Office of the Chief Medical Examiner assessment and revitalization plan

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December 2009
OFFICE
OF THE CHIEF
MEDICAL EXAMINER
ASSESSMENT AND
REVITALIZATION PLAN
Board of Medicolegal Investigations
Subcommittee for Assessment and Revitalization
~\ OFFICE OF THE CHIEF MEDICAL EXAMINER
,~l Board of Medicolegal Investigations
Dean, OU College of Medicine
Dewayne Andrews, M.D. (Chairman)
Vice President for Health Affairs,
OUHSC
Executive Dean, College of Medicine
940 Stanton L Young, BMSB 357
OKC, OK 73104
405.271.3223 Office
Oklahoma Osteopathic Association
C. Michael Ogle D.O.
PO Box 1467
Enid, OK 73702.1467
580.233.9310 Office
Oklahoma State Medical
Association
Douglas Stewart, D.O., MPH
Dept. of Pediatrics
4502 E. 41st St.
Tulsa, OK 74135
918.660.3400 Office
Commissioner of Health OSDH
Rocky McElvaney, M.S.
Oklahoma State Department of Health
1000 NE 10th
OKC, OK 73117
405.271.4200 Office
MEMBERS
Oklahoma Funeral Board
Christopher Ferguson (Vice Chairman)
Director-Oklahoma Funeral Board
4545 N Lincoln Blvd #175
OKC, OK 73105
405.522.1790 Office
Oklahoma State Bureau of
Investigation
Charles Curtis, Deputy Director Oklahoma
State Bureau of Investigation
6600 N Harvey #300
OKC, OK 73136
405.848.6724 Office
Dean/Provost - OSU College of
Osteopathic Medicine
Karlis Sioka, D.O.
Chairman Department of Pathology
OSU College of Osteopathic Medicine
1111 W 17th St
Tulsa, OK 74107
918.561.8201 Office
Oklahoma State Bar Association
Shanda McKenney, Esq
Love, Beal & Nixon PC
6621 N Meridian
OKC, OK 73116
405.720.0565 Ext 125 Office
TABLEOFCONTENTS
Executive Summary---------------------------------------------------------------- 3
HistoricaI I nformation-------------------------------------------------------------4
Problem Statement----------------------------------------------------------------7
Identified Deficiencies------------------------------------------------------------8
Accreditation--------------------------------------------------------------------------9
AdministrativeLeadership-----------------------------------------------------------------------------11
Oversight-----------------------------------------------------------------------------15
BacklogandReportingIssues----------------------------------------------------------18
EquipmentNeeds----------------------------------------------------------------------20
EvidenceandPropertyHandlingProcedures---------------------------------------------24
Facilities------------------------------------------------------------------------------26
MedicolegalDeathInvestigativeOperations---------------------------------------------30
PersonnelShortages-------------------------------------------------------------------33
PolicyandProcedureDevelopment------------------------------------------------------36
TrainingNeeds------------------------------------------------------------------------38
Budget/ FiscaIRequirements-----------------------------------------------------41
Implementation Plan--------------------------------------------------------------45
Summary---- ---------- ------ --- ------- ---- --------- ----------- --- --- ---- ----- --- ---51
Attachments:
National Association of Medical Examiners Report
University of Central Oklahoma ProposedMedical Examiner Facility Site
Sourcesof Information
2
EXECUTIVE SUMMARY
In the late summer of 2009, at the request of Governor Brad Henry, Speaker
of the House of Representatives, Chris Benge, and President Pro Tempore of
the State Senate, Glenn Coffee, a subcommittee of the Board of Medicolegal
Investigations was created to draft a proposal for the revitalization of the
Oklahoma Office of the Chief Medical Examiner (OCME). The challenging
assignment was to draft a proposal for the Governor's Office and Oklahoma
legislature for an implementation strategy that would enhance services and
update antiquated facilities and equipment, in addition to other strategies for
restoring national accreditation.
The subcommittee has created this implementation strategy detailing steps
that must be taken to accomplish the goals delineated above. Some steps
involve changes in law. Others require financial support from general
revenue funds allocated from the state legislature. Internal administrative
actions can be used to implement the remainder of the subcommittee
recommendations.
This proposal was written to provide State leaders with a strategy that will
revitalize the OCME through sound management principles,
recommendations from subcommittee members, medicolegal board
members, legislative personnel and professionals within the existing medical
examiner's system. Historical events associated with the OCME were
evaluated as factors in the decision making process.
The OCME's mission is to protect the public health and safety of Oklahomans
through the scientific investigation of deaths as defined by state statutes.
This process involves death scene investigation and Medicolegal autopsy
complementing the activities of law enforcement agencies and public health
officials. It is therefore a critical component of Oklahoma State government
that demands the highest degree of professionalism and medical expertise.
Both historical and recent events have eroded the Agency's credibility and its
capacity to meet the expectations of state citizenry and government officials
alike. This document proposes the changes needed to restore the
community's trust in one of Oklahoma's most fundamental services.
Finally, the report contains proposed draft legislation for the statutory
changes necessary to effectively accomplish the goals listed above.
3
OFFICE OF THE CHIEF MEDICAL EXAMINER
HISTORICAL INFORMATION
The Oklahoma Medical Examiner system came into being as the Board of
Unexplained Deaths in 1961, largely due to the 'activities of a woman named
Nannie Doss, Oklahoma's first convicted serial killer. Dr. T.W. Violett served
as the first Chief Medical Examiner from 1965 through 1967. In 1967, the
Agency was renamed the Board of Medicolegal Investigations with Dr. James
L. Luke serving as the Chief Medical Examiner. The Agency had four part-time
employees, a budget of $75,000, and an average annual autopsy total
of 205. Doctor Luke left the office in 1971.
A. Jay Chapman; M.D., was appointed the next Chief Medical Examiner and
served until the fall of 1982. Under his tenure, the statutes pertaining to the
medical examiner's office were enacted and physical offices were acquired at
813 N.W. 15th in Oklahoma City. The budget was increased to $349,000,
autopsies increased to more than 620 annually, and the Agency had six full-time
employees. In 1971 the Agency also hired its first toxicologist, Dr.
Bonny Orndorf, who was unfortunately murdered in the early summer of
1972 while on a camping trip in Alabama.
In December 1973, the Board of Medicolegal Investigations established
administrative and fiscal control over the Agency and in 1975 the Agency
moved to wing 4-B of University Hospital. Concurrent with that move was the
introduction of field investigators to the Oklahoma City Metropolitan area.
The Eastern Division of the Medical Examiner's system was established in
1976 and opened for operations at 2421 W. 41st in Tulsa. This first location
was the previous Admire Auto Parts, and was locally referred to as the "Body
Shop". In that same year, the Agency was successful in obtaining a "local
works" grant for $700,000, and construction began on a new building in
Oklahoma City. 'The morgue portion of the Central Office was completed in
1978 and autopsy operations were then moved to 901 N. Stonewall. The
remainder of the building was completed in 1980 and Oklahoma City
operations were then under one roof.
4
In 1981 the new Eastern Division office was completed on the campus of the
Oklahoma State University College of Osteopathic Medicine located at 1115
W. 17th, in Tulsa. The next year, Dr. Robert Hemphill joined the Agency as
the Deputy Chief in charge of the Eastern Division.
In 1986, facing funding problems, the Agency made an attempt to generate
revenue by charging local governments $100 for each autopsy that was
necessary in a death that occurred in that jurisdiction. A lawsuit was filed
against the Agency by several municipalities, including Oklahoma City.
Ultimately, the Oklahoma Supreme Court found the fee unconstitutional in
the spring of 1987.
In 1990, the state legislature authorized over $300,000 in additional funding
to address personnel needs, replace obsolete equipment, and fund a
substantial increase in transportation costs for the Oklahoma City area
necessitated by the withdrawal of AMCAREfrom its contract with the Agency.
The same year, the Agency was also approved for the Fellow in Forensic
Pathology training program, a post-graduate fellowship training program that
has produced eight forensic pathologists, to date.
During 1992, the Agency was forced to spend over $94,000 to make
emergency roof repairs to both the Oklahoma City and Tulsa buildings. This
expenditure was closely followed by another expenditure for new equipment
for the Tulsa office.
Legislation in 1994 authorized the Agency to begin receiving monies
generated by cremation permits directly into its revolving fund. The same
legislation decreased the total regular annual appropriation by a like amount.
In 1996, funding and one FTE were appropriated for a third forensic
pathology position in the Tulsa office. The same year, the Oklahoma State
University College of Osteopathic Medicine and OCME began preliminary
studies with regard to incorporating a much needed addition to the Tulsa
office, with the expansion of the OSU-COMcampus.
Funding for the Tulsa addition was appropriated in 1998, 1999, and 2000,
totaling $1.193 million. This allowed for additional space and renovation of
the existing building. During this time period, the Agency began
implementing the regional investigator program adding the first four of 19
5
rural medicolegal investigators. Also appropriated at this time were funds to
make much needed adjustments to the professional staff positions of the
Agency. In 2000, Deputy Chief Medical Examiner Dr. Robert Hemphill,
retired and Ron Distefano, D.O. was promoted into that same position to
provide leadership for the Eastern Division of the Agency.
After several years of increasing appropriations, the Agency, along with the
entire state, suffered financial setbacks in 2002 and 2003. While receiving
six additional FTE for regional investigators, the total reduction in
appropriations for this period was over $464,000. The Agency weathered
these cuts without furloughing employees, however, budget cuts significantly
reduced the number of bodies from the rural areas that were examined in
Oklahoma City and Tulsa.
In 2004, the Agency began a new era as Chief Medical Examiner Dr. Fred
Jordan retired and returned to his home in Maine. Jeffery Gofton, M.D.,
became the Chief Medical Examiner on July L", 2004. During his tenure, the
Agency maximized the regional investigator program to station lay
investigators across the state by using additional FTE and appropriations.
In 2008, Dr. Gofton left the Agency to accept a position in Virginia. Following
his departure, Eric Duval, D.O., assumed responsibility for the Agency on an
interim basis. In early 2009, the Board of Medicolegal Investigations
appointed Collie Trant, M.D. as the new Chief Medical Examiner for the State
of Oklahoma.
6
PROBLEM STATEMENT
Controversy has been associated with the aCME since the 1970's when
the Chief Medical Examiner performed autopsies in an open field in an effort
to draw the attention of media and state legislators in hopes of securing
funding for a new facility. Recent problems center around the failure of the
Agency to secure reaccreditation through the National Association of Medical
Examiners (NAME) due to shortages in personnel, antiquated equipment, and
an inadequate and aging headquarters facility. This was followed by
revelations prompting a Grand Jury indictment of the Agency's former Chief
Investigator. Further, the statutory structure of the agency, in which the
Chief Medical Examiner is directly responsible for administrative functions as
well as medicolegal functions, does not allow for proper oversight of all
agency functions, particularly administrative functions such as fiscal
management and human resources.
7
IDENTIFIED DEFICIENCIES
The Board of Medicolegal Investigations Subcommittee on Agency
Assessment and Revitalization has identified the following areas of the
OCME as critical areas for review. The categories are not listed in
priority order:
• Accreditation
• Administrative Leadership
• Oversight
• Backlogs - Reporting Issues
• Equipment Needs
• Evidence and Property Handling Procedures
• Facilities
• Investigative Operations
• Personnel Shortages
• Policy and Procedure Development
• Training Needs
8
ACCREDITATION
In April 2009, an audit of the OCMEwas conducted by NAMEfor purposes of
reaccrediting the Agency. During the audit, an excessive number of
deficiencies were identified in both the Oklahoma City and Tulsa offices. The
majority of the deficiencies were related to the inadequate facilities and
staffing shortages. However, "a chronic lack of funding" was mentioned by
NAME as an underlying factor in operational deficiencies. This resulted in a
failure to meet the minimum criteria established for accreditation.
NAME recommends that forensic pathologists perform no more than 250
autopsies annually in order to devote the time and attention required for
appropriate medicolegal descriptions, reports and related mattes. Currently,
OCME pathologists are averaging approximately 350 autopsies per year,
significantly exceeding the recommended maximum number.
Because of this high caseload and staff shortage, the agency is forced to limit
the types of cases for which it conducts autopsies, thus excluding certain
categories of cases which may merit more thorough investigation.
The OCMEcurrently has a 1,550 case backlog of autopsy reports. This delay
in processing is the source of numerous complaints from families awaiting
death certificates needed for insurance purposes and prevents closure for
grieving family members. This, too, can be attributed to a shortage of
personnel such as toxicologists needed to perform laboratory examinations of
biological specimens, transcriptionists to type autopsy reports, forensic
pathologist, pathologist assistants, and medical records staff.
The NAME auditor cites the core problem with the OCME as "a lack of
funding" to support the Agency. It should be noted that these problems have
a long history and precede the arrival of the new Chief Medical Examiner, Dr.
Trant, who has already initiated corrective actions in several areas where
personnel and funding allow.
9
Recommended Course of Action
If a renewed facility and additional personnel are added as suggested by the
Subcommittee, reaccreditation will be forthcoming. Reaccredition will not
happen overnight. Improvements are still needed and some will take years,
while others may take only a few days. Some recommended changes come
with a hefty price tag, while others are fairly inexpensive. The Subcommittee
for Assessment and Revitalization recommends that the cost associated with
revitalization be spread over three years so that the fiscal impact to the State
may be minimized.
Depending on general revenue funding levels during the FY-2011 legislative
session, the aCME anticipates having the accrediting organization return to
Oklahoma at the earliest possible date for reexamination of the aCME
accreditation status. The Board of Medicolegal Investigations intends to work
diligently to correct the numerous deficiencies responsible for the loss of
accreditation.
10
ADMINISTRATIVE LEADERSHIP
After consideration of historical information, the findings of the Multi-County
Grand Jury, and discussions with current legislative leadership, it is the
recommendation of the Board of Medicolegal Investigations Subcommittee
for Agency Assessment and Revitalization that in order to provide the Agency
and the Chief Medical Examiner with much needed administrative structure
and assistance that a Chief Administrative Officer be appointed to assume
responsibility for all Agency administrative functions.
The committee recommends that the statutes authorizing the creation of the
Office of the Chief Medical Examiner be amended to create an organizational
structure which provides for the addition of a Chief Administrative Officer
with equal authority to that of the Chief Medical Examiner. The Chief
Administrative Officer would be appointed by and also serve at the pleasure
of the Board of Medicolegal Investigations. The Board would serve as a
check and balance system with authority to override any act by the Chief
Administrative Officer and/or Chief Medical Examiner that jeopardizes the
integrity, efficiency or fiscal viability of the Agency. Discrepancies would be
addressed by the Board through a simple majority vote.
The Subcommittee members want to be clear that they do not question the
medical competence of the Chief Medical Examiners, past or present. These
highly educated and skilled individuals have traditionally provided quality
forensic analysis dealing with cause and manner of death for many years.
However, there is little question that the case loads and forensic duties
associated with the position leave little time for managing the day-to-day
administrative operations of the OCME.
11
The Subcommittee recommends the following for qualifications
and key characteristics of the Chief Administrative Officer:
The candidate for this position shall have the following qualifications
including, but not limited to; being an individual of high integrity, who
possesses a masters degree from an accredited college or university with a
minimum of five (5) years experience serving in an executive leadership
capacity with a private or government organization having at least 50
employees and an annual operating budget of at least five million dollars.
Preference will be given to those individuals who are skilled, experienced or
have specialized training in the areas of business management, employee
evaluation procedures, human resource practices, budget preparation and
fiscal issues, procurement law, computer skills, legislative process and/or
liaison experience, inventory control, public relations, customer service,
records management, continuing education and employee training; strategic
planning, organizational skills, law enforcement, verbal and written skills.
The Board of Medicolegal Investigations shall be the deciding entity on
whether a person's qualifications meet the minimum standards for
administrative experience. Input from the Chief Medical Examiner shall be
considered in the deliberations of the Board regarding this matter. Key
characteristics shall include promoting quality through established
performance standards, appraising staff accomplishments using developed
and consistent standards, taking action to reward, counsel, and/or remove
employees, as appropriate. Additional important characteristics include
valuing cultural diversity and other differences and fostering an environment
in which people who are culturally diverse can work together cooperatively
and effectively in achieving organizational goals, while fostering commitment,
team spirit, pride, trust and group identification.
The successful candidate must be capable of taking steps to prevent
situations that could undermine Agency goals, and must be capable of
resolving conflicts in a positive and constructive manner using accepted
human resource standards. This includes promoting labor/management
partnerships, dealing effectively with employee relations matters, tending to
office morale and organizational climate issues, handling administrative,
12
labor management and EEO issues, and taking disciplinary action where
appropriate. The Chief Administrative Officer must be able to work
effectively with the Chief Medical Examiner.
The Subcommittee recommends the following duties for the
Chief Administrative Officer:
The Chief Administrative Officer of the OCMEis the Executive Director of the
Agency and is responsible for the day-to-day operations and management of
the Agency. The Chief Administrative Officer shall design and implement
strategies that maximize employee potential and foster high ethical
standards in meeting the Agency's vision, mission, and goals. He/she shall
provide leadership along with the Chief Medical Examiner in setting the work
force's expected performance levels, commensurate with the organization's
strategic objectives, by inspiring, motivating, and guiding others toward goal
accomplishment. The Chief Administrative Officer shall make timely and
effective decisions that produce results through strategic planning,
implementation, and evaluation of programs and policies. The Chief
Administrative Officer, or their appropriate designee, shall be responsible for:
1. Human resource and staffing issues, such as the employment and
hiring process, including the appointment, promotion, demotion
and/or discipline of any personnel on the operational and
administrative side of the Agency;
2. Budgeting issues such as the reporting of financial documentation
and quarterly budgetary review by the Board;
3. Reporting of Agency assets and other documents required by the
State Auditor's Office;
4. Purchasing in accordance with the Oklahoma Central Purchasing Act;
5. Assisting families, legislators, and the public in procuring requested
information;
13
6. Processing death certificates, out-of-state and cremation permits in
a timely manner;
7. Establishing professional policies and procedures addressing all
non-clinical areas of Agency operations;
8. Establishing written qualifications and duties for each staff position
within the Agency;
9. Providing at least quarterly information to the Board of Medicolegal
Investigations regarding operational statistics, advancement in
meeting Agency goals and benchmarks, critical issues affecting the
progress and success of the Agency, personnel issues affecting
operations, and all formal complaints against the Agency;
10. Providing minutes of all Board meetings for public inspection;
11. Directing administrative staff in adhering to all State and Federal
laws associated with human resources, procurement, budgeting
issues, promulgation of administrative rules, and destruction of
records no longer of value to the Agency.
12. All other duties prescribed by the Board of Medicolegal
Investigations.
The Chief Administrative Officer is a full-time position and is eligible for state
benefits. The position may require the individual to be available outside of
normal business hours. Compensatory time is provided for hours worked
outside of normal business hours. A state-owned cellular telephone and
laptop computer will be provided. Some inter-state and intra-state travel
and overnight stays will be required.
The Chief Administrative Officer shall maintain a clean driving record and
valid driver's license as a condition of employment in order to properly
perform the duties of the office. Salary is set by the Board. This is an at-will,
unclassified position and the employee is subject to dismissal with or
without cause.
14
OVERSIGHT
Concerns about lack of proper oversight of the aCME prompted legislators to
propose legislation during the 2009 legislative session, to dissolve the
current Board of Medicolegal Investigations. The proposed legislation would
have placed the Agency under the direct supervision of the Governor's office.
The committee does not believe this provides a satisfactory solution, and
proposes alternative strategies to address the concerns.
There are presently no statutory mandates or administrative rules requiring
the aCME leadership to provide necessary data and information regarding
Agency operations, such as fiscal matters and personnel issues, to the Board.
As a result, the Board was often kept in the dark regarding issues that might
tarnish the reputation of the Agency, or reflect negatively on medical
examiner leadership.
In light of recent events, the Board has also taken a more aggressive role in
Agency operations and has requested more frequent meetings to address the
multitude of issues currently facing the aCME. Board members have
established a closer relationship with the Chief Medical Examiner in an effort
to resolve problematic issues through administrative means.
The current Chief Medical Examiner, Dr. Collie Trant, has been extremely
receptive to Board involvement in resolving problems associated with the
Agency. The Board of Medicolegal Investigations has established a
relationship with Dr. Trant that is moving the aCME in a positive direction.
15
RECOMMENDED COURSE OF ACTION
The Board of Medicolegal Investigations is established and governed by the
63 0.5. §931, et. seq. It is comprised of eight members, as follows:
• The Director of the Oklahoma State Bureau of Investigation, or a
designee
• The State Commissioner of Health, or a designee
• The Dean of the College of Medicine of the University of Oklahoma, or
a designee
• The Dean of the Oklahoma State University College of Osteopathic
Medicine, or a designee
• The President of the Oklahoma State Medical Association, or a
designee
• A funeral director, as provided by 59 0.5. §396.3 , appointed by the
Oklahoma Funeral Board
• The President of the Oklahoma Bar Association, or a designee
• The President of the Oklahoma Osteopathic Association, or a designee
It is the recommendation of the Oklahoma Board of Medicolegal
Investigations, Assessment and Revitalization Subcommittee, that the Board
of Medicolegal Investigations remain as the governing body of the State
Medical Examiner's Office, in its current composition. The current Board is
comprised of individuals who are highly skilled and experienced in their
respective disciplines. The Board is extremely diverse in its statutory design,
and its members have a broad range of backgrounds capable of addressing
the various issues commonly associated with medicolegal investigations.
The Subcommittee further recommends that an additional position be
statutorily added to the Board of Medicolegal Investigations to include the
16
Director of the University of Central Oklahoma Forensic Science Institute, or
a designee. This position is currently held by Dr. Dwight Adams, former
Director of the Federal Bureau of Investigation forensic laboratory in
Quantico, Virginia. Dr. Adams, specifically, would bring additional
perspectives and expertise of the highest degree to the Board in the areas of
accreditation, forensic laboratory leadership, and managerial skills. He would
be an invaluable asset to both the aCME and the State of Oklahoma.
It is the Subcommittee's position that placing the aCME under the direct
supervision of the Governor's Office would do little to change the much
needed continual oversight that is necessary to address the issues plaguing
the Agency at the current time. Conversations with the Governor's Office
indicate that Governor Henry's primary interest is the restoration of
credibility and integrity to the aCME and that he supports whatever
methodology is necessary to achieve this goal.
Statutory amendments are also recommended to clarify the powers and
duties of the Board of Medicolegal Investigations so there are no
misunderstandings as to its authority. Other necessary statutory changes
include mandating the aCME to provide specific information critical to the
Board of Medicolegal Investigations during regularly scheduled Board
meetings. This information should include, but not be limited to, budget and
personnel issues, new and existing projects and programs, complaints
against the Agency, and any other information critical to the Board's
statutory responsibilities and the functioning of the Agency.
17
BACKLOG AND REPORTING ISSUES
The aCME has recently been criticized for the extreme number of
backlogged death certificates and autopsy reports pending completion.
This issue has plagued the Agency for some time. Historically, the
Agency has taken as long as two years to produce finalized death
certificates and autopsy findings.
A completed death certificate for a decedent who is subjected to an
autopsy cannot be issued until an autopsy report has been finalized.
Although an incomplete certificate (one that does not state the cause
and manner of death) can be used for burial purposes, the next of kin
must have a completed death certificate in order to claim insurance
and government benefits, settle a probate estate, or initiate certain
legal actions. Best practices show that autopsy reports should be
produced promptly so that completed death certificates can be
generated and provided to the next of kin with minimal delay. NAME
recommends that 95% of autopsy reports be completed within two
months from the time of the autopsy in cases involving homicide, and
within three months from the time of autopsy in all other cases.
The aCME's records indicate that there are a total of 1,550 cases from
2008 and 2009 that remain in "pending" status as of October, 2009.
These are unacceptable statistics and changes must be made to
alleviate these escalating backlogs. As determined by NAME, most of
the backlog can be attributed to staff shortages, excessive caseloads,
inadequate administrative support, and a lack of standardized
operating procedures.
Despite having completed the autopsy, laboratory analysis, and
examination of investigative concerns, there is still no final written
disposition of the case until it is transcribed. It is important to note
that incomplete reports could have a lasting impact on the medical
and/or legal standing of the case.
18
RECOMMENDED COURSE OF ACTION
The Subcommittee for Assessment and Revitalization recommends an
increase in the number of forensic pathologists to reduce the pending
backlog of autopsy reports requiring a physician's attention. The
Subcommittee further recommends establishing standardized policies
and procedures and medical protocols, thereby insuring the timely
completion of autopsy reports commensurate with NAME accreditation
standards.
Administrative personnel are encouraged to consult with NAME in the
development and implementation of policies and procedures
specifically addressing existing case backlogs. Research indicates that
NAME will provide guidance and direction on written standards and
case management. Based on experience with similar issues in other
jurisdictions, NAME recommends the development of policies and
procedures that prioritize delinquent and aging cases. It also
recommends implementation of internal controls to minimize the
manual processing and tracking of cases.
The Agency administration must conduct workflow studies that can
improve the overall efficiency of Agency operations in final case
dispositions. This includes updating procedures, protocols, forms and
documentation used for automated tracking and reporting purposes.
The aCME must redesign autopsy report forms so that completion and
sign-off dates are readily visible in future reviews. Implementation of
quality assurance guidelines will assist in the reduction of case
backlogs and operational efficiencies. It will also promote
accountability by staff in meeting Agency and customer expectations in
case turn-around times.
Finally, the Subcommittee recommends that regular reviews of
pending backlogged autopsy reports occur to address Agency
accountability. Supervisory personnel need to make recommendations
on methods of expediting the closure of all current and future cases in
accordance with accreditation standards. Dr. Trant indicates that
efforts are being made to address some of the Agency's oldest pending
cases, but additional efforts to reduce the turn-around time for all
cases need to be made.
19
EQUIPMENT NEEDS
Historical information and a simple walk through of the Agency provides a
glimpse of the inadequate working conditions and antiquated equipment that
current OCME personnel must utilize. After many years of neglect, some
equipment is either obsolete or subject to break down at any time, leaving
the Agency at a virtual stand-still.
The Subcommittee for Assessment and Revitalization recommends
the following equipment be purchased:
After speaking with many employees within both the Oklahoma City and
Tulsa Offices, the Subcommittee for Assessment and Revitalization has
determined that the following basic equipment is essential to restore
efficiency and accreditation to the office. The equipment needs are broken
down by office and/or department, and include estimated costs for the
procurement of these items. Listed below is the physical location of the
requested equipment. They are listed in priority order, within each
department:
#1 TOXICOLOGY I @
Serving OKC and Tulsa
No. ITEM PURPOSE COST
1 CO Oximeter Instrument Detects body carbon $15,000
monoxide
2 Refrigerators Storage of lab $7,000
specimens
2 Freezers Storage of lab $7,000
specimens
20
1 LCjMS Analysis Instrument Comprehensive drug $400,000
screening
1 Alcohol Analysis Instrument Detects alcohol $60,000
1 Digital X-Ray Machine with X-ray of human
computer and server remains
1 Digital Dictation System Dictation during $28,000
autopsies
4 Rolling Cart Table Systems Body transport $68,000
1 Tissue Tek Instrument Processing tissue $35,000
samples on slides
3 Digital Cameras Pathology autopsy $1,500
Examinations
1 Bariatric 1000 LB Cart For human remains $3,669
1 Tissue Tek Bedding Instrument Embed tissue $10,000
samples in wax
1 Acid Cabinet Chemical storage $1,500
1 Washer and Dryer Morgue coats, scrubs, $2,000
towels
1 Floating X-ray Table X-ray of human $9,600
remains
1 Metal Building to attach to Morgue and autopsy $100,000
existing building in OKC space
21
1 Additional Photo Equipment Pathology autopsy $20,000
Examinations
MEDICOLEGAL
INVESTIGATIONS /
#3
Serving OKC and Tulsa
No. ' ITEM PURPOSE COST 11
>
30 GPSDevices Statewide directions $6,000
60 Uniforms Scene attire $8,100
30 Vehicles Scene response $450,000
#4 MORGUE / TULSA
No. ITEM PURPOSE COST
2 Rolling Cart Table Systems Body transport $34,422
#s OKLAHOMA CITY OFFICE
li 10
No. ITEM
,
i PURPOSE COST
1 Computer Station with sca"n, Use by $1,200
print, and fax capability transcriptionists
1 Multi-Head Scope/Computer/ Viewing of tissue $15,000
Monitor slides by physicians
1 Emergency Generator/ Fire Electricity to building $75,000
Safety
22
1 Multi-Head Scope/Computer/ Viewing of tissue
Monitor slides by physicians
1 Emergency Generator/ Fire Electricity to building $40,000
Safety
Equipment Cost $1,022,991.
Vehicle Costs: $ 450,000
TOTAL1,472,991.00
NOTE:The equipment listed above will only help the Agency regain
accreditation. Future and consistent funding will be necessary to maintain
existing equipment and provide for replacement purchases over time.
23
EVIDENCE AND PROPERTY HANDLING
The aCME has recently experienced criticism for allegedly mishandling
both physical evidence and personal property associated with
medicolegal death investigation. This gave rise to concerns from both
law enforcement and attorneys regarding the integrity of evidence
being processed by State or Federal laboratories or used in criminal
prosecutions.
The Committee proposes the following procedures pertaining to
evidence handling and property control. These procedures will help
ensure that evidence is maintained in such a fashion as to be of value
in legal proceedings and to ensure the return of personal property to
its rightful owner.
24
RECOMMENDED COURSE OF ACTION
The Subcommittee on Assessment and Revitalization recommends the
following actions be taken to correct the problems associated with
evidence handling procedures within the aCME:
1. Establish policy for the maintenance of an inventory system for
property taken into custody, whether it is evidence or forfeitable
property.
2. Comply with all applicable state and federal requirements for
seized or forfeited property.
3. All property must have the chain of evidence properly
documented and recorded in an established database or file.
4. Property to be used in criminal proceedings must be properly
packaged and stored in a secure location.
5. Law enforcement agencies need to be immediately notified when
evidence needs to be analyzed and is available.
6. All handling of personal property or physical evidence needs to
be properly documented for investigative files and future
reference.
7. Routine supervisory inspections of all property and evidence
storage facilities must be made, to ensure that accepted
protocols are being followed.
8. There should be limited and controlled access to personal
property/evidence storage facilities.
9. Funding permitting, the aCME should employ a full-time FTE to
address the continuous receipt of property and evidence.
10. The handling of personal property and physical evidence needs
to be a core part of the basic training for all medicolegal
investigators.
Evidence handling, packaging, storage, and transportation training can
be obtained free of charge from the Physical Evidence Technicians at
the Oklahoma State Bureau of Investigation. These specialists handle
thousands of. pieces of evidence daily and can provide hands-on
training to aCME investigative personnel. The Tulsa Office has
adequate space to properly dry clothing that has been soaked in fluids,
but the Oklahoma City Office does not.
25
FACILITIES
For several years now, members of the Board of Medicolegal Investigation
have advocated for improved facilities, which would address the vast
majority of problems presently associated with the OCME. As a preliminary
matter, there is a critical need for construction of a new facility to replace the
rapidly aging and antiquated structure currently serving as the Agency's
headquarters.
The OCME has medicolegal operations in two physical facilities within the
State. The headquarters is located at 901 N. Stonewall in Oklahoma City,
while a second office is located at 1115 West 17th in Tulsa. According to
OCMEstaff, the Tulsa office seems to be physically adequate to facilitate the
needs of the Agency, for that location.
However, the headquarters facility is grossly inadequate to house existing
staff, let alone a much needed expansion, including additional personnel.
There is also inadequate space for Agency documents and storage of human
cadavers.
The OCME in Oklahoma City has modified the structure through renovation
on several occasions. The much needed training room has been converted
into office space to accommodate the addition of medical and support staff.
This space is insufficient for the current FTE load. However, to
accommodate all available FTE's, additional office space is desperately
needed. Dr. Trant indicates that the Agency is looking into the rental of
portable buildings as a temporary accommodation for existing staff, but
additional permanent office space is necessary to obtain reaccreditation by
NAME.
A recent assessment of the OCMEby NAME left no doubt that the antiquated
facility was a primary reason for this denial of reaccreditation. Coupled with
a severe shortage of personnel the assessment resulted in what has been
described as one of the worst reviews of an Agency in NAME history.
Oklahoma was cited with twenty-two (22) Phase nviolations, and nineteen
(19) phase I violations. NAME accreditation standards allow an Agency only
ten (10) Phase I and zero (0) Phase II violations in order to maintain
accreditation status.
The NAME reaccreditation assessment reported that the 18,500 square foot
OCME headquarters facility has adequate space to accommodate 26
employees. However, the Agency currently houses 37.4 FTE in that area,
and not all available FTE positions are presently filled.
26
RECOMMENDED COURSE OF ACTION
The Board of Medicolegal Investigations, Subcommittee for Assessment and
Revitalization of the OCME, recommends that the Oklahoma State Legislature
approve funds in the amount of 60 million dollars (60M) from the Oklahoma
Capitol Improvement Authority (OCIA), and annual recurring funds to reduce
the 60M bond for the construction of a new OCMEheadquarters facility.
The proposed new facility is critical for meeting the escalating needs of the
OCMEin its effort to restore national accreditation and operational efficiency.
It is anticipated that the project will take approximately three years from
date of approval to complete.
The OCMEis currently evaluating two possible locations in the Oklahoma City
metropolitan area as possible options for construction of a new facility:
Option #1 proposes total destruction of the existing headquarters facility at
901 N. Stonewall, and the reconstruction of a multi-level structure on
existing property. This option provided the advantage of maintaining the
Agency in close proximity to the University of Oklahoma College of Medicine
and other nearby health care facilities. However, the agency would have the
added expense of securing temporary facilities to continue operations while
new construction was occurring.
Option #2 proposes that the Agency to relocate to property on the east side
of the University of Central Oklahoma campus in the City of Edmond,
approximately 13 miles north of the current location. The advantage of this
option is the close proximity to the Oklahoma State Bureau of Investigation
Forensic Science Center, and the University of Central Oklahoma Forensic
Science Institute, both of which are new, state-of-the-art facilities.
It is the position of the Subcommittee that the location of a new facility is
immaterial, so long as it is constructed using state-of-the-art technology, and
is based on "best practices" and "accepted standards" of construction and
27
design by members of the medical examiner's profession and forensic
community. However, option #2 has several distinct practical advantages
over option #1. These advantages include:
• The Edmond location will be located in close physical proximity to the
Oklahoma State Bureau of Investigation (OSBI) Forensic Science
Center (FSC). The OSBI FSC has a large training classroom with
state-of-the-art audio-visual technology, and teaching laboratory
space available to medical examiner personnel.
• The OSBI FSC has a full-service toxicology laboratory with well -
trained and accredited personnel, and updated toxicological equipment
available to medical examiner personnel.
• The OSBI FSC has well qualified physical evidence technicians
available for the handling of violent death investigation evidence slated
for OSBI submittal. This will assist the aCME in maintaining the
integrity of evidentiary items.
• The University of Central Oklahoma (UCO) Forensic Science Institute
(FSI) has planned construction that will include a teaching and
research laboratory for pathology and anthropology that can be
utilized by medical examiner personnel.
• The University of Central Oklahoma has planned construction on a
teaching and research facility for chemistry and toxicology that will be
available for medical examiner personnel.
• The University of Central Oklahoma plan calls for the integration of the
aCME into their forensic science, nursing, criminal justice, and
mortuary science programs for purposes of research, training and
education.
• Offer of continuing education for medical examiner investigative
personnel.
• Association with the University of Central Oklahoma allows the state
medical examiner's office access to the following personnel resources,
as well:
1. Dwight E. Adams, Ph.D. - Forensic DNA Analysis, Laboratory
Administration
2. Thomas Jourdan, Ph.D. - Analytical Chemistry, Nuclear
Forensics, WMD
3. Wayne Lord, Ph.D. - Forensic Entomology, Behavioral Profiling,
Evidence collection and preservation
4. Mark McCoy, Ed.D. - Digital Forensics
28
Construction of a new facility will significantly enhance the recruitment and
retention of members of the forensic pathology profession and toxicological
laboratory experts, both of which are desperately needed for restoration of
national accreditation status.
Conversations with chief medical examiners throughout the nation indicate
that the sharing of resources between university, crime laboratory, and
medicolegal operations is an extremely viable collaboration option and can
have a positive impact on Agency operations and morale.
29
MEDICOLEGAL DEATH INVESTIGATION UNIT
It is essential that appropriate training and equipment be provided to address
various issues within the OCMEDeath Investigations unit.
Due to a lack of formal training, there are currently only two OCME field
death investigators who have national death investigation certification. The
training necessary to obtain such certification should be paid for by the OCME
and should be a mandatory requirement for each and every field death
investigator serving in this capacity. This training should be completed within
a prescribed amount of time in order to provide efficiency and integrity within
the investigative ranks of the OCME.
Equipment for investigative personnel has also become a critical issue
needing immediate attention. Currently, field investigators share vehicles
and cell phones within a designated region. This slows response time to
death scenes and creates logistical issues for management personnel.
Investigators are relying on their own personal desktop computers to store
and transmit information pertaining to their jobs, which can cause a
significant delay in transmitting such information to the OCMEoffices. Laptop
computers that can be transported to the scene are needed for each
investigator so critical information can be documented and electronically
forwarded to a database in Oklahoma City and/or Tulsa for referencinq, as
quickly as possible. GPS devices need to be purchased, installed in Agency
vehicles, and implemented into field investigator protocols to enhance
response times to investigation locations.
30
RECOMMENDED COURSE OF ACTION
The OCME must have a Chief Investigator who has the training, education
and experience to address the multitude of issues dealing with investigative
operations. This person must possess excellent people skills and be
customer service oriented. The Chief Investigator should have supervisory
and managerial skills, and be familiar with human resource rules and
regulations, as they relate to Oklahoma and Federal law. In August 2009,
Dr. Trant appointed Timothy Dwyer as his Chief Investigator.
Generally speaking, Death Investigators are defined as people who work with
medical examiners to obtain and document information on reported deaths,
conduct scene investigations and participate in other aspects of death
investigations as directed by, or in conjunction with, the medical
examiner. In furtherance of this objective, the Subcommittee recommends
training for all OCME Field Investigators in the area of crime scene
reconstruction, blood spatter interpretation and annual membership in the
International Association of Identification.
There are numerous credible death investigators training courses offered by
universities, health science centers, and medical examiner's offices located in
other states.
The Subcommittee on Assessment and Revitalization of the OCME
recommends that training for all death investigators be budgeted for both the
basic and advanced training courses provided by St. Louis University. OCME
should explore the possibility of hosting training sessions in Oklahoma City
for death investigation training if this option is provided by St. Louis
University. The basic training session at St. Louis University currently runs
from $295 to $825 per student, not including travel expenses.
The Subcommittee also recommends that all OCME investigative personnel
receive continuous training in the proper handling and storage of forensic
evidence. The Oklahoma State Bureau of Investigation has full-time physical
evidence technicians who are trained in the efficient handling of evidentiary
items that can provide professional and periodic training to OCME
investigative personnel, at no cost to the Agency. Other organizations also
31
provide this type of professional training, but ata cost to each of its
students.
When funds and facility space become available, the OCME needs to
purchase and install drying chambers for the purpose of preserving items of
evidence which have been saturated with body fluids. Currently, there is no
space within the Oklahoma City headquarters facility to implement this
recommendation.
Additionally, there needs to be a clear and concise understanding of
Oklahoma Statutes dealing with crime scenes, human remains, and
evidentiary items presented to OCME investigative personnel by legal
authorities. In the past, investigators have misunderstood their powers,
duties and responsibilities in these areas. Implementation of these
recommendations will alleviate the sometimes strained relationship between
OCMEinvestigative personnel and law enforcement.
Funds need to be budgeted to procure the following equipment for each
OCMEDeath Investigator:
GPSdevice
Cell Phone (currently being shared)
Vehicle (currently being shared)
Uniform Allowance (currently are only issued three each)
Implementation of the
recommendations will
investigative system.
aforementioned personnel, training, and equipment
substantially enhance the Medical Examiner's
32
PERSONNEL SHORTAGES
The National Association of Medical Examiners (NAME) conducted a
reaccreditation assessment on the aCME in April 2009. NAME
detected an excessive number of deficiencies that prohibited the
agency from obtaining reaccreditation status (19 Phase I and 22 Phase
II). According to Debra Kay, M.D., who conducted the assessment,
the majority of the deficiencies were attributed to the Medical
Examiner facility and a shortage of staffing. {Cover letter page dated
June 8, 2009 and signed by Jeffrey M. Jentzen, M.D., Chairman, NAME
Inspections and Accreditation) Dr. Kay noted in her final report that
"the quality of investigations and autopsies is excellent, but that
personnel have an excessive workload" (Page 1 of final assessment
report written by Dr. Kay to Dr. Jensen).
This shortage in FTEis evident by the backlog of reports, over-time by
investigators, and an unacceptable number of autopsies and viewings
being required from each staff pathologist (Page 3, #15, Inspection
Report on aCME by Deborah Kay, M.D.).
33
RECOMMENDED COURSE OF ACTION
The Subcommittee on Assessment and Revitalization recommends the
addition of the following personnel in order to bring the aCME into
compliance for NAME accreditation. As stated in the "Implementation
Plan" section of this proposal, the increase in personnel can be
phased-in over a period of two years. However, the Subcommittee
strongly suggests that the minimal number of new FTE be approved
for employment as soon as funds permit, in order to reduce existing
backlogs, improve efficiency, and bring the agency into NAME
compliance for reaccreditation.
A total of 30 additional FTE are requested to facilitate the needs of the
State Medical. Examiner's Office. This number includes an
administrator, staff pathologists, pathology assistants, medicolegal
death investigators, toxicologists, a family assistance coordinator, a
cremation technician, medical transcriptionists, security guard, and
support staff for both the Oklahoma City and the Tulsa offices.
Recommended staff includes:
NUMBER POSITION BENEFITS TOTAL
Chief Administrative
Officer
Five Forensic Pathologist $875,000 $260,000 $1,135,000
(5)
Four Medicolegal Death $35,000 $24,530 $238,120
(4) Investigator
Six Forensic Toxicologist $53,000 $28,931 $491,586
(6) (Chemist)
One Toxicology Secretary $28,500 $22,940 $51,440
(1)
34
One Family Assistance $37,000 $25,019 $62,019
(1) Coordinator
Four Pathology Assistant $31,000 $23,552 $218,208
(4)
One Cremation Specialist $28,500 $22,940 $51,440
(1)
Two Medical Records $21,500 $21,229 $85,458
(2) Specialist
One Security Guard $23,600 $21,742 $45,342
(1)
Four Medical $21,500 $21,229 $42,729
(4) Transcriptionist
30 TOTAL
Endnote:
It is strongly suggested that the Agency conduct a criminal history
background check through the Oklahoma State Bureau of Investigation
and a pre-employment drug screen on all future employees. This
procedure will help insure the safety and security of current employees
and the integrity of Agency operations and documentation. OCME
administrators need to adopt a policy that creates a minimum
standard commensurate with nationally accepted human resource and
hiring practices ..
35
POLICY AND PROCEDURE DEVELOPMENT
Policy and procedure reflect the standards of operation and
performance by which employees of the aCME are expected to
perform their assigned duties. Agency employees are expected to
conduct business and regulate their activities in accordance with
Agency policies and procedures.
Currently, the aCME existing policies and procedures do not
adequately address all necessary areas of agency operations. Further,
polices are not adequately communicated to employees or consistently
enforced.
36
RECOMMENDED COURSE OF ACTION
The Subcommittee on Assessment and Revitalization of the aCME
recognizes that Dr. Trant has begun the process of reviewing, revising,
and creating new polices where needed. The Committee recommends
that the newly appointed Administrator be assigned the responsibility
of oversight of administrative policy and procedure development and
enforcement, including annual review to insure that polices and
procedures are in compliance with current laws and technological
advances. It shall be the responsibility of the Agency Administrator to
work with the aCME Hunan Resource officer for the development and
implantation of all personnel policies and procedures. It shall further
be the responsibility of the agency administrator to see that all agency
employees are familiar with these policies and procedures and that
they have continual access to them in hard copy and electronic format.
The Chief Medical Examiner shall maintain oversight of polices and
procedures relating to Medicolegal functions, including but not limited
to scene investigations, autopsies, toxicology, and evidence handling
and property storage.
Development of policies and procedures will not only increase morale
within the Agency by providing standardized direction for employees, it
will also aid in preventing grievances within the agency resulting from
the absence of standardized protocols.
The Oklahoma Office of Personnel Management can assist aCME with
this project. Other state agencies like OSB1, University of Oklahoma
Medical School, and the Oklahoma Funeral Board have all offered their
policies and procedures to use as a guide in the development of
policies and procedures that can be modified to meet the needs of the
Agency.
37
TRAINING NEEDS
Providing training for employees not only assists them in the
development of their skills and knowledge, it is also motivational and a
building block to organizational success. It is important for any state
agency to plan the training that its employees may need. Training
must be for the right people and needs to be the right type of training.
One of the best ways to encourage and support employees within the
OCME is through professional development and training opportunities.
Investing in training opportunities provides the tools for proper
execution of the job as it changes or evolves. Sometimes, just getting
employees out of the day-to-day routine of their everyday work
schedule is enough to jump-start their enthusiasm and encourage
them to recommit to their jobs and the Agency. Learning new skills
and interacting with new and different people has a direct impact on
the productivity and atmosphere of the work environment.
Training has to be an integral part of any agency rebuilding strategy.
The rewards become evident through the renewed spirit of employees
and the revitalization of creativity and productivity, and can yield
many positive benefits for the Agency.
38
RECOMMENDED COURSE OF ACTION
Consultation with both medical and investigative personnel within the
aCME has revealed a critical need for appropriate training for both
departments. The Subcommittee on Assessment and Revitalization
recommends annual funds be budgeted for new and continuing
education training.
Pathologists at aCME are trained forensic specialists holding physician
pathologist credentials. However, continuing education through the
National Association of Medical Examiner's (NAME), the
accrediting organization for this profession, is absolutely essential to
rebuilding the reputation and credibility of the Agency. An alternative
to NAME is the American Academy of Forensic Science, another
recognized professional organization offering annual specialized
training in the area of forensic pathology.
Training for the medicolegal investigative staff of the Agency has been
partially addressed under the "Investigative Operations" portion of the
Identified Deficiencies section of this document, which identifies the
need for basic and advanced certification as forensic death
investigators. However, an association with the American Board of
Medicolegal Death Investigators should be established in order to
obtain the necessary credentials and networking resources needed to
restore more competence and credibility to this sizeable workforce
within the medical examiner system. It is recommended that aCME
pay for all investigative personnel to have professional memberships
with the American Board of Medicolegal Death Investigators (ABMDI)
and encourage involvement with the Oklahoma Division of the
International Association of Identification.
Continuing education for staff toxicologists needs to be implemented in
order to maintain compliance with accepted forensic protocols. It is
recommended that all of the existing Toxicologists attend training
conducted by the American Academy of Forensic Scientists, or another
recognized organization in order to promote certification standards
Continuing education for support staff of the Agency, can be obtained
relatively inexpensively in most cases, or at no cost to the agency
39
through the Oklahoma Office of Personnel Management (OPM) or
Institutes of higher Education.
The Subcommittee further recommends that managerial traininq be
provided to staff members in leadership positions within the Agency
This will help to shore up deficiencies in leadership capabilities that are
critical to the organization's success. All of the aforementioned
recommendations are an integral part of the leadership and
administrative process that should be standardized within the OCME.
40