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A Senate investigative committee is calling for major reforms to the Hawaii State Hospital in an effort to curb violence and restore trust in a mental health system that has been mismanaged for many years.

On Wednesday, the committee, which is co-chaired by Hawaii Sens. Clayton Hee and Josh Green, issued its final report after holding nearly a dozen hearings in which top officials from the hospital and state Department of Health were subpoenaed to testify under oath.

The report’s recommendations are wide-ranging and include everything from building a new state hospital — something that would cost hundreds of millions of dollars — to sending the most troublesome, violent patients to an out-of-state facility to receive treatment.

The report also says that officials must work with public employee unions to rein in overtime at the hospital as well as improve its hiring practices to cut down on staff shortages and nepotism.

It even asks for the Legislature to pump additional funds into the Kaneohe hospital’s budget in 2015 to help address the committee’s concerns.

“We felt that there had to be some reforms at the hospital to make sure that those who work on the wards are safe from injury,” Green said after the hearing. “Some of the people that are hospitalized there have very severe illnesses and can be quite violent.”

“The cost obviously will impact the degree to which the recommendations can be made.” — Hawaii Sen. Clayton Hee

The committee launched its investigation after several Hawaii State Hospital workers came forward in November 2013 to complain of patient assaults on employees, which were occurring at a rate of once every three days.

Those workers also revealed that there was rampant overtime abuse, a high rate of nepotism among some high-ranking staffers and threats of retaliation against those of spoke up.

The 87-page report provides more than two dozen recommendations for how the state can repair the Hawaii State Hospital’s policies, protocols and infrastructure to help reduce the violence and improve management.

One recommendation that sticks out is the idea to send the most violent patients to a private facility on the mainland, something the state has already implemented.

The hospital is designed to hold 168 patients, but the daily count is closer to 200. Almost all the patients come through the court system after being found not guilty by reason of insanity for a particular crime.

Some of those crimes are minor, but others are more violent. The hospital, which has a budget of $52.8 million, was not built to care for these court-committed patients, and neither is the staff.

“It was told to us off the record that there might be handful of really dangerous, psychotic individuals,” Hee said, “and if they were off campus it would impact the number of assaults.”

“When you have good facilities and you treat people right the success rates are good. But without proper facilities the outcome is not good.” — Mike Durant, director of NAMI Hawaii

Two patients have already been shipped to the mainland after incidents at the hospital, including one who fractured the orbital bone of a hospital worker in 2007.

The state has developed a policy to send more patients to a South Carolina facility, which officials expect to be cheaper than treating them in Hawaii. In all, it’s expected that only 5 percent of the hospital’s population, or about 10 patients, might be eligible for relocation.

Lynn Fallin, the Deputy Director for Behavioral Health, said the state carefully reviewed its new policy for sending mentally ill patients to out-of-state facilities to ensure it complied with their rights as well as provided for quality care. She said the program will be employed on a case-by-case basis that is reviewed by the hospital’s clinical staff.

“The criteria are specific as to who we might send out of state,” Fallin said. “It is when all resources and clinical services have been exhausted. It’s the last resort.”

But the new policy has some in the mental health field concerned. Mike Durant, a board member of the Hawaii chapter of the National Alliance on Mental Illness, also sits on the State Council on Mental Health.

Durant says the state should focus its resources on improving and expanding the aged and out-of-date hospital to help reduce overcrowding and improve services.

Sending patients to the mainland is not a good solution, he said, they should be treated here.

“We need better facilities,” Durant said. “When you have good facilities and you treat people right the success rates are good. But without proper facilities the outcome is not good.”

Money will be a major part of the discussion moving forward for the Hawaii State Hospital. Many of the recommendations involve major capital improvements, such as building a fence around the hospital campus.

It will be up to the Legislature to appropriate the funds to build any new infrastructure. There will also likely need to be a bigger discussion about how far the state wants to go to improve its facilities.

Hee, who will not be in the Legislature next year, said it’s obvious that the state needs to do something, whether it’s adding a forensic wing to the current hospital or building a new one.

And while Hee’s confident Green, who chairs the Senate Health Committee, can keep the dialogue going during session, it will require much more support.

“The cost obviously will impact the degree to which the recommendations can be made,” Hee said. “That’s for the Legislature and the new governor to wrestle with but it doesn’t change the recommendation. It’s a good recommendation.”

Read the report here: