Psychiatr News March 2, 2007
Volume 42, Number 5, page 22
© 2007 American Psychiatric Association
Historic Hospital Rebuilds for New Century
Aaron Levin
Historic St. Elizabeths Hospital in Washington, D.C., breaks ground for
a new building, but legal hurdles slow reforms.
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Patrick Canavan, Psy.D. (left), the new CEO of St. Elizabeths Hospital,
and Stephen Baron, L.C.S.W.-C., director of the District of Columbia
Department of Mental Health, stand before the construction site that will
become the new St. Elizabeths in 2009.
Credit: Aaron Levin
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St. Elizabeths Hospital in Washington, D.C., has broken ground for a new
building and set out simultaneously to reconstruct its organizational
structure and image and how it cares for patients.
St. Elizabeths opened in 1855 as the Government Hospital for the Insane to
provide the "most humane care and enlightened curative treatment of the
insane of the Army, Navy, and District of Columbia," in the words of
19th mental health reformer Dorothea Dix. The hospital also served as a center
for psychiatric research and training for much of the 20th century. Its 32
psychiatry residents now train in one of the few programs not affiliated with
a medical school.
No major new buildings have been built since 1962 because the hospital was
in a political tug of war between the federal government and the city from
then until 1984. That's when the city took control of the hospital, according
to Roger Peele, M.D. Peele, an APA Trustee, trained at St. Elizabeths in the
early 1960s and served as acting superintendent from 1975 to 1977, when money
for a new structure was shifted to renovate an older building.
Construction on the new hospital began on December 19, 2006, and is
scheduled for completion in 2009. Currently the forensic and civil units are
in different buildings but will be combined in the new building. The two
units, which will house 292 patients, will be connected by a corridor and
share some areas. Some forensics patients—although not maximum-security
inmates—will come to the "treatment mall" for therapy, new
hospital CEO Patrick Canavan, Psy.D., told Psychiatric News.
In both units, all rooms will be single occupancy to increase safety and
the dignity of individual patients, said Canavan. Units will have a
semicircular radial plan so that hallways can be viewed simultaneously from a
central nursing station.
"The new building is a huge goal in itself and a metaphor for future
progress," said Canavan.
Canavan, who began work on January 2, was appointed to his post by new D.C.
Mayor Adrian Fenty and is in the process of making changes to improve
care.
Canavan trained as a psychologist and once worked as a ward administrator
in St. Elizabeths' John Howard Building, the forensic unit. However, he has
spent much of the last decade in the Washington, D.C., mayor's office, most
recently as director of the Department of Consumer and Regulatory Affairs.
City government experience gave him an insider's view and an understanding of
how big organizations work, he said.
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Plan of the new St. Elizabeths Hospital. The forensic wing is at top of
plan, civil wing at bottom. Common areas, including an auditorium, connect the
two.
Credit: Einhorn Yaffee Prescott Architecture & Engineering
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"We need to concentrate on how we function as an interdisciplinary
team," said Canavan. "We have to put together an integrated system
of care so that the staff knows each patient will get clinically appropriate
care."
That in turn will mean stabilizing the community side of the D.C. mental
health system by creating acute-care beds in the city's general hospitals and
improving payment systems for providers, said Canavan's boss, Steven T. Baron,
L.C.S.W.-C., director of the city's Department of Mental Health. Baron wants
to strengthen community mental health resources, as well, so patients assigned
to St. Elizabeths' civil unit can eventually live outside the hospital.
"We will also have much more active discharge activities and have
targeted 65 patients for September discharge," said Baron in an
interview.
Besides internal organizational issues, St. Elizabeths faces outside
pressures for change. The hospital has not had JCAHO accreditation for about
two decades. That may represent more of a perceptual than a practical problem,
but it's one Baron and Canavan would like to overcome.
They're also dealing with a 66-page report issued by the U.S. Department of
Justice in May 2006, saying that "numerous conditions and practices at
St. Elizabeths violate the constitutional and federal statutory rights of its
residents."
St. Elizabeths, said the report, "fails to provide its patients
adequate (1) protection from harm, (2) psychiatric and psychological care and
treatment, (3) medical and nursing care and treatment, and (4) discharge
planning and placement in the most integrated setting."
The report was "embarrassing," said Baron, who started his job
just a week after its release. The Department of Justice is working with
hospital and District officials to find some resolution, according to a
department spokesperson.
However, the report has also spurred Baron, Canavan, and their staffs to
accelerate their reorganization.
"We're trying to gather all the pieces of the puzzle together to make
one integrated plan and return to JCAHO accreditation," said
Canavan.
More problematic is a lawsuit filed by University Legal Services (ULS), a
non-profit entity that provides federally mandated protection and advocacy for
the rights of people with disabilities in D.C. (Similar organizations exist in
all states.) The suit grew out of a 2004 ULS report complaining that
"patients and staff at St. Elizabeths Hospital... face serious risks to
their health and safety everyday."
Problems the report cited included "overcrowded wards, inadequate
clinical staff, insufficient medical resources, overworked and demoralized
staff, deficient quality assurance/improvement efforts, inefficient mechanisms
for discharging consumers to community-based alternatives, [and] substandard
physical conditions."
"We see these issues as violations of the Americans With Disabilities
Act [ADA] and also failures of a constitutional duty to provide a safe place
and treatment for patients," said Mary Nell Clark, J.D., the lead ULS
attorney on the case, in an interview. The ADA claim includes failing to make
treatment accommodations for individuals with co-occurring disabilities,
especially cognitive disabilities, and accessibility problems for people with
mobility issues.
"We hope that the new administrators will change things, but we
haven't seen it," she said. "We support Steve Baron's efforts to
expand community care. It's not our goal to see inordinate resources spent on
an institution where people get stuck. From our point of view, the primary
problem is a lack of respect toward patients. We think that Patrick Canavan
and Steve Baron do have respect for patients, and we hope that will work its
way down to the wards."
At present, though, the suit is now in the discovery process, as both sides
give litigation a chance. As it works its way through the U.S. District Court,
some observers feel encouraged by the new regime.
"The problem in the past with St. Elizabeths has been budget problems
and poor management," said Richard Ratner, M.D., president of the
Washington Psychiatric Society and a part-time consultant at the John Howard
Pavilion. "Today, we believe that the mayor is concerned and that
Patrick Canavan is an excellent choice to run the hospital." 
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