourselves as we are currently situated – under fire with crisis oriented management dependent on the opinions of outside consultants who mean well but who do not really understand our problems in the field. Our leadership has been frantically grasping for solutions like structural reconfiguration and signing on to the consultants suggestions and advice - including concepts largely unfamiliar to them like “Quality Assurance” (as it is currently applied it’s utility is misunderstood!) for a cure.
Literally with their backs to the wall and with no identifiable organizational vision as a guide and even less understanding of field-level health care delivery, the HCSD management now is acting out of abject desperation. Defeated, they are now also “identifying with the aggressor” and, incredibly, taking on the agenda of the Prison Law Office (PLO), as their own! The PLO agenda is also well intended but it is not necessarily in the best interest of our population and our department – nor is their criticism entirely correct.

HOWEVER, there is absolutely no excuse for the depth of mismanagement, managerial incompetence and inexcusable neglect of ones duty to correct errors that manifest when new policy and programs are set in play, as was done in the name of enhanced health care delivery during more then a decade of focused staffing and budget expansion in each and every correctional facility in California’s vast and geographically scattered Archipelago of prisons – and it must be told.
If nothing else, it is about to cost the California taxpayer a whopping new bill – when Central Office managers finally act out the last chapter of their cynical agenda and “contract out” medical services to the private sector.

II (optional) ABOUT THE ROLE OF “INSIGHT” – A BRIEF DIVERSION:

IN the preface to his monumental work describing a very different Archipelago of prisons in a very different time and place Aleksandr Solzhenitsyn recounts his reaction to an erstwhile insignificant news item published in Nature, the magazine of the (Soviet) Academy of Sciences. In it is described “in tiny type” the discovery of an ice lens during the course of excavations of a subterranean branch of the Kolyma River in frozen Siberia .In the ice lens were found frozen prehistoric fish or salamanders “preserved in so fresh a state.. that those present immediately broke open the ice encasing them..and devoured them with relish on the spot.” Solzhenitsyn noted that most readers would not be “able to decipher the genuine and heroic meaning of this incautious report.” But he “understood instantly.” Having been a prisoner himself – really a forced political exile - in the Soviet prison Archipelago he understood instantly what would likely escape most other readers. He understood the unintended (“incautious”) parallel report about the prisoner-slaves who accompanied the scientists - people who were starving to death. So hungry, in fact, that they actually “broke up the ice in frenzied haste..and flouting the higher claims of ichthyology and elbowing each other to be first, they tore of chunks of the prehistoric flesh” and “devoured” it “with relish on the spot.” Most readers would not be able to decipher the “meaning” unwittingly conveyed by the article’s author simply because most readers would lack the special insight that Solzhenitsyn had acquired during his confinement in the Siberian Gulag - acquired indelibly and forever.
Such is the nature of the “understanding” acquired during fourteen-plus years of service to the state and presented here.

III THE STAGE WAS ALREADY SET:

CRISIS has loomed for many years on several critical fronts and the only thing keeping the veneer of control from dissolving under increasingly intrusive public scrutiny was the massive inertia that is characteristic of a huge, complicated bureaucracy with a vital public safety mission, a powerful and politically savvy employees union (CCPOA) and an arcane and feudal structure with a foundation designed for an earlier era. Compounding this anachronistic nightmare is an intolerant organizational tradition that is grounded in the notion that "the Corrections way" trumps all other considerations. Employees who learned and accepted these things became eligible for a seat in the "car." Promotion and success was absolutely linked to this acceptance - and those given a seat were guaranteed a good career in Corrections - and a good life. Corrections culture remained hidebound and complacent for decades. Prisons – especially prisons with the kind of population that California created are a kind of social blight, a symbol of the depth of a societies failures in many ways. Its best for reasonable people to not give this subject too much thought.

INSTITUTIONS were semi-autonomous and Wardens operated like feudal Lords, enjoying prerogatives and an independence that was the envy of their peers in other agencies of the state. Feudal and hidebound, this entity rolled merrily along, and like a huge ball of molasses, it simply steam-rolled its opposition sucking some in to become part of itself and spitting out those who resisted. Although critics were everywhere, it remained resilient - even to occasional meddling by the 9th Circuit Court - and its budget was left essentially unchallenged.

WHEN the first important medical class action litigation alleging constitutionally inadequate psychiatric care for class members began, HQ managers, without consulting field "commanders" (i.e., the CMOs) in any meaningful way cut unbalanced (unfavorable to the CDC) deals and agreements with the Plaintiff's attorneys. The Orders and Consent Decrees that followed began the painful process of self-discovery for Corrections officials. That’s because, having bit off more then we could chew, our inability to deliver on the promises made to the Court (failure to implement Corrective Action Plans-‘CAPs’) caused one institution after the other to belly flop until, collectively, CDC’s efforts began to look like a demonstration of “The Domino Principal.” When the Feds finally threatened to place the entire organization under Federal receivership with a Special Master calling the shots, the leadership started to pay attention to something they avoided and denied for years – the role of correctional “culture.”

IN fact, that same “culture” is the primary obstacle and always has been - if someone had only been courageous enough to admit it. Today, that is practically all we do talk about. That and things like “ethics”, “values”, “integrity” and how “snitches” are really – REALLY – good people! My, how things have changed. The only grudging holdouts are a group of diehard Wardens and some Warden-wanna-bes who see the payoff for 20 – 30 years of ladder-climbing dissolving away before their very eyes, as Central Office control over field institutions continues its relentless advance.

IV WARDENS: PARADISE LOST:

CORRECTONS officials also discovered budgetary inconsistencies and over inflated costs, excessive overtime expenditures and other gross inefficiencies that revealed aspects of the Wardens managerial capabilities. When control agencies began to threaten the Corrections budget as well, all pretences about their ability to resist the Second Law of Thermodynamics (entropy) began to crumble – along with the worn out values of its now untenable “culture.” Discovering its fundamental dilemma, the reality of having to somehow bring this "old-world" and very cumbersome organization quickly into the 21st Century, the appointed elite - mainly the Wardens - were caught by surprise. Simply stated, the fundamental dilemma confronting the Wardens are the new policies and mandates flowing from a now unsympathetic HQ to bring this old, tradition bound, maladaptive and very unwieldy Aircraft Carrier of an organization quickly into the 21st Century.
Attaining this lofty goal, however, requires Wardens, Executive Staff and all other managers to abandon the culture that has brought so much discredit to an organization of otherwise good and capable people. The primary obstacle has been the sustained resistance by some Wardens and their “cultural allies” to any kind of meaningful acceptance of that goal – outside of a lot of huffing and puffing and token lip service.

THEIR resentment and passive (and active!) resistance gave way, finally, to tacit acceptance – but then only grudgingly. Unfortunately, instead of recognizing the positive and adaptive value of culture shift some Wardens remain angrier then ever. Although suppressed and well covered in many cases, their anger is revealed by a pervasive and thinly veiled hostility - to medical concerns, in particular. The reason is because “medical” [issues] have been the specific catalyst for having to learn all the tap dancing silliness and - even worse - the loss of their coveted prerogatives, to which many still feel they are entitled.

FOR Chief Medical Officer/Health Care Managers who depend on the good will of the institution’s Warden and on the general health of that relationship this situation can be – and has been for many – disastrous. At this institution the reasonably capable Warden retired about one year ago and managing medical operations there has been very difficult since then.

BECAUSE the Warden is the “leader” at the institutional level and because the leader sets the general tone for the organization, an atmosphere bitter and resentful toward things “medical”, the medical manager in particular, has become a pervasive and persistent force in many CDC institutions.

BECAUSE the relationship with the Warden is the single most important factor for successor or for failure for a conscientious CMO/HCM, this writer is has been compelled to write "memos" for record and for historical informational purposes documenting factual events that reveal the realities of working under circumstances of passive hostility. This must be done to protect the institution’s medical staff and medical operations – operations for which the CMO/HCM is responsible. If the leadership at HQ knows these things - and they do - they certainly keep it to themselves. In spite of the Warden’s representations of support for “medical” or how things are crafted for appearances it is obvious that very little has changed at all – least of all, bad attitudes.

V CAN IT GET ANY WORSE? - THE PLO RAISES THE ANTE:

BY around January, 2000 the Prison Law Office (PLO) had discovered CDC’s Achilles Heal. Other, equally punitive Class Action driven medical litigation soon followed. Since then, Corrections has had a succession of Directors and a new "Division" for Health Care Services and new health care missions.
IMPLEMENTING new health care missions, however, is another story. It really, really does involve resolving the Custody- Health Care conflicts that sprang from the intolerant, non-adaptive "correctional culture" – a culture that wants to have it both ways. That is, they will declare their support for change – but they do not want to actually do anything about it. There exists an institutional denial of reality so massive it has confounded four successive Deputy Directors of health care - so far. Also, so far, it gets quite a lot of "lip-service" but no one wants to seriously - and definitively - deal with it. Once again accounting for the reason this writer is obliged to write so many time consuming memo documenting the structural (and other) obstacles that frustrate reaching our stated goals. I hope, eventually, to stimulate our leadership into effective realty testing.

AN excellent overview of this subject, including recommendations for change, can be found in the "EXECUTIVE SUMMARY" of the recent “CALIFORNIA PERFORMANCE REVIEW" report. It provides an excellent account of the background and captures a vivid portrait of this organization’s culture and values. Until, that is, it takes up the question of Health Care delivery.

VI ROBIN DEZEMBER RESURECTS HIMSELF-AND HIS AGENDA:

IN PARTICULAR, the question of what to do about Corrections’ increasingly unwieldy and frustrating health care delivery system is taken up once again in the “RISK MANAGEMENT AND HEALTH CARE SERVICES" section of the “INDEPENDENT REVIEW PANEL’S” report. The report itself refracts factual information through the personal prism of a well known “stakeholder” which is unabashedly designed to support the recommendations that author makes later. What this report omits –or neglects to reveal – is that, in essence, it is a minimally redacted recitation of an agenda long espoused by this author-“stakeholder.” The recommendations made here were considered in the past and were rejected - if not discredited, as well. Also, the representation that the Panel's conclusions were collectively arrived at is, frankly, deceitful. The “recommendations” have, ostensibly, already been accepted and are on the cusp of being implemented - if the report is accurate. If correct, embarking on such a path would lead to further trouble by compounding the problems we already have. This is a subject so profoundly significant and important to any discussion about health care delivery it warrants separate cover. Therefore, I will reserve further comment for now.

VII “BAD DOCTORS” ARE LIKE “RUMORS OF MY DEATH..etc.”:

SYMPTOMS of our sickness are everywhere:
• Physicians who find themselves overwhelmed, become jaded and, unable to change anything, then complacent and lazy.
• Nurses who have similar situations and who come to think that “giving report” means waiting for the next shift to “report”, then leaving.
• Medical Technical Assistants (MTA) who are powerfully conflicted about their role. Caught between “custody” responsibilities and their responsibilities as LVN-level nurses (a dead end job without additional advanced education and training), they frequently over-identify with the Correctional Officer role, correctly seeing a brighter future for themselves on the custody side.
• And on and on…………..

IT should be obvious that all the “Quality Assurance” in the world cannot correct this system, which is flawed by design, because QA is a tool to “tune up” and make more efficient and “better” a product that is already at least “adequate” from a system that is already at least functional. Our “system” of health care delivery is neither adequate nor functional and needs almost total redesign before “Continuous Quality Improvement” techniques can be applied with effective outcome.

HOWEVER, here may be found an opportunity to actually begin a focused discussion of why the delivery of health care to our inmate population is generally weak, frequently inadequate and why all the good will in the world can only lead to one outcome: desk-pounding frustration. And it has little or nothing to do with "bad doctors” allegations. Such allegations are dishonest and deceitful acts of desperation - and a temporary refuge from responsibility for failures for which the principal leadership elements should be held accountable.

HERE, we reach the root of the problem and touch its very heart. It is not “bad doctors” that we need to focus on – it is bad managers - the principals whose policies and decisions led us down a “primrose path.” It is their reliance on the opinions and pronouncements of outsiders having only token understanding about field conditions as they effect medical operations – rather then their own field “experts.” It is their failure to follow and enforce their own policies, procedures and goals about which numerous pronouncements and promises were made. These are some of the things that brought us here. Traveling down the chain of authority from policy to operational execution, the medical division leadership at HQ failed to resolve glaring ambiguity that quickly emerged at many levels, and, even worse, then refused - or otherwise failed (frequently by simple neglect!) – to support the Regional Administrators who were far “outclassed” by their counterparts from the very beginning and then the Chief Medical Officers - many of whom became victims of a cynical ploy that assigned them the functional title “Health Care Manager,” making them conveniently available to scapegoat. These failures compounded geometrically at each successive level and, astonishingly, with each passing year. Failure to resolve deeply ingrained conflict has led us, inexorably, to crisis. Crisis was inevitable. And that is where I began this note.

VIII IS IT A “WRAP” YET?:

MY INTENT has been to try to represent the atmosphere of frustration and resistance to change in which all professional class employees must work 8 - 10 hrs/day. Doctors and other professionals are difficult to recruit. They are unaccustomed to practicing in an atmosphere that may be brutal, abusive “negative”, both by its very nature and by definition. When recruited doctors frequently anticipate this and decline to "sign on." The vast majority of recruitment solicitations go unanswered. Those who decide to “chance it” and then (frequently!) become discouraged are soon faced with the difficult decision about continuing – a decision which requires some kind of personal reconciliation with the "paranoiagenic" and very negative correctional environment, if they stay. They will have to adapt to it.

MANY of those who stay have few options by then because they may have sold their practice or face similar situations. If they want to continue practicing their profession they must do so for individuals who are frequently hostile, angry, contrary and ungrateful. Custody staff are mostly contemptuous and resentful of (medical) staff whose job is "helping" inmates - and the physical facilities are mostly austere and lacking much of the technical capability professionals on the outside take for granted.

IN many ways, doctors and other committed professional staff working in our state prisons are "heroes" -whose motives stem from other - perhaps more humanistic - considerations. (elaborate later)

MY attempt to describe the circumstances in our prisons confronting medical professionals - most of whom are totally unprepared professionally, emotionally and physically – can never really be adequate. An account of the impact of a large organization’s culture on our ability to deliver health care to inmates – an underclass of “throwaway” ex-citizens people don’t care much about anyway – becomes more like a curious tale – abstract and impersonal. “How awful! tisk, tisk!”

WHEN contemplating this I remember Solzhenitsyn’s account of the Soviet scientific expedition in Siberia and the prehistoric fish – and feel somehow better. Of course! – one cannot “teach” insight!

IF any reader has not yet been overtaken by boredom or cynicism and is still interested and wants to learn more, please ask the undersigned. If inmate health care doesn’t much interest you –remember – finally we are taxpayers, you and I. We give these people our money – a lot of our money – to run our prisons. We have every right to demand accountability.

I AM, by choice, a public "servant”. When things that the people hold me responsible for are wrong the standard for me is greater – and I have a duty to do what is necessary to correct them.
I serve - and I expect to be held accountable for how I serve.

I demand nothing less from and for my superiors.

X POSTSCRIPT; INTO THE FUTURE:

IS it too late to recover, reconvene, reconstitute and redirect toward an adaptive and credible vision?
I don’t know the answer.
It depends on the understanding of our partners for change – mainly the plaintiff’s attorneys (PLO) and the 9th Circuit Court of Appeals - and their willingness to let us start over again. We should at least argue that doing so is reasonable because:

1. It is to our credit that we do not want to abrogate our responsibilities and abandon the great task we have been given and which is our duty to deliver to the people repaired and operationally functional.

2. “Receivership” is a very bad choice for all concerned for numerous and obvious reasons – not the least of which is the inevitable multiplied costs.

3. It is my opinion that the unfortunate selection of recent Deputy Directors of Health Care who were unprepared or unable to do the job for one reason or the other does not mean CDC with all its vast resources cannot produce one single good and competent manager for CDC medical affairs, statewide. Such an assertion is ludicrous, on its face. But that seems to be what some at our HQ are alleging.

Rx: Ten Parallel Tracks to Health:

To be provided later and under separate cover.

MICHAEL L. FRIEDMAN, MD
Chief Medical Officer
Monterey
4/18/05

Here is an essay I wrote about 18 months ago. I won't even begin to comment about the retaliation that was launched against me for speaking frankly - and truthfully. I have "pasted" it here - but the footnotes didn't make it for some reason.
Here you go: * A PORTRAIT OF ORGANIZATIONAL DYSFUNCTION
*(This version supercedes any previous version and is the only one approved by the author.)
MLF
Monterey, Ca.
April 18, 2005

I INTRODUCTION:

AS I write this the physicians employed by the California Department of Corrections (CDC) are, after being unfairly maligned as a class, under fire and absorbing the blame for failures of Central Office policy makers. The Institution’s Chief Medical Officers (CMOs) are being systematically “picked off” by the same management at Health Care Service Division (HCSD), HQ. And, unorchestrated - and for all practical purposes leaderless - the entire system of health care delivery in California’s 32 disparate prisons is on the cusp of total meltdown.

BUT what should not be happening is this unprincipled and irresponsible assault on CDC physicians. It is egregious enough that they have been singled out to scapegoat for failures higher up but now our leadership proposes to compound the calumny by forcing them to endure “testing” without cause or due process - and summary dismissal if they resist. The whole horrifying thing is unconscionable – at least.

MOST of the problems plaguing the CDCs efforts to deliver adequate health care and recently to “improve” it spring from unresolved classic conflicts. It was inevitable that we would find ourselves as we are currently situated – under fire with crisis oriented management dependent on the opinions of outside consultants who mean well but who do not really understand our problems in the field. Our leadership has been frantically grasping for solutions like structural reconfiguration and signing on to the consultants suggestions and advice - including concepts largely unfamiliar to them like “Quality Assurance” (as it is currently applied it’s utility is misunderstood!) for a cure.
Literally with their backs to the wall and with no identifiable organizational vision as a guide and even less understanding of field-level health care delivery, the HCSD management now is acting out of abject desperation. Defeated, they are now also “identifying with the aggressor” and, incredibly, taking on the agenda of the Prison Law Office (PLO), as their own! The PLO agenda is also well intended but it is not necessarily in the best interest of our population and our department – nor is their criticism entirely correct.

HOWEVER, there is absolutely no excuse for the depth of mismanagement, managerial incompetence and inexcusable neglect of ones duty to correct errors that manifest when new policy and programs are set in play, as was done in the name of enhanced health care delivery during more then a decade of focused staffing and budget expansion in each and every correctional facility in California’s vast and geographically scattered Archipelago of prisons – and it must be told.
If nothing else, it is about to cost the California taxpayer a whopping new bill – when Central Office managers finally act out the last chapter of their cynical agenda and “contract out” medical services to the private sector.

II (optional) ABOUT THE ROLE OF “INSIGHT” – A BRIEF DIVERSION:

IN the preface to his monumental work describing a very different Archipelago of prisons in a very different time and place Aleksandr Solzhenitsyn recounts his reaction to an erstwhile insignificant news item published in Nature, the magazine of the (Soviet) Academy of Sciences. In it is described “in tiny type” the discovery of an ice lens during the course of excavations of a subterranean branch of the Kolyma River in frozen Siberia .In the ice lens were found frozen prehistoric fish or salamanders “preserved in so fresh a state.. that those present immediately broke open the ice encasing them..and devoured them with relish on the spot.” Solzhenitsyn noted that most readers would not be “able to decipher the genuine and heroic meaning of this incautious report.” But he “understood instantly.” Having been a prisoner himself – really a forced political exile - in the Soviet prison Archipelago he understood instantly what would likely escape most other readers. He understood the unintended (“incautious”) parallel report about the prisoner-slaves who accompanied the scientists - people who were starving to death. So hungry, in fact, that they actually “broke up the ice in frenzied haste..and flouting the higher claims of ichthyology and elbowing each other to be first, they tore of chunks of the prehistoric flesh” and “devoured” it “with relish on the spot.” Most readers would not be able to decipher the “meaning” unwittingly conveyed by the article’s author simply because most readers would lack the special insight that Solzhenitsyn had acquired during his confinement in the Siberian Gulag - acquired indelibly and forever.
Such is the nature of the “understanding” acquired during fourteen-plus years of service to the state and presented here.

III THE STAGE WAS ALREADY SET:

CRISIS has loomed for many years on several critical fronts and the only thing keeping the veneer of control from dissolving under increasingly intrusive public scrutiny was the massive inertia that is characteristic of a huge, complicated bureaucracy with a vital public safety mission, a powerful and politically savvy employees union (CCPOA) and an arcane and feudal structure with a foundation designed for an earlier era. Compounding this anachronistic nightmare is an intolerant organizational tradition that is grounded in the notion that "the Corrections way" trumps all other considerations. Employees who learned and accepted these things became eligible for a seat in the "car." Promotion and success was absolutely linked to this acceptance - and those given a seat were guaranteed a good career in Corrections - and a good life. Corrections culture remained hidebound and complacent for decades. Prisons – especially prisons with the kind of population that California created are a kind of social blight, a symbol of the depth of a societies failures in many ways. Its best for reasonable people to not give this subject too much thought.

INSTITUTIONS were semi-autonomous and Wardens operated like feudal Lords, enjoying prerogatives and an independence that was the envy of their peers in other agencies of the state. Feudal and hidebound, this entity rolled merrily along, and like a huge ball of molasses, it simply steam-rolled its opposition sucking some in to become part of itself and spitting out those who resisted. Although critics were everywhere, it remained resilient - even to occasional meddling by the 9th Circuit Court - and its budget was left essentially unchallenged.

WHEN the first important medical class action litigation alleging constitutionally inadequate psychiatric care for class members began, HQ managers, without consulting field "commanders" (i.e., the CMOs) in any meaningful way cut unbalanced (unfavorable to the CDC) deals and agreements with the Plaintiff's attorneys. The Orders and Consent Decrees that followed began the painful process of self-discovery for Corrections officials. That’s because, having bit off more then we could chew, our inability to deliver on the promises made to the Court (failure to implement Corrective Action Plans-‘CAPs’) caused one institution after the other to belly flop until, collectively, CDC’s efforts began to look like a demonstration of “The Domino Principal.” When the Feds finally threatened to place the entire organization under Federal receivership with a Special Master calling the shots, the leadership started to pay attention to something they avoided and denied for years – the role of correctional “culture.”

IN fact, that same “culture” is the primary obstacle and always has been - if someone had only been courageous enough to admit it. Today, that is practically all we do talk about. That and things like “ethics”, “values”, “integrity” and how “snitches” are really – REALLY – good people! My, how things have changed. The only grudging holdouts are a group of diehard Wardens and some Warden-wanna-bes who see the payoff for 20 – 30 years of ladder-climbing dissolving away before their very eyes, as Central Office control over field institutions continues its relentless advance.

IV WARDENS: PARADISE LOST:

CORRECTONS officials also discovered budgetary inconsistencies and over inflated costs, excessive overtime expenditures and other gross inefficiencies that revealed aspects of the Wardens managerial capabilities. When control agencies began to threaten the Corrections budget as well, all pretences about their ability to resist the Second Law of Thermodynamics (entropy) began to crumble – along with the worn out values of its now untenable “culture.” Discovering its fundamental dilemma, the reality of having to somehow bring this "old-world" and very cumbersome organization quickly into the 21st Century, the appointed elite - mainly the Wardens - were caught by surprise. Simply stated, the fundamental dilemma confronting the Wardens are the new policies and mandates flowing from a now unsympathetic HQ to bring this old, tradition bound, maladaptive and very unwieldy Aircraft Carrier of an organization quickly into the 21st Century.
Attaining this lofty goal, however, requires Wardens, Executive Staff and all other managers to abandon the culture that has brought so much discredit to an organization of otherwise good and capable people. The primary obstacle has been the sustained resistance by some Wardens and their “cultural allies” to any kind of meaningful acceptance of that goal – outside of a lot of huffing and puffing and token lip service.

THEIR resentment and passive (and active!) resistance gave way, finally, to tacit acceptance – but then only grudgingly. Unfortunately, instead of recognizing the positive and adaptive value of culture shift some Wardens remain angrier then ever. Although suppressed and well covered in many cases, their anger is revealed by a pervasive and thinly veiled hostility - to medical concerns, in particular. The reason is because “medical” [issues] have been the specific catalyst for having to learn all the tap dancing silliness and - even worse - the loss of their coveted prerogatives, to which many still feel they are entitled.

FOR Chief Medical Officer/Health Care Managers who depend on the good will of the institution’s Warden and on the general health of that relationship this situation can be – and has been for many – disastrous. At this institution the reasonably capable Warden retired about one year ago and managing medical operations there has been very difficult since then.

BECAUSE the Warden is the “leader” at the institutional level and because the leader sets the general tone for the organization, an atmosphere bitter and resentful toward things “medical”, the medical manager in particular, has become a pervasive and persistent force in many CDC institutions.

BECAUSE the relationship with the Warden is the single most important factor for successor or for failure for a conscientious CMO/HCM, this writer is has been compelled to write "memos" for record and for historical informational purposes documenting factual events that reveal the realities of working under circumstances of passive hostility. This must be done to protect the institution’s medical staff and medical operations – operations for which the CMO/HCM is responsible. If the leadership at HQ knows these things - and they do - they certainly keep it to themselves. In spite of the Warden’s representations of support for “medical” or how things are crafted for appearances it is obvious that very little has changed at all – least of all, bad attitudes.

V CAN IT GET ANY WORSE? - THE PLO RAISES THE ANTE:

BY around January, 2000 the Prison Law Office (PLO) had discovered CDC’s Achilles Heal. Other, equally punitive Class Action driven medical litigation soon followed. Since then, Corrections has had a succession of Directors and a new "Division" for Health Care Services and new health care missions.
IMPLEMENTING new health care missions, however, is another story. It really, really does involve resolving the Custody- Health Care conflicts that sprang from the intolerant, non-adaptive "correctional culture" – a culture that wants to have it both ways. That is, they will declare their support for change – but they do not want to actually do anything about it. There exists an institutional denial of reality so massive it has confounded four successive Deputy Directors of health care - so far. Also, so far, it gets quite a lot of "lip-service" but no one wants to seriously - and definitively - deal with it. Once again accounting for the reason this writer is obliged to write so many time consuming memo documenting the structural (and other) obstacles that frustrate reaching our stated goals. I hope, eventually, to stimulate our leadership into effective realty testing.

AN excellent overview of this subject, including recommendations for change, can be found in the "EXECUTIVE SUMMARY" of the recent “CALIFORNIA PERFORMANCE REVIEW" report. It provides an excellent account of the background and captures a vivid portrait of this organization’s culture and values. Until, that is, it takes up the question of Health Care delivery.

VI ROBIN DEZEMBER RESURECTS HIMSELF-AND HIS AGENDA:

IN PARTICULAR, the question of what to do about Corrections’ increasingly unwieldy and frustrating health care delivery system is taken up once again in the “RISK MANAGEMENT AND HEALTH CARE SERVICES" section of the “INDEPENDENT REVIEW PANEL’S” report. The report itself refracts factual information through the personal prism of a well known “stakeholder” which is unabashedly designed to support the recommendations that author makes later. What this report omits –or neglects to reveal – is that, in essence, it is a minimally redacted recitation of an agenda long espoused by this author-“stakeholder.” The recommendations made here were considered in the past and were rejected - if not discredited, as well. Also, the representation that the Panel's conclusions were collectively arrived at is, frankly, deceitful. The “recommendations” have, ostensibly, already been accepted and are on the cusp of being implemented - if the report is accurate. If correct, embarking on such a path would lead to further trouble by compounding the problems we already have. This is a subject so profoundly significant and important to any discussion about health care delivery it warrants separate cover. Therefore, I will reserve further comment for now.

VII “BAD DOCTORS” ARE LIKE “RUMORS OF MY DEATH..etc.”:

SYMPTOMS of our sickness are everywhere:
• Physicians who find themselves overwhelmed, become jaded and, unable to change anything, then complacent and lazy.
• Nurses who have similar situations and who come to think that “giving report” means waiting for the next shift to “report”, then leaving.
• Medical Technical Assistants (MTA) who are powerfully conflicted about their role. Caught between “custody” responsibilities and their responsibilities as LVN-level nurses (a dead end job without additional advanced education and training), they frequently over-identify with the Correctional Officer role, correctly seeing a brighter future for themselves on the custody side.
• And on and on…………..

IT should be obvious that all the “Quality Assurance” in the world cannot correct this system, which is flawed by design, because QA is a tool to “tune up” and make more efficient and “better” a product that is already at least “adequate” from a system that is already at least functional. Our “system” of health care delivery is neither adequate nor functional and needs almost total redesign before “Continuous Quality Improvement” techniques can be applied with effective outcome.

HOWEVER, here may be found an opportunity to actually begin a focused discussion of why the delivery of health care to our inmate population is generally weak, frequently inadequate and why all the good will in the world can only lead to one outcome: desk-pounding frustration. And it has little or nothing to do with "bad doctors” allegations. Such allegations are dishonest and deceitful acts of desperation - and a temporary refuge from responsibility for failures for which the principal leadership elements should be held accountable.

HERE, we reach the root of the problem and touch its very heart. It is not “bad doctors” that we need to focus on – it is bad managers - the principals whose policies and decisions led us down a “primrose path.” It is their reliance on the opinions and pronouncements of outsiders having only token understanding about field conditions as they effect medical operations – rather then their own field “experts.” It is their failure to follow and enforce their own policies, procedures and goals about which numerous pronouncements and promises were made. These are some of the things that brought us here. Traveling down the chain of authority from policy to operational execution, the medical division leadership at HQ failed to resolve glaring ambiguity that quickly emerged at many levels, and, even worse, then refused - or otherwise failed (frequently by simple neglect!) – to support the Regional Administrators who were far “outclassed” by their counterparts from the very beginning and then the Chief Medical Officers - many of whom became victims of a cynical ploy that assigned them the functional title “Health Care Manager,” making them conveniently available to scapegoat. These failures compounded geometrically at each successive level and, astonishingly, with each passing year. Failure to resolve deeply ingrained conflict has led us, inexorably, to crisis. Crisis was inevitable. And that is where I began this note.

VIII IS IT A “WRAP” YET?:

MY INTENT has been to try to represent the atmosphere of frustration and resistance to change in which all professional class employees must work 8 - 10 hrs/day. Doctors and other professionals are difficult to recruit. They are unaccustomed to practicing in an atmosphere that may be brutal, abusive “negative”, both by its very nature and by definition. When recruited doctors frequently anticipate this and decline to "sign on." The vast majority of recruitment solicitations go unanswered. Those who decide to “chance it” and then (frequently!) become discouraged are soon faced with the difficult decision about continuing – a decision which requires some kind of personal reconciliation with the "paranoiagenic" and very negative correctional environment, if they stay. They will have to adapt to it.

MANY of those who stay have few options by then because they may have sold their practice or face similar situations. If they want to continue practicing their profession they must do so for individuals who are frequently hostile, angry, contrary and ungrateful. Custody staff are mostly contemptuous and resentful of (medical) staff whose job is "helping" inmates - and the physical facilities are mostly austere and lacking much of the technical capability professionals on the outside take for granted.

IN many ways, doctors and other committed professional staff working in our state prisons are "heroes" -whose motives stem from other - perhaps more humanistic - considerations. (elaborate later)

MY attempt to describe the circumstances in our prisons confronting medical professionals - most of whom are totally unprepared professionally, emotionally and physically – can never really be adequate. An account of the impact of a large organization’s culture on our ability to deliver health care to inmates – an underclass of “throwaway” ex-citizens people don’t care much about anyway – becomes more like a curious tale – abstract and impersonal. “How awful! tisk, tisk!”

WHEN contemplating this I remember Solzhenitsyn’s account of the Soviet scientific expedition in Siberia and the prehistoric fish – and feel somehow better. Of course! – one cannot “teach” insight!

IF any reader has not yet been overtaken by boredom or cynicism and is still interested and wants to learn more, please ask the undersigned. If inmate health care doesn’t much interest you –remember – finally we are taxpayers, you and I. We give these people our money – a lot of our money – to run our prisons. We have every right to demand accountability.

I AM, by choice, a public "servant”. When things that the people hold me responsible for are wrong the standard for me is greater – and I have a duty to do what is necessary to correct them.
I serve - and I expect to be held accountable for how I serve.

I demand nothing less from and for my superiors.

X POSTSCRIPT; INTO THE FUTURE:

IS it too late to recover, reconvene, reconstitute and redirect toward an adaptive and credible vision?
I don’t know the answer.
It depends on the understanding of our partners for change – mainly the plaintiff’s attorneys (PLO) and the 9th Circuit Court of Appeals - and their willingness to let us start over again. We should at least argue that doing so is reasonable because:

1. It is to our credit that we do not want to abrogate our responsibilities and abandon the great task we have been given and which is our duty to deliver to the people repaired and operationally functional.

2. “Receivership” is a very bad choice for all concerned for numerous and obvious reasons – not the least of which is the inevitable multiplied costs.

3. It is my opinion that the unfortunate selection of recent Deputy Directors of Health Care who were unprepared or unable to do the job for one reason or the other does not mean CDC with all its vast resources cannot produce one single good and competent manager for CDC medical affairs, statewide. Such an assertion is ludicrous, on its face. But that seems to be what some at our HQ are alleging.

Rx: Ten Parallel Tracks to Health:

To be provided later and under separate cover.

MICHAEL L. FRIEDMAN, MD
Chief Medical Officer
Monterey
4/18/05

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