B is for Bureaucracy

My first assignment as a newly minted aircraft maintenance officer at Keesler Air Force Base in Biloxi, Mississippi in the fall of 1968 was to follow the new Chief of Maintenance, Colonel James M. Slaughter, around the sprawling organization — flight by flight, shop by shop, office by office.

Colonel Slaughter had been in aircraft maintenance for two decades after having been a Korean War combat pilot. He had quit flying due to an eye condition. Colonel Slaughter was nearing retirement and Keesler was going to be his last duty station. He and I arrived at Keesler the same week. Thus my assignment to follow him around. The familiarization tour, as they called it, lasted for a week. Colonel Slaughter wanted to meet everyone in the organization and understand what each office, shop or flight did or didn't do. I would tag along as a kind of on-the-job training. 

The heart of the maintenance organization was the maintenance control branch. It was run by an experienced Senior Master Sergeant named Buckheiser. Maintenance control was a square semi-circular room of large metal boards with miniature aircraft and equipment magnets positioned and moved around on a detailed diagram/map of the entire maintenance organization. There were also side boards showing the status of each airplane, staffing levels for each office, shop, and flightline maintenance squadron. Three or four more NCOs sat in front of the control boards under Buckheiser’s supervision, constantly on their phones and intercoms keeping track of planes, equipment and staffing in each segment of the organization. A speaker broadcasting all air-traffic control tower radio talk crackled in the background. Sitting in the back of the maintenance control room behind some glass was Major Newberry who supposedly oversaw operations and made whatever decisions that called for a field grade officer. 

It was obvious after a few minutes of conversation between Colonel Slaughter and Sergeant Buckheiser that Sergeant Buckheiser was the true boss of maintenance control. After a few pleasantries and introductions, Colonel Slaughter asked Sergeant Buckheiser, "What’s your operational ready rate, Sergeant?"

The “OR rate” is a standard measure of maintenance performance, meaning, essentially, what percent of the time the aircraft ready to fly.

Sergeant Buckheiser sat in a sturdy banged-up old-fashioned gray rolling desk chair which allowed him to scoot easily around the maintenance control room. He wheeled himself closer to Colonel Slaughter, looked up and said, "What rate would you like, sir?”

Colonel Slaughter replied, “Don't play any games with me, Sergeant. Call it like you see it.”

Buckheiser pointed out that since the 3380th Maintenance Squadron was supporting a training operation, standard OR rate numbers didn’t mean as much as they did in the regular Air Force where military planes were supposed to be ready to go at a moment’s notice. In a training context, there were many ways to calculate the operational ready rate such as whether you included weekends when no one flew anyway, whether a plane had all of its instruments working, but could still be used for training, whether a plane in a hangar that was not being worked on was considered operationally ready, whether the plane was properly configured and equipped for a particular training mission, etc.

Colonel Slaughter replied, "OK. I just need to know what percentage of the training flights are canceled due to maintenance."

“In that case, Colonel,” Buckheiser replied, “we have a very high operational ready rate. I'll be happy to calculate it that way for you. Yes sir.”

* * *

I was reminded of this anecdote when I watched Mendo’s helping professionals discuss numbers having to do with mental health service effectiveness. There are many ways to calculate such amorphous matters as these, none of which provide much useful information about how effectively Mendo’s tens of millions of annual mental health dollars are spent. There are so many ways to slice the pie, so many categories of funding, so many layers of bureaucracy, so many soft terms that defy specific definition and mean mainly what the person uttering them wants them to mean, that attempts to measure mental health effectiveness almost always fall flat. Hence the default measure: how much money is spent on it.

Mike Mertle, the Fort Bragg electrical contractor who represents the Fourth District on the Measure B mental health facilities oversight committee, listened to some discussion about the County’s relatively new Mobile Outreach and Prevention Services (MOPS) van, which the county recently set up to assist mental health patients (or possible patients) in the farther reaches of the county.

According to the County’s website: Mobile Outreach and Prevention Services (MOPS): Mobile Outreach and Prevention Services is a collaboration between Mendocino County Behavioral Health and Recovery Services and the Mendocino County Sheriff’s Department for outreach to individuals at risk of going into mental health crisis in outlying target areas of the county. These areas are remotely distant from emergency rooms and crisis services. The program focuses on the team connecting clients with local and larger area resources prior to meeting 5150 criteria and thereby reducing the duration of untreated mental illness, and dependency on emergency services for preventable service needs. The targeted outreach areas are North County, South Coast, and Anderson Valley. The program consists of three teams which include a Rehabilitation Specialist and a Sheriff Services Technician. Each team travels to the various communities in these outlying areas and meet with referred individuals that have been identified as in need of urgent services. Mobile Outreach also includes in-reach to the jail.”

Mertle asked, "People on the coast ask me what does the County do for people that are in crisis? Does the MOPS vehicle deal with crisis patients?”

County Mental Health Director Janine Miller replied, “Not at the level that you might be thinking by that.”

Mertle: “So that still goes back to the emergency department at the hospital and the sheriffs and local law enforcement. So this won't help that.”

Sheriff Allman: “That is true. It won't. In March of 2016 the Sheriff's office did a 90 day study in March, April and May, of all 5150 calls that were nonviolent, non-weapons, non-threatening. And we found that only 30% of the 5150 calls involved weapons, threatening or violence. The other 70% of those calls we would love to be able to get to a point where the MOPS is responding at the same time as law enforcement is responding. We would have professional mental health advocates there at the earliest contact.”

Mertle: “That's what I mean. What this is isn't really what we need. Right? Because you are not going to reduce your calls — the way I'm understanding it these people work four-day weeks so you can't respond to your residential crisis in situations where people are 5150.”

Allman: “What we've seen is if you visit the people at least once a week, and our potential 5150s are touching a professional, or shaking hands or are invited into their house, we see a reduction in the number of those 5150s who are repeat 5150. So we are taking away some of the frequent flyer 5150 calls and sort of stabilizing them.”

Mertle: “But that's on the back end. Dispatch is not saying, MOPS: Go deal with this.”

Allman. “No. However, they are referred by family members and mental health staff. People may wonder how those MOPS know to go to a certain address — it comes from school references, it comes from county personnel, as well as medical facilities and mental health staff who are giving references of people who need that face-to-face contact.”

Mertle: “Have you seen a reduction in 5150s since the MOPS program was put in place?”

Allman: “Absolutely. In the first 12 months of this, the people who were referred to MOPS— we saw a — and I can say this now — but we saw a 100% reduction in crisis 911 calls at the Sheriff's office. We certainly had some that were seen by MOPS and went into the crisis mode. But for the most part I can easily say that over 90% of the people who MOPS sees we are no longer seeing as crisis line, 911, 5150 people.”

Miller: “Yes, they are not going out in the moment we have a crisis. We get the referrals early. We have relationships with the clinics and the community where the family members can say that they think their family member needs a visit. Before they are in crisis they are calling and asking MOPS to come in. So we are doing prevention services. We get a lot of referrals. So we are stopping people from reaching a crisis level by touching them right when they needed.”

* * *

Mertle is on to something, but the rest of the committee was trying as hard as they could to avoid it: The crisis van. Even though Sheriff Allman acknowledges that something like two out of three 5150 calls could best be turned over to mental health staff, he didn’t follow up on Mertle’s implied suggestion. The MOPS vehicle does probably help and the committee’s recommendation to expand it from three MOPS units to five sounds like a good idea. But why can’t the MOPS program also include mobile crisis response? With five teams (of two people each, one a “Sheriff’s Service technician,” and one a “rehabilitation specialist”) why can’t they also be set up to respond to 5150 calls as circumstances dictate?

Mendo has been avoiding this important mental health service for years and it looks like it’s still off the table.

PS. In semi-response to an audience question about where MOPS data can be found, Ms. Miller said “it” was on the Behavioral Health Board’s web-page. It’s only for October 2018 and shows that a few dozen people were “contacted,” along with gender, race, age and who referred them. A note says that there were six new referrals in October. Average number of contacts was about 4 per month, with some not contacted and a few up to 18 times. According to the Kemper report summary, about 900 contacts were made to an average of 52 people from July 2017 to June 2018 costing about $207k. Essentially, then, contacts alone are considered “success.”

* * *

In other Measure B news, the Oversight Committee heard presentations from Adventist Health admin staffers about how both their Willits facility (“New Howard”) and Ukiah facility could easily be remodeled to provide a few “crisis residential” beds which could also be near medical staff in necessary cases. Both ideas are worth considering. But the proposals quickly bogged down in bureaucracy as the committee discussed who would own the buildings or facilities, how would contracts be arranged, who would staff them, which funding could be used for which services and how that would be tracked, who would do the contracting, would the facilities have to comply with time-consuming “OSHPD” standards, would it be temporary or long-term, how long could patients stay at one location or the other before funding ran out or diagnoses changed, how would transfers be made from one facility to the other, etc. etc. etc. Sheriff Allman said he was going to ask the County Counsel’s office for a legal opinion on some of the questions, so it could be months before the Adventists’ offerings are seriously considered — if at all.

I’m starting to think The Editor is right: if Sheriff Allman’s noble idea of developing facilities to really help the obvious and manageable population of those mental health casualties who need to be steered into non-law enforcement channels is turned over to the grant grabbers and bureaucrats, most of the needy will die before a single brick is mortared.