Honorable Tom Ammiano
and Members of the Board or Supervisors
City and County of San Francisco
401 Van Ness, Room 308
San Francisco, California 94102

Dear Supervisor Ammiano and Members of the Board of Supervisors:

Pursuant to your request, transmitted herewith is our Management Audit Report of the Medical Examiner"s Office of the City and County of San Francisco. This audit was conducted in accordance with generally accepted auditing standards established by the Comptroller General of the United States, as detailed in the United States General Accounting Office publication, Government Auditing Standards 1994 Revision.

While conducting this management audit, the Budget Analyst consulted with numerous professionals in the field of forensic medicine and toxicology, and with individuals well-versed in regulations governing safety practices in clinical, laboratory and medical settings. These experts included:

• The pathologists of the San Francisco Medical Examiner"s Office;

• Pathologists from other jurisdictions across the United States, specifically King County, Washington; Cook County, Illinois; Bexar County, Texas; Hennepin County, Minnesota; and Milwaukee County, Wisconsin;

• Toxicologists from the Medical Examiner-Coroner facilities in the counties of Los Angeles and San Diego, as well as independent toxicologists in private practice and with the Institute of Forensic Science; and,

• Regulatory personnel with the California Department of Health Services, the Center for Disease Control, the American Board of Pathology and the United States Department of Labor Occupational Safety and Health Administration.

The Budget Analyst"s audit staff made observations of various aspects of the Medical Examiner"s Office operations on at least twelve separate occasions. These observations were performed of the service floor (autopsy area), the laboratories (toxicology and histology), the administrative office area, and during ride-alongs with investigators. Additionally, the Budget Analyst"s staff requested information from the Department of Public Health"s (DPH) Environmental Health Management Division regarding the disposal of regulated and medical waste. This request for information resulted in an inquiry and inspection by the DPH Environmental Health Management Division and the disclosure that the Medical Examiner"s Office was transporting biologically hazardous waste without appropriate permits. Our report notes that the Medical Examiner"s Office is working with Environmental Health Management to remedy this situation.

In addition to our consultation with outside experts, consultations with professional staff within the Department, and our direct observations, we interviewed 33 managers and staff of the Medical Examiner"s Office. Some of the interviewed staff expressed concern that their comments remain confidential and not be shared with management because of fear of retribution. Accordingly, at the request of these individuals, the Budget Analyst conducted some interviews with employees in the presence of witnesses and conducted other interviews with employees in neutral locations outside of normal business hours.

Since transmitting the draft report, the Budget Analyst has received letters from some of these staff recanting information provided in the original interviews. Although we recognize the difficulties these staff may have with the results of our review and analysis, and acknowledge their right to amend statements, in all cases the findings contained in our final report are based on independent observations and analysis, as well as the information obtained during the initial interviews.

Our report contains nine findings and 43 recommendations which identify opportunities to increase the efficiency and effectiveness of the Medical Examiner"s operations. If properly implemented, our recommendations would generate $478,860 in annual savings, net of identifiable costs.

Major Accomplishments

The Budget Analyst found through interviews with other medical examiner and coroner offices in California and selected jurisdictions across the United States, that the current Chief Medical Examiner is very well respected in the forensic pathology community, and is certified by a majority of the western states and western Canada as a forensic expert. The recognition which the Chief Medical Examiner receives as an expert is of great value to the City and County of San Francisco, and has been a key factor in generating the City"s reputation for providing the highest quality forensic services.

In addition, we found that the Medical Examiner"s Office staff is an extremely dedicated group of individuals who are committed to providing high quality and compassionate service to the citizens of San Francisco. We wish to recognize that this group of employees face extremely difficult challenges each work day, interacting with the public during very stressful and emotional times. These staff are clearly concerned that any contact with the public be as humane as possible, and that information provided to these citizens be accurate, helpful and afford some degree of solace.

The Budget Analyst"s staff also found the Medical Examiner"s Investigators to be an extremely professional group of individuals who must regularly perform their duties during very intense and stressful situations. There are reported incidents of citizens who were not pleased with the outcome of their interaction with the Medical Examiner"s Office, and Investigators in particular. Upon reviewing and investigating incidents that were brought to our attention, we believe that the Investigators responded appropriately, and acted in accordance with established laws of the State of California and existing policies and procedures of the Department.

The Medical Examiner"s Office has been a leader in Sudden Infant Death Syndrome (SIDS) research since the 1970s. The Chief Medical Examiner is one of the authors of what has become the standard for the SIDS Investigation and Autopsy protocols for the State. His participation in the "Back to Sleep" program and recognition as a leader in efforts to reduce the number of deaths due to SIDS is commendable. During Fiscal Year 1994-95, there were only six SIDS cases in San Francisco. This was a substantial decrease from the 15 cases in the previous fiscal year. By working in conjunction with the State and the DPH, the Chief Medical Examiner is personally committed to isolating the causes of SIDS and making SIDS a rare to nonexistent occurrence.

The Chief Medical Examiner serves as the Chair of the City"s Child Death Committee. Although this committee is mandated by law, the City and the Medical Examiner conducted meetings prior to this mandate to review the deaths of all individuals under the age of eighteen. The Child Death Committee meets monthly to share information available on the deaths of children, the services available to the families and the resources needed by the community to address concerns surrounding the deaths of juveniles and surviving siblings and family members. The Committee also assesses the state of the Mayor"s Rapid Intervention Program and its ability to respond to crises, and provides additional resources to schools and other groups needing such resources.

There are other significant recent accomplishments of the Medical Examiner"s Office. These specific accomplishments have been enumerated in the Introduction Section of this report.

After completing our fieldwork and preparing the draft report, we held an exit conference with the Administrative Services Director, senior management of the Office of the Medical Examiner and a representative of the City Attorney"s Office. The Chief Medical Examiner provided a written response to this management audit report, transmitted through the Director of Administrative Services, which has been included as an attachment beginning on page 146. Where appropriate, we have commented on the Chief Medical Examiner"s response in the body of this transmittal letter.

Broad Conclusions Regarding Medical Examiner Operations

Based on the results of this management audit, the Budget Analyst staffhave drawn the following broad conclusions regarding the operations of the Medical Examiner"s Office:

These conclusions are discussed in detail within the body of this report. Our detailed recommendations, included at the end of each finding, provide specific steps that the Medical Examiner"s Office should take in order to improve the operational efficiency of the Office.

Our findings and recommendations are summarized below.

Section I: Testing of Employees for Communicable Diseases

In 1985, the State of California passed legislation requiring written consent prior to testing any person for the presence of Human Immunodeficiency Virus (HIV). The requirements of obtaining written consent prior to testing any individual for HIV are also contained in the San Francisco Municipal Code.

Two employees contend that in July 1994, the Chief Medical Examiner for the City and County of San Francisco tested them for HIV without their implied or written consent. The Medical Examiner" Office also provides testing for Tuberculosis, Hepatitis B, and, as a benefit for Medical Examiner"s Office employees, will administer Tetanus Booster shots, Hepatitis B vaccinations and flu shots.

As a result of the Medical Examiner"s Office"s failure to have its employees sign written consents prior to HIV screening, two employees tested in July of 1994 have filed charges with the Equal Employment Opportunity Commission against the City and County of San Francisco. One of these claims is still pending.

In order to comply with State regulations and minimize the City"s risk of exposure, the Medical Examiner"s Office should:

I.1 Review and consistently enforce policies and procedures for testing employees for HIV, which include:

I.2 Establish a protocol and form which segregates samples submitted for HIV screening for living and deceased subjects and work with the Department of Public Health to obtain the appropriate authorization to submit blood samples for HIV screening that are not part of any State or Federally funded AIDS surveillance projects.

I.3 Enforce the established informed consent protocol to be administered to all employees who are either tested for or receive vaccinations for Hepatitis B.

I.4 Enforce the established informed consent protocol to be used when administering flu and all other vaccines to employees in order to reduce the City"s risk of exposure to legal actions or other claims due to adverse reactions to such vaccines.

As a result of the Medical Examiner"s Office practices with regard to HIV testing for employees, two claims have been filed against the City and County of San Francisco by individuals alleging they were tested involuntarily for HIV in July of 1994. As of the writing of this report, the Medical Examiner"s Office reports that one law suit was filed, but has been dismissed in favor of the City. The other action, an Equal Employment Opportunity claim, is pending. Consequently, no monetary damages have been paid by the City with regard to these matters. Based on discussions with the City Attorney"s Office, implementing the recommendations noted in this section would significantly reduce the City"s future risk of exposure from allegations of improper testing.

Additionally, the City"s exposure to risk resulting from adverse reactions to vaccines administered by the Medical Examiner"s Office would also be reduced significantly by implementing bona fide informed consent protocols. These recommendations would require a change in procedure and the implementation of testing and vaccination policies. However, all of the recommendations could be implemented at no cost to the City.

In the response to Section I of the audit report, the Chief Medical Examiner states:

• "No Medical Examiner"s Office employee has ever been required, at any time, to submit to any medical procedure at the behest of the Medical Examiner"s office, either on-site or elsewhere." and,

• "The OSHA Bloodborne Pathogen Standard requires the Office to "make [hepatitis B] vaccination available at no cost and at a reasonable time and place, to all employees who have potential exposure.:"

The Budget Analyst"s report clearly states:

• Members of the Medical Examiner"s Office staff acknowledge that employees have been tested for the presence of HIV antibodies and that two of those employees contend that such testing was involuntary.

• "Federal regulations require that all employees exposed to Hepatitis B receive testing, upon request and that the vaccine be available to them in order to prevent inoculation. In order to comply with this requirement, the Medical Examiner"s Office offers Hepatitis testing, and, vaccinations to employees;"

The Chief Medical Examiner further comments on Section I by stating:

• "Your report correctly points out that the coroner"s offices in most of the other jurisdictions your team surveyed do not offer such testing and vaccination; however, you fail to note that all, or nearly all of those other jurisdictions do not even have a medical examiner"s office, but instead operate simply as a coroner"s office. A county coroner is not a trained physician."

The Budget Analyst"s audit team surveyed seven Medical Examiner"s Offices, two Medical Examiner/Coroner"s Offices, one Sheriff/Coroner"s Office and one Coroner"s Office. The jurisdictions surveyed are as follows:

• King County, Washington Medical Examiner"s Office with six trained and licensed physicians;

• Cook County, Illinois Medical Examiner"s Office with 13 trained and licensed physicians;

• Hennepin County, Minnesota Medical Examiner"s Office with five trained and licensed physicians;

• Milwaukee County, Wisconsin Medical Examiner"s Office with seven trained and licensed physicians;

• Bexar County, Texas Medical Examiner"s Office with five trained and licensed physicians;

• San Diego County Medical Examiner"s Office with five trained and licensed physicians;

• Santa Clara County Medical Examiner"s Office with four trained and licensed physicians;

• Los Angeles County Medical Examiner/Coroner"s Office with 18 trained and licensed physicians;

• Ventura County Medical Examiner/Coroner"s Office with 2 trained and licensed physicians;

• Alameda County Sheriff/Coroner which contracts out autopsy services, but has one trained and licensed pathologist (medical doctor) on staff; and,

• Marin County Coroner which contracts out all services and has no licensed medical staff.

The Chief Medical Examiner"s response suggests that our report recommends that all testing and vaccination should be terminated, and that such termination would be inconvenient for employees.

The Budget Analyst"s report actually recommends that the Medical Examiner consistently enforce policies with regard to testing and vaccinations or, in the absence of enforcing policies, refer all employees to other health care facilities or professionals.

In his response to the audit report, the Chief Medical Examiner states that the information on the actions filed by the two employees who contend that they were involuntarily tested for HIV is a misrepresentation of the facts and that:

• The law suit was thrown out of court; and,

• The EEOC investigation has just begun.

The Budget Analyst states:

• The law suit has been dismissed in a summary judgment, in favor of the City; and,

• The Budget Analyst acknowledges that the second claim is pending and has documentation, with an EEOC case number, for the second claim dating back to March 8, 1995 .

Section II: Sanitary Conditions and the Use of Universal Precautions

To prevent the spread of infectious diseases transmitted via airborne and bloodborne pathogens, the Center for Disease Control (CDC) has developed universal precautions to be used in medical settings. Universal precautions are defined as a set of hygienic practices employed by healthcare workers that, when properly and consistently used, will reduce the risk of infection to patients and staff from bloodborne and airborne pathogens. Additionally, the Federal Department of Labor, Occupational Safety and Health Administration (OSHA) issued guidelines on precautions in Occupational Exposure to Bloodborne Pathogens; Final Rule on December 6, 1991.

Based on observations and interviews with pathologists, precautions are not generally observed in the autopsy areas of the Medical Examiner"s Office. For example, disposable needles and syringes are reused; instruments are not appropriately cleaned, disinfected or sterilized; and protective masks, face shields and glasses are not worn during all procedures.

Failure to observe universal precautions unnecessarily exposes staff to the possibility of contracting infections from bloodborne and airborne pathogens. Additionally, the failure to properly clean, disinfect or sterilize instruments after each procedure increases the risk of contaminating specimen.

The Forensic Lab Manager is responsible for ensuring that all employees adhere to the Exposure Control Plan and that universal precautions are observed. However, the Forensic Lab Manager does not routinely observe procedures in the laboratories nor monitor autopsy procedures to ensure that the pathologists are following the guidelines set forth in the OSHA Rules and Exposure Control Plan. By their own admission, the pathologists do not always wear masks, do not always wear protective gowns and sleeve guards, and do not always use the recommended ten percent bleach solution for cleaning instruments. Additionally, laboratory work areas (both Toxicology and Pathology) were generally unclean.

Other concerns with regard to compliance with OSHA rules include individuals walking through the autopsy area with open beverage containers, individuals entering the autopsy area without the proper protective clothing, rinsing instruments in only water between cases, and no inspection of area or procedures to document the use or violation of universal precautions in laboratory and autopsy areas. Compliance with all applicable OSHA rules is important to decrease the risk of infection from bloodborne pathogens (specifically HIV and Hepatitis B), and other pathogenic microorganisms.

In order to reduce the risk of employee exposure to bloodborne and airborne pathogens, the Medical Examiner"s Office should devise a plan to conduct inspections of all work areas where exposure and contamination could occur to ensure that all employees are observing the OSHA regulations regarding protective equipment, clothing and procedures. The inspections also should include the monitoring of general housekeeping to ensure that the service floor and storage areas are sanitary, and to verify that all biologically hazardous waste is properly discarded and disposed of in a manner that is consistent with State regulations. Additionally, the Medical Examiner"s Office should implement new policies with regard to the reuse of needles and syringes, and strictly enforce the OSHA regulation on the recapping of needles.

The Medical Examiner"s Office should:

II.1 Enforce established protocols and generally adhere to the universal infection control and sanitary condition standards that are outlined in the Code of Federal Regulations publication announcing the OSHA rules.

II.2 Actively enforce the OSHA rules regarding the reuse of syringes and recapping of needles by:

II.3 Comply with all State and Federal regulations regarding the disposal of regulated waste and develop a method of providing proof of such compliance. Proof could be obtained by:

II.4 Revise the Housekeeping section of the Exposure Control Plan to include a specific schedule for cleaning all areas and equipment on the service floor of the Medical Examiner"s Office and laboratories. The revisions should include:

II.5 Assign specific staff to supervise and ensure the cleaning of specific areas of the service floor and develop a schedule for inspecting the service floor, including laboratories, to verify compliance with universal infection control and sanitary conditions outlined in the OSHA Occupational Exposure to Bloodborne Pathogens: Final Rule dated December 6, 1991.

Adopting a policy to use disposable needles only once prior to discarding them could be implemented at an estimated annual cost of $9,950. Based on financial data obtained from the FY 1995-96 year-end reports, these expenditures could be absorbed within the existing budget.

By complying with the OSHA regulations and CDC guidelines for observing universal precautions, the City can reduce its risk of accidental infections caused by needle sticks and other forms of inoculation (e.g. touching contaminated surfaces, splatter from blood and other body fluids, etc.). Reducing the risk of accidental infection also reduces the potential for legal actions, which may be filed by employees who are accidentally inoculated with bloodborne pathogens and other pathogenic microorganisms found in their work place.

In response to Section II of the audit report, the Chief Medical Examiner states:

• The office has been inspected by knowledgeable inspectors from the National Association of Medical Examiners (NAME); and,

• The autopsy area was active during the Budget Analyst"s inspection of the facility;

In conducting this audit the Budget Analyst:

• Utilized the expertise of many individuals to understand and evaluate the Medical Examiner"s Office"s adherence to universal precautions, and used the audit team member who had experience inspecting autopsy areas from previous audits in other jurisdictions inspect the autopsy area in the Medical Examiner"s Office;

• The autopsy area was not active during the observation cited in the Medical Examiner"s response. The audit team member conducting the inspection was never asked to sign any release or put on appropriate protective clothing to conduct the inspection, as should have been the case if the area was active. Additionally, on two separate occasions, audit staff was admonished by the Pathologists and the Administrative Coroner not to enter the autopsy area because the area was active and the members of the audit team were not appropriately attired;

• The request to re-inspect the autopsy area was not made until the Chief Medical Examiner and his staff became aware of the Budget Analyst"s concerns and the Forensic Autopsy Technician staff had returned to full strength; and,

• The audit team conducted at least 12 separate observations of the Medical Examiner"s facilities and equipment which included the autopsy area, toxicology laboratory, histology laboratory, and the administrative area, and various other areas during ride-alongs.

The Chief Medical Examiner states in his response that:

• He is in disagreement with the Budget Analyst on the difference between sterilization, disinfection and decontamination; and,

• Universal precautions and OSHA regulations are always followed.

The Budget Analyst used citations from the Code of Federal Regulations; Occupational Exposure to Bloodborne Pathogens; Final Rule December 1991, which states that facilities subject to the regulations set forth in this citation should clean, sterilize or disinfect, as appropriate all contaminated surfaces and instruments, and regulations regarding the availability and use of protective clothing and equipment.

As noted in the audit report the Budget Analyst found:

• The Medical Examiner"s Office has complied with the letter of the regulations by developing an Exposure Control Plan which contains all of the required elements;

• Staff conducting procedures, by their own admission, do not always properly clean, disinfect or sterilize instruments and surfaces as appropriate;

• Staff, by their own admission, do not always wear the proper protective clothing and equipment; and,

• It is the responsibility of the Chief Medical Examiner to ensure that staff adhere to all universal precaution regulations, and that protocols are adapted to facilitate adherence.

The Chief Medical Examiner states that:

• The Budget Analyst has misunderstood the difference between unregulated waste and regulated waste.

The Budget Analyst"s audit report states:

• There are discrepancies between staff"s accounting of the disposal of waste and the Management"s accounting of the disposal of waste;

• Prior inspections by CalOSHA resulted in citing the Department for failing to provide the proper disposal bags and/or labels in the Histology Laboratory, and during our tour of the Histology Laboratory, "red" bags were not present in any of the waste receptacles; and,

• The Budget Analyst"s request for information from the Department of Public Health"s Environmental Health Management Division, to clarify the waste disposal situation, resulted in a inquiry and inspection, and the disclosure that the Medical Examiner"s Office"s has transported biologically hazardous waste without the appropriate permits.

The Chief Medical Examiner states that:

• The Budget Analyst"s concern over the re-use of disposable needles and syringes is unfounded and the practice is consistent with the industry standard;

• That the rules were not promulgated to protect the healthcare workers; and,

• Since his "patients" are dead, there is no danger of infecting them.

The Budget Analyst acknowledges that there is no danger of any of the Medical Examiner"s patients contracting any type of infection. However, in discussions with the Center for Disease Control and in literature provided by the Center on nosocomial infections, the danger of infection extends to staff. The Budget Analyst also acknowledges that there is no OSHA regulation specifically on the re-use of "disposable" needles. However, there are regulations on the re-use of needles. In this audit report, the Budget Analyst cites:

• The OSHA regulations regarding the proper treatment and handling of contaminated needles;

• The Center for Disease Control"s cautions regarding the increased probability of a needle stick with the repeated cleaning and handling of needles;

• The storage of needles in sponges; and,

• A method of eliminating this concern that may cost $10,000.

The Medical Examiner states that:

• A cleaning protocol has existed since 1992;

• The protocol is followed by staff; and,

• Adherence is monitored by spot inspections.

The Budget Analyst found:

• A cleaning protocol that lacked the specificity needed to provide staff with detailed instructions on how cleaning should be carried out to meet the requirements of the OSHA regulations;

• Evidence during observations that the autopsy areas and laboratories are not regularly cleaned as outlined in the cleaning protocol; and,

• No reports or logs to substantiate the spot inspections and reports from staff that management"s "visits" to the service floor are for one to two minutes and are not inspections of the conditions of the facility.

Section III: Toxicology

The National Association of Medical Examiners, the Society of Forensic Toxicologists, and the American Academy of Forensic Sciences have established guidelines for the accreditation of forensic toxicology laboratories. These guidelines state that an accredited forensic toxicology laboratory should be directed by a chief toxicologist to: 1) provide overall management of the laboratory; 2) supervise laboratory staff; 3) validate new drug assays; and 4) maintain a quality assurance program.

The San Francisco Medical Examiner"s Office currently does not have a lead forensic toxicologist who provides an appropriate level of supervision and day to day management of the Toxicology Laboratory, and has not had such a position since 1993. As such, the San Francisco Medical Examiner"s Office does not fully conform to the guidelines established by the professional associations recognized for setting the standards used to accredit forensic toxicology laboratories.

The Office of the San Francisco Medical Examiner is performing almost five times as many tests per case as Santa Clara and Alameda counties, and almost three times as many tests per case as Los Angeles County. Increased testing requires additional staff and increases the costs of operations for Toxicology. According to the Medical Examiner"s Office staff, and assessments from independent toxicologists, the disproportionately high number of tests is attributable to a lack of communication between the pathologists and the Assistant Forensic Toxicologists, and the lack of review of toxicological test requests and forms by a chief toxicologist or other qualified and authorized staff. A review process would provide a forum for the pathologists to discuss the case with the Forensic Toxicologist to determine the types of tests that should be conducted to obtain the required information and the most efficient method of conducting those tests.

The Chief Toxicologist in San Diego reported that the cost and time required to provide the analysis from comprehensive, or "C" screens, warrants limiting their use. For example, at an average cost of $300 per "C" screen, a same sample of 32 cases, conducted for this study, San Diego would have expended $1,800 to conduct the tests, Los Angeles would have expended $2,700 to conduct the tests, and San Francisco would have expended $7,800 to conduct the tests. Based on this analysis, it is costing the City three to four times as much to conduct the same type of toxicological testing as in other jurisdictions.

The staff of the Toxicology Laboratory has not been adequately cross trained. Consequently, the efficiency of the Laboratory is compromised. As reported by the Pathologists and other staff, laboratory technicians have been trained to perform a limited number of tests and to operate limited types of equipment. This insufficient cross training reportedly delays the processing of requests if the trained staff person is absent. Also, outdated procedures and the lack of comprehensive operating manuals for staff further impact the efficiency of the Laboratory. Finally, the chain-of-custody process is poorly coordinated with the case review process, and there is inadequate quality control and review of the analyses that are conducted.

The Medical Examiner"s Office should:

III.1 Reinstate the position of Forensic Toxicologist to perform the technical duties of :

III.2 Update and revise the toxicology test request form to improve the efficiency of toxicological analyses.

III.3 Evaluate the existing staff with regard to training needed to ensure that each staff member has the requisite skills to conduct all tests performed in the laboratory and that each staff member is able to operate all of the laboratory equipment.

III.4 The recommended Forensic Laboratory Manager/Forensic Toxicologist should develop and implement a training program within 90 days of assuming his/her position, that will provide the Toxicology Laboratory staff with:

III.5 Upon completion of the training, the workload should be redistributed in a more equitable manner and a thorough analysis of the actual staffing requirements should be conducted under the direction of the Director of Administrative Services. This staffing analysis should be based on actual and projected workload and performance data that includes both quantitative and qualitative criteria that is used and accepted by professional forensic toxicology organizations, such as the Society of Forensic Toxicologists and the American Academy of Forensic Sciences.

III.6 Upon completion of the staffing and workload analysis, the Chief Medical Examiner should prepare a report for the Director of Administrative Services that includes supporting evidence to justify the retention of 5.5 FTEs to manage the workload in the Toxicology Laboratory or, based on the same information available for this report, recommends a reduction in the number of Assistant Forensic Toxicologists.

III.7 Develop a quality assurance program that meets the standards established by the Society of Forensic Toxicologists/American Academy of Forensic Sciences guidelines and includes the verification of standards, calibrators and controls by outside laboratories.

III.8 Conduct a critical, in-house review of the operations and processes used in the Toxicology Laboratory in order to:

Reinstatement of the Forensic Toxicology position could be accomplished at a net cost of approximately $17,834 in salary and associated fringe benefits ($85,289 Forensic Toxicologist Salary and Fringes, less $67,455 Forensic Lab Manager Salary and Fringe Benefits), and no increase in FTEs. This position could be funded with savings obtained through the reorganization of staffing in the Medical Examiner"s Office (see Section VI: Staffing and Organization), which combines the function of the Forensic Laboratory Manager and the Forensic Toxicologist.

Should allocating the total workload in a more equitable manner and cross-training staff create greater efficiencies, allowing the Medical Examiner"s Office to reduce the number of Assistant Forensic Toxicologist I positions, approximately $69,135 in annual savings would be generated for each eliminated position. Currently, all of the Assistant Forensic Toxicologist Positions are filled. Accordingly, the elimination of these positions and potential savings would have to be generated through attrition.

In response to Section III of the audit report, the Chief Medical Examiner states:

• The entire Medical Examiner"s Office is accredited by the National Association of Medical Examiner"s (NAME);

• The Chief Medical Examiner and his staff believe that they are in compliance with all guidelines set forth by NAME; and,

• By law, forensic laboratories are exempt from regulation with the sole exception of forensic alcohol analysis.

In our report, the Budget Analyst acknowledges the accreditation of the Medical Examiner"s Office facility by the National Association of Medical Examiners (NAME). However, based on the guidelines for the accreditation of toxicology laboratories as set forth by the Society of Forensic Toxicologists and the American Academy of Forensic Sciences, there are deficiencies in the operation of the Medical Examiner"s Office Toxicology Laboratory.

• In the exit conference, the Chief Medical Examiner stated that the facility could lose its NAME accreditation if it had 15 infractions on the order of not having a person to provide the type of management and oversight in the Toxicology Laboratory that is cited in the previous bullet; and,

• The Laboratory Manager does not provide any management of staff, does not inspect the autopsy area, which is part of Medical Services, for safety compliance, does not have any records to show that any inspections have occurred to enforce universal precautions, and only visits the Toxicology Laboratory one hour per week to re-order supplies.

The Budget Analyst simply notes that the current incumbent of the Laboratory Manager position holds a Ph.D. in pharmacology and could be better utilized to provide real hands-on management of the Toxicology Laboratory, and provide the types of services the Chief Medical Examiner enumerates in his response which are the preparation of protocols for improved methodology and training and court appearances.

The Chief Medical Examiner states that he:

• Disagrees with the Budget Analyst" recommendations regarding workload distribution;

• Has initiated cross-training for all personnel in equipment and procedures; and,

• Spends a minimum of 10 to 20 hours per week in the Toxicology Laboratory overseeing its operations.

In the audit report the Budget Analyst states:

• The analysis of workload distribution and staffing requirements was based on observations and information obtained from Toxicology Laboratory staff during interviews;

• Recommends a formal cross-training program that includes systematic training on procedures and tests staff competency in conducting procedures so that each member of the staff is certified and competent in all aspects of the work to be performed. The training program should include dated documentation on who led, who attended, and who successfully completed the training session. This is more formal and verifiable than the current program of rotating staff to unfamiliar equipment and tests once each month and instructing them to ask for help if they have any questions; and,

• Acknowledges that including nights and weekends, the Chief Medical Examiner spends more than five hours per week in the Toxicology Laboratory. However, during our observations of the Laboratory on three days from 8:00 AM to 4:00 PM, the Chief Medical Examiner did not provide any supervision in the Laboratory and staff clearly indicated that five hours per week was the amount of supervision they received. Our reports notes that the time spent on nights and weekends does not provide opportunities for supervision and oversight of staff"s work.

The Chief Medical Examiner states that it is not true the chain of possession procedures have been compromised. He states specifically:

• Chain of Custody procedures are constantly reviewed;

• Such procedures have withstood the scrutiny of civil and criminal trials for over 25 years; and,

• Chain of possession typically begins prior to evidence being under the Medical Examiner"s jurisdiction.

As discussed during the exit conference, the Budget Analyst"s report states:

• The Society of Forensic Toxicologists and the American Academy of Forensic Sciences guidelines state that the chain of custody should be properly linked to a case review process; and,

• In the Medical Examiner"s Office Toxicology Laboratory, the chain of custody is poorly linked to case review and the case review process is inadequate.

The Budget Analyst has differentiated between quality assurance and quality control. We note that with the exception of the alcohol analysis, there is no quality assurance; and that quality control is not adequate as the individual conducting the initial test may also be the individual who runs the quality control on said test. To have adequate quality control there should be separation between the two functions. The only retesting conducted by outside laboratories is in a litigious situation. A bona fide quality assurance program would entail routine confirmation by outside laboratories as a matter of practice as opposed to conducting such confirmations as a defensive maneuver in judicial proceedings.

Section IV: Planning and Budget

During the City"s annual budget process, the Medical Examiner"s Office is required to submit a budget request that reflects the level of resources that are needed to meet the Office"s stated mission. The Fiscal Year 1996-97 expenditure appropriation for the San Francisco Medical Examiner"s Office totals $3,242,150. This level of funding is $180,330 greater than the 1995-96 revised budget appropriation of $3,061,820 and $352,369 greater than the actual year-end expenditures of $2,889,781 reported by the Controller"s Office for FY 1995-96.

Despite their participation in the annual budget process, the Medical Examiner"s Office is unable to provide any specific information on the manner in which the budget request was generated, resource requirements for specific activities, or the current status of the budget at a project or activity level.

The inability to provide specific information on the origin of the Office"s budget request makes it difficult to: a) provide an adequate level of justification for the items requested; b) allocate resources appropriately within the Office; c) determine how resources should be reallocated and whether all of the tasks necessary to complete the mission and purpose of each program can be accomplished; and d) estimate the unit cost of tasks conducted within the Office.

As part of the field work for this audit, the Budget Analyst requested information from budget submissions prepared by the Medical Examiner"s Office for Fiscal Year 1996-97. The Medical Examiner"s Office staff was unable to provide any such information. Additionally, the staff was unable to provide any explanation on the origin of the amount of funding requested, justifications for the amounts requested in specific line items, or whether any reallocation of resources was requested or has taken place. Yet, the Medical Examiner"s Office holds that there is a prohibition, by the Mayor"s Office, against requesting new equipment which would allow the replacement of outdated equipment in the Toxicology Laboratory.

Further, the Chief Medical Examiner and his staff were unable to provide any information on: a) how the non-personnel budget was formulated; b) how much of the non-personnel budget is allocated to each of the three major activities within Medical Services; and c) how much of the non-personnel budget has been expended on each of the three major activities, year-to-date. Consequently, Budget Analyst staff derived a method for determining the approximate allocation for each of the activities within the Medical Services Program.

It should be noted that the Chief Medical Examiner does not believe that the allocation of the medical services derived by the Budget Analyst"s staff is accurate. However, he was unwilling to assist in developing a more accurate allocation and as of the writing of this report, has not provided back-up documentation used to prepare the FY 1996-97 budget for the Medical Examiner"s Office.

The Chief Medical Examiner and his staff also indicated that they are not proficient in reviewing and analyzing the financial reports that are produced and distributed to departments by the Controller"s Office on a monthly basis. The Budget Analyst"s review of such documents noted that the Medical Examiner"s Office had a balance of $119,875 at the close of Fiscal Year 1995-96, showing that the overall appropriation for the department had been underexpended. To the extent possible, these resources could have been reallocated during the year to provide the Medical Examiner with the ability to obtain needed equipment, update the Toxicology Laboratory, adhere more closely to Universal Precautions, or request essential staff.

In order to plan more efficiently and prepare budget submissions that provide compelling and accurate information stating the resource needs of the Medical Examiner"s Office, staff should make greater efforts to understand the financial reports that are provided by the City to monitor budget activities. Additionally, the Medical Examiner"s Office should start documenting problems resulting from using laboratory equipment long past is useful life. By taking these measures, the Medical Examiner"s Office would be able to take advantage of opportunities to request replacement equipment and essential staff positions, and reallocate resources in order to operate as efficiently as possible.

To gain a better understanding of the budget process and provide information on the estimated unit cost of activities, the Medical Examiner"s Office should:

IV.1 Develop a better understanding of the information generated by the City"s financial system (FAMIS) and utilize that information to monitor the Office"s budget.

IV.2 Develop in-house expenditure and activity reports that can be used to estimate the amount and cost of various activities such as the cost of conducting toxicological tests, autopsies, and the production of slides and tissue samples.

IV.3 Take greater responsibility for determining how resources are allocated between the three programs by:

The recommendations in this section can be implemented without adding financial or staff resources to the Medical Examiner"s Office. All financial reports prepared by the Controller are available to the Medical Examiner"s Office staff, as well as budget instructions. Additionally, the recent migration from the Wang Computer System to a LAN have given the Medical Examiner"s Office the ability to develop the spreadsheet applications needed to monitor workload and expenditures in order to determine an estimated unit cost for specific activities.

Section V: Medical Examiner"s Inquests

Section 27491.6 of the California Government Code allows the Coroner/Medical Examiner of a city or county to hold inquests to determine the circumstances and manner of death in cases that are within the Coroner/Medical Examiner"s jurisdiction. A Coroner"s Inquest is defined as a formal "court" proceeding that is conducted to provide information that will assist in determining the manner in which an individual died.

Within the City and County of San Francisco, such inquests are held at the discretion of the Chief Medical Examiner, or when requested by the Attorney General, District Attorney, Sheriff, City Attorney or Chief of Police; are generally held without benefit of an inquest jury; and are generally held without representatives from the Police Department"s Homicide or Criminal Investigations Unit or the District Attorney"s Office.

As a result, the Homicide and Criminal Investigation Units of the Police Department and the District Attorney may not be alerted to situations that would warrant further investigation due to the questionable responses or behavior of witnesses in the inquest process.

In order to provide additional checks and balances to the inquest process, the Chief Medical Examiner should: 1) develop criteria to use in determining which inquests should be held with a jury; and 2) formally advise the District Attorney"s Office and the Homicide and Criminal Investigation Units of the Police Department of the time and dates of all Medical Examiner"s inquests.

In making the determination on the manner of death, the Chief Medical Examiner is usually the sole arbiter of the facts and information presented during the inquest. This results from a loss of funding for jury panels, and the authority granted to the Chief Medical Examiner by the California Government Code. Since the California Government Code grants such authority to the Medical Examiner, he is not required to notify the Police or District Attorney of the intent to hold an inquest nor ask them to attend the proceedings. However, due to the nature of some of the questions surrounding the circumstances of death, in inquested cases, notification of the Police and District Attorney may be prudent.

During this audit, the Budget Analyst"s staff was present as two such cases were inquested. The failure to notify the Police and the District Attorney of the pending inquests appeared to directly contradict the Chief Medical Examiner"s explanations of when it would be prudent to alert those entities of the planned proceedings. While technically meeting the requirements of the statutes and maintaining compliance with the Government Code, this practice does not allow the Police or the District Attorney to make independent assessments of the possible legal issues surrounding an individual"s death.

Based on the results of our limited survey, the practice of holding inquests is waning throughout the Country. In the limited survey of Medical Examiner"s Offices in California and elsewhere in the United States, only three of the eleven responding jurisdictions indicated that inquests of any kind are held. Only one of the eleven indicated that the inquests, when held, are conducted by the Chief Medical Examiner. One jurisdiction, Los Angeles County, indicated that Psychological Autopsies are now used to determine between "Suicide" and "Accident" as the manner of death. Los Angeles County finds this practice much more efficient and economical than conducting inquests.

The practice of conducting psychological autopsies, used in Los Angeles County reportedly costs approximately $1,000 per case. Medical staff estimates that approximately six to eight psychological autopsies are conducted annually at a cost of approximately $6,000 to $8,000. In San Francisco, Medical Examiner"s Inquests are conducted with known costs of approximately $34,914, (the cost of the salary and benefits for the 0.6 FTE Court Reporter). With an average of 20 inquests per year, the unit cost of conducting each inquest is at least $1,724, excluding the cost of the Chief Medical Examiner"s and Investigator"s time. Changing current practices of conducting inquests to using psychological autopsies could result in savings of $724 per case inquested using the psychological autopsy process.

The Medical Examiner should:

V.1 Use psychological autopsies to make determinations between accident and suicide as the manner of death. This could result in savings of $724 per case inquested, using the psychological autopsy process.

V.2 Develop a method of estimating the cost of conducting an inquest so it is possible to determine what portion of the Medical Examiner"s Office resources are dedicated to this function and the viability of alternatives based on cost, time and informational value of the proceedings.

V.3 Develop a policy of formally notifying the Police Department and District Attorney"s Office of inquests so they can make their own assessment regarding the need to send an observer.

Implementation of these recommendations could result in net savings of up to approximately $14,480 per year. Additionally, implementing these recommendations would allow the Police and District Attorney to make independent assessments regarding the potential legal issues surrounding the circumstances of the death of the individual being inquested. In the event that legal proceedings are required, a much stronger case could be presented by the Police and District Attorney.

In response to Section V of the audit report, the Chief Medical Examiner states:

• The Department always notifies appropriate agencies of inquests that may be of interest to them and will continue to make notification a formal policy in the future;

• Psychological autopsies are commonly performed by the Chief Medical Examiner and his staff; and,

• The Chief Medical Examiner is a licensed physician, board certified in several specialties, and has special training in the determination of the cause and manner of death.

In the audit report, the Budget Analyst:

• Does not question the Chief Medical Examiner"s qualifications with regard to determining the cause and manner of death nor suggest that it is not his duty to make such determinations under Section 27491 of the California Government Code;

• Recommends a formal process of notifying the Police and District Attorney of all inquests after determining, through interviews with the responding Police Officer in one case, and six Deputy District Attorneys and the District Attorney, that these parties are not routinely or formally notified of scheduled inquests and the basis of the inquests; and,

• Recommends that when appropriate, the Chief Medical Examiner use psychological autopsies to determine between "accident" and "suicide" as the manner of death.

The Budget Analyst"s report states that the Chief Medical Examiner should continue to use information from the Investigator"s reports and increase the use of information gathered by professionals trained in human behavior. To our knowledge, based on a review of the Chief Medical Examiner"s Curriculum Vitae, he is not board certified in psychiatry, and does not possess any special training in the field of mental health, or hold advanced degrees in psychology. As such, the Chief Medical Examiner, while cognizant of human behavior, is not a behaviorist. Our recommendation specifically states that the psychological information should be gathered and analyzed by professionals trained in human behavior and mental health.

Section VI: Organization

The current organizational structure of the Medical Examiner"s Office illustrates an overly broad span of management control for the Chief Medical Examiner and Administrative Coroner as a result of 1) the extensive duties, activities and supervisory responsibilities undertaken by these two individuals; and 2) recent events related to staffing changes, vacancies and litigation.

As a result of these broad spans of control, problems have arisen, such as: a general lack of supervision of line staff; the neglect of internal controls, policies and other duties; irrational and unclear lines of reporting; and low employee morale.

The Chief Medical Examiner has direct management and supervisory responsibility over the Toxicology Laboratory, the Histology Laboratory and the Pathology Section (Autopsies). Of the 39 employees, which equates to approximately 36.51 permanent FTEs in the Medical Examiner"s Office, there are 13 employees who report directly to the Chief Medical Examiner, including the part-time Court Reporter. The Chief Medical Examiner also has indirect oversight over Investigations and Administration, through the Administrative Coroner. Additionally, numerous outside duties require the Chief Medical Examiner"s time. These duties include (1) serving as Medical Director for Igenex Laboratories in Palo Alto, California; (2) periodically appearing in court as an expert witness for other jurisdictions; (3) giving presentations at seminars and conferences; and (4) conducting research and co-authoring articles.

The Administrative Coroner has direct oversight responsibilities for property control, budget, purchasing, clerical, billing, medical transcription, payroll, personnel and investigative functions. In addition, the Administrative Coroner manages the Indigent Burial Program. Of the 39 employees in the Medical Examiner"s Office, there are 26 full-time and part-time employees who directly report to the Administrative Coroner.

Both the Chief Medical Examiner and the Administrative Coroner have taken personal responsibility for performing certain tasks which could be performed by lower-level staff. For example, the Chief Medical Examiner administers flu shots and other vaccines to City staff on demand and manages the two laboratories. The Administrative Coroner performs various clerical duties such as answering telephones, releasing property to families and other functions which could easily be performed by lower level investigative or clerical personnel.

Based on our interviews with current and former staff and our review of the Department"s organization and operations, we do not believe that it is reasonable to expect two individuals to perform such a wide range and large number of duties effectively. As a result, sufficient time has not been dedicated to preparing and updating administrative and procedures manuals throughout the Department. Although an administrative guidelines manual exists, it applies only to investigations. There are no comprehensive procedural manuals for either of the two laboratories (Toxicology or Histology) or for autopsies.

Further, due to the elimination of the Forensic Toxicologist position, the Chief Medical Examiner has undertaken the responsibility of managing and supervising the toxicology laboratory. According to guidelines established for forensic toxicology laboratories by the National Association of Medical Examiners (NAME), the Society of Forensic Toxicologists (SFT) and the American Academy of Forensic Toxicologists (AAFT), a toxicology laboratory should be directed by a chief forensic toxicologist. The Chief Medical Examiner states that he meets the requirements for membership in the society of Forensic Toxicologists, but it is clear from our review that he cannot dedicate the required time towards supervision of the toxicology laboratory function due to his competing responsibilities.

In accordance with the position description, the Forensic Lab Manager is responsible for maintaining a quality assurance program for both laboratories. However, based on our observations and interviews with toxicology staff, the existing Forensic Lab Manager spends only one hour per week in the lab to check inventory and verify supply orders. Thus, this position is not being utilized to its full potential and should be required to provide managerial and supervisory oversight of all laboratory functions.

Our interviews with staff of the Medical Examiner"s Office revealed widespread dissatisfaction with the management styles of both the Chief Medical Examiner and the Administrative Coroner. Complaints related primarily to the large span of control of these two positions and the lack of clearly stated policies and procedures. This dissatisfaction with management has been a major contributor to low employee morale negatively impacting productivity and performance. Although this is a personnel issue, there are structural changes which could be made to the Department which would reduce the span of control for these top two positions, establish clearer reporting and supervisory responsibilities, and thus potentially lessen the friction between existing management and line staff.

Because of the sameness of functions described above, several jurisdictions have combined the Public Administrator and Coroner functions into one office. In fact, in a survey of 37 California counties by the San Mateo County Coroner"s Office, seven counties reported that they have combined Coroner/Public Administrator offices. These counties are: Fresno, Kern, Humboldt, Sutter, Tehama, Trinity and Kings Counties.

To improve the overall management and organization of the Medical Examiner"s Office (1) the Chief Medical Examiner should (a) assume supervisory and management responsibility of the Medical Services functions of the Office, in accordance with Recommendation VI.1 of this report; and (b) delegate certain management and supervisory responsibilities to more appropriate Medical Examiner"s staff, in accordance with Recommendations V1.2, VI.3 and VI.4; and, (2) the Director of Administrative Services should reorganize the Medical Examiner and the Office of the Public Administrator/Guardian in accordance with Recommendations VI.5 and VI.6 of this report, for an estimated savings of $109,610 annually.

Specifically, the Chief Medical Examiner should:

VI.1 Work with the Human Resources Department to revise the position description for the Chief Medical Examiner, in order to provide the Chief Medical Examiner with responsibility for oversight of the medical and technical functions of the Medical Examiner"s Office, as well as limited supervisory duties.

VI.2 Work with the Human Resources Department to create a consolidated Forensic Laboratory Manager/Forensic Toxicologist position in the Medical Examiner"s Office and delegate responsibility for management and supervision of the Medical Examiner"s Office laboratories to this consolidated position.

VI.3 Revise reporting relationships in the Medical Services Division in order to delegate supervisory responsibility for Histology Laboratory staff, Pathology staff and Medical Transcriber Typists to the Forensic Pathologists.

VI.4 Transfer responsibility for supervision of the investigative function from the Administrative Coroner to the most senior Coroner"s Investigator in the Medical Examiner"s Office, and implement a formal reporting procedure for documenting the frequency and duration of field visits and recording the observations made during such visits by the Senior Coroner"s Investigator.

VI.5 Pending the recommended consolidation of the Medical Examiner"s Office and the Public Administrator/Guardian"s Office by the Director of Administrative Services,

The Public Administrator/Guardian should:

VI.6 Pending the recommended consolidation of the Medical Examiner"s Office and the Public Administrator/Public Guardian"s Office by the Director of Administrative `Services, the Public Administrator/Public Guardian should implement various administrative procedures, including:

The Director of Administrative Services should:

VI.7 Reorganize the Medical Examiner"s Office and the Public Administrator/Public Guardian"s Office in accordance with Recommendations VI.5 and VI.6, above.

In response to Section VI of the audit report, the Chief Medical Examiner states:

• The passage in this audit report regarding the property control audit by the Controller does not mention that the Controller found that with the new safeguards in place, the Medical Examiner"s property and revenue money control was appropriate.

The Budget Analyst acknowledges that two of the specific recommendations, outlined in the Controller"s audit report have been implemented. However, the Medical Examiner"s Office, as of the writing of this report, has not:

• Worked with the Controller"s Office and the Acting Director of Administrative Services to determine whether the property bank account should be closed and payments to relatives of decedents be paid through the Controller"s Office;

• Provided adequate supervision of the employees assigned to account for the cash and revenues of the Office;

• Provided evidence of summary records of the cash it collects from decedents and the amounts it distributes;

• Provided summary records of its revenues and reconciled the amounts it records as collected to the amounts it deposits with the Treasurer on a monthly basis; or,

• Provided evidence that it remits to the Treasurer any decedents" cash the Office has not distributed within 90 days after an inquest of the decedent.

Without specifically addressing each of the recommendations contained in the Controller"s audit report, the Medical Examiner"s Office has not provided sufficient remedy for the problems that led to the Controller"s findings.

Section VII: Staff and Training

During the course of this management audit, the Chief Medical Examiner expressed concerns regarding staffing levels and workload as a result of budget and staffing reductions, as well as existing vacancies in authorized positions. The number of authorized positions has decreased from 39.00 authorized permanent positions in FY 1992-93 to 36.51 authorized permanent positions in FY 1996-97, or a reduction of 2.49 positions (6.4 percent).

As part of the management audit of the Medical Examiner"s Office, the Budget Analyst examined issues related to staffing levels, workload, training and staff qualifications within each division of the Medical Examiner"s Office. In summary, the Budget Analyst found:

• Deficiencies in training for Pathology, Investigations and Toxicology staff. For example, new pathologists are not trained in the protocols used in the Medical Examiner"s Office and a comprehensive procedure manual has not been prepared to provide information on expected protocols. Additionally, the toxicology staff is not adequately cross-trained in all testing procedures, and in the operation of all instruments and equipment required to independently complete the various toxicological analyses, nor has a comprehensive procedural manual been prepared to provide detailed outlines of protocols for such tests.

• Discrepancies between staff qualifications and the required duties of and/or the actual duties being performed by staff members in the Pathology Section. For example, two of the five pathologists are not board certified in forensic toxicology nor have they been declared qualified to sit for the certification examination by the American Board of Pathology. As such, they do not meet the minimum qualifications outlined in the Civil Service job description.

• Excessive staffing in Pathology, based on a workload analysis. For example, on average each Forensic Pathologist in San Francisco conducts 1.2 full autopsies per day and including the 1.2 full autopsies, discharges 1.4 cases per day. In other jurisdictions surveyed for this management audit, the Forensic Pathologists conduct an average of 1.01 to 1.6 full autopsies per day and, including those full autopsies, discharge between 1.35 and 4.2 cases per day. As such, the Forensic Pathologist"s in San Francisco are at the lower end of the range for the total number of cases discharged per day.

Additional detail on the specific findings with regard to staff and training are included in the following three sections.

Section VII.1: Pathology

In our review of the Pathology Section"s staffing and training, we found that: (1) two of the three full-time Forensic Pathologists currently employed by the Medical Examiner"s Office are not board eligible or board certified in forensic pathology; (2) the current staff of Forensic Autopsy Technicians are not being utilized to their potential; (3) two of the observations made by the Office of the Chief Administrative Officer (CAO) in a 1990 review of the Medical Examiner"s Office regarding (a) the lack of in-service training for Pathology staff, and (b) the lack of training for Pathology staff in the use of x-ray equipment, have not been addressed; (4) a comprehensive policies and procedures manual for the Pathology Section does not exist; and (5) the workload in Pathology does not appear to justify the current authorized staffing level for Forensic Pathologists.

As a result, some staff do not meet qualifications as outlined in the Civil Service job descriptions; opportunities for ongoing training are compromised; no clear policies and procedures are articulated; and the overall workload for Pathology staff is low.

The Chief Medical Examiner should establish clearly articulated autopsy procedures; reclassify two Forensic Pathologist positions to Physician Specialist positions; establish a program to improve the training and qualifications of the Pathology staff; and devote half of his time to conducting forensic exams and observing staff who conduct autopsies. This can be accomplished by eliminating current duties such as managing the Toxicology and Histology laboratories, responding to homicide and accident scenes when not required to do so, and directly supervising and managing responsibility for 13 employees.

The Chief Medical Examiner should:

VII.1.1 File a requisition with the Department of Human Resources to reclassify the two Forensic Pathologists who currently do not meet the minimum qualifications for this classification, to the appropriate classification which is consistent with their qualifications. The reclassification would not affect the compensation of the current incumbents. However, salary savings would be achieved if the incumbents vacate these positions.

VII.1.2 Eliminate three 2582 Forensic Pathologist positions and create two new, less costly 2230 Physician Specialists which have completed a residency program and are Board eligible in anatomic pathology. These two new staff should be available to assist the two remaining Forensic Pathologists in performing autopsies and other procedures but should not be required to participate in the on-call rotations for Forensic Pathologists. This change would result in a reduction of one position. These reductions could be achieved through attrition.

VII.1.3 Assist the Forensic Pathology staff with the performance of autopsies on a routine basis, and participate in on-call rotations.

VII.1.4 Establish a detailed written protocol for Forensic Autopsy Technicians which takes into account the medical backgrounds and/or forensic experience of the Forensic Autopsy Technicians currently employed by the Medical Examiner"s Office.

VII.1.5 Prepare a policies and procedures manual for the Pathology Section which includes

VII.1.6 Report back to the Board of Supervisors within six months of the issuance of this report on progress made in

In response to Section VII.1 of the audit report, the Chief Medical Examiner states:

• Four out of the five Pathologists are board certified or board "eligible" in forensic pathology;

• For accreditation the Medical Examiner"s Office requires five full-time forensic pathologists in order to re-establish the training program and handle the workload; and,

• The Budget Analyst"s data comparison of the number of cases per position per year between various departments around the country is not valid.

The Budget Analyst has contacted the American Board of Pathology and the National Association of Medical Examiners (NAME), and obtained information from the medical staff of the Medical Examiner"s Office to ascertain that:

• There are not five full-time Pathologists in the Medical Examiner"s Office; there are three full-time and two part-time Pathologists. Moreover, the Budget Analyst has not made any recommendations to reduce the number of licensed doctors in Medical Services;

• Of the five Pathologists, two are board certified in forensic pathology, one is board certified in anatomic and clinical pathology; one is qualified to sit for the anatomic pathology certification exam; and one has completed fellowships in clinical and forensic pathology but has not provided information that states he/she is qualified to sit for the forensic pathology certification exam. This information on the status of the current staff has been confirmed from documents provided by the Chief Medical Examiner;

• NAME does not state anywhere in its regulations on accreditation that there must be five board certified or qualified forensic pathologists on staff for an operation the size of the San Francisco Medical Examiner"s Office. The requirements are for one Chief Medical Examiner and five other licensed physicians (e.g. pathologists, surgeons, etc.) who perform forensic work; and,

• The data shown in Appendix III accounts for the difference between the total number of cases reported and the number of cases determined to be under the jurisdiction of the Medical Examiner"s Office. For example, the Chief Medical Examiner does not acknowledge that the 6,000 case difference between the 19,000 deaths reported to the Los Angeles Medical Examiner/Coroner"s Office and the 13,000 deaths determined to be under their jurisdiction is analogous to the 5,000 deaths reported to the San Francisco Medical Examiner"s Office and the 1,800 determined to be under its jurisdiction.

The Budget Analyst would further note that the American Board of Pathology does not recognize the term "board eligible" as it clearly states on page 36 of its Booklet of Information, and the Chief Medical Examiner stated in the exit conference that he determined, based on the training of the applicants, that the successful applicants were "board eligible" in forensic pathology. The Chief Medical Examiner does not appear on the list of current or former officers and trustees of the American Board of Pathology and also does not appear as a member of one of the 16 test and recertification committees, which includes the test committee for forensic pathology.

Section VII.2: Investigations

A review of minimum staffing requirements and current staffing levels in the Investigations Division revealed that the Division is overstaffed in permanent Coroner"s Investigator positions. Additionally, the staff of part-time Drivers are paid at the same salary as entry level Coroner"s Investigators, even though Drivers do not possess the same licensing and other qualifications as full-time Coroner"s Investigators.

In addition, based on interviews with staff and on discussions with other jurisdictions, we recommend that the Medical Examiner"s Office prepare a comprehensive training program for all Coroner"s Investigators, which should include some combination of training in homicide investigations, blood spatter analysis, crime scene investigations, etc. Additional training would assist the Forensic Pathologists in making determinations as to the cause and manner of death and would help ensure that Forensic Pathologists are called to suspected homicides and motor vehicle accidents only when absolutely necessary.

The implementation of these recommendations would (a) reduce the minimum staffing requirements for Coroner"s Investigators while maintaining the current level of service; (b) allow the Medical Examiner to provide backfill coverage for Coroner"s Investigators with lower-cost Drivers; (c) increase the competency of all Coroner"s Investigators, thereby possibly reducing call-outs, which are responses to death scenes by Forensic Pathologists; and, (d) result in cost savings of an estimated $81,957 per year.

The Chief Medical Examiner should:

VII.2.1 Change the minimum staffing practices for Coroner"s Investigators during the swing shift from two to one Coroner"s Investigator by arranging for calls to be automatically forwarded to the DPH Paramedic Dispatch phone number after four rings, if no one is available to answer the phone in the Medical Examiner"s Office, as is currently the practice during the midnight shift.

VII.2.2 Reduce the number of Coroner"s Investigator positions by one position, which presently totals 11 positions, to 10 positions. This could be accomplished immediately since there is currently one vacancy in the Coroner"s Investigator classification.

VII.2.3 In cooperation with the Human Resources Department, formally create a part-time Driver classification to perform the duties performed by current staff. This new class of part-time Driver would be paid at the same hourly rate as the 2520 Morgue Attendant classification or the 2523 Forensic Autopsy Technician classification.

VII.2.4 Reduce the annual temporary salaries budget for Investigative Services by $14,149 , from $70,000 to $55,851 per year.

VII.2.5 Prepare a comprehensive training program for all Coroner"s Investigators, which would include some combination of homicide investigations, blood spatter analysis, crime scene investigations and/or other types of training.

In response to Section VII.2 of the audit report the Chief Medical Examiner states:

• He disagrees with the Budget Analyst"s recommendation to reduce the number of Investigators by one because it increases overtime;

• That it is unfair to ask the paramedics to answer the phones between 4:00 PM and Midnight since the phones are typically extremely busy; and,

• The Office has previously requested the Department of Human Resources to create a new classification for the as-needed Investigator who would be paid an entry level salary instead of the same salary as a full-time permanent Investigator.

The Budget Analyst states in the audit report:

• There is currently a vacancy in the Investigator classification and the scheduling presented by the Department meets the current desired staffing requirement for Investigators without requiring increased overtime;

• Based on the Budget Analyst"s observations, the call volume drops significantly after 7:00 PM and the DPH Paramedic Division may have to field a total of 20 calls in a 16-hour period; and,

• The current staffing consists of on-call Drivers who are paid the same amount as an entry level Investigator, but who do not possess the skills or training to qualify for an Investigator position.

The Budget Analyst would also note that the argument that the paramedics do not have access to Medical Examiner"s Office records to furnish information is specious. Under the current arrangement the paramedics take a message that is forwarded to the Investigators on duty. The paramedics currently have no access to the Medical Examiner"s Office records and do not attempt to provide information to individuals calling regarding deceased persons. Also, the Medical Examiner"s Office staff has rejected technological solutions to the telephone answering dilemma such as forwarding such calls to beepers and the use of cellular telephones.

Section VII.3: Toxicology

The National Association of Medical Examiners (NAME), the Society of Forensic Toxicologists (SFT) and the American Academy of Forensic Toxicology (AAFT) recommend cross-training for all toxicology laboratory staff.

The Budget Analyst has determined that the amount of training on instrumentation and procedures should be increased for all toxicology personnel and that the additional training would improve the flow of work, eliminate the dependence of staff on a specific person to complete a test, and reduce turn-around time.

Accordingly, the Chief Medical Examiner should (a) revise the position description for the Assistant Forensic Toxicologist I position to place a greater emphasis on training in the use of laboratory equipment used to conduct tests; (b) develop a procedural manual for Toxicology staff; and (c) as recommended in Sections III and VI of this report, hire a qualified staff person to manage the Toxicology Laboratory.

The Chief Medical Examiner should:

VII.3.1 Revise the position description for the 2456 Assistant Forensic Toxicologist I position to provide a greater emphasis on the ability to independently complete toxicological tests, and to possess familiarity with the equipment and instruments used in conducting such tests.

In response to Section VII.3 of the audit report, the Chief Medical Examiner states:

• The experience held by the staff of the Toxicology Laboratory and the credentials of the personnel qualify them for membership in the Society of Forensic Toxicologists; and,

• Both the Chief Medical Examiner and the Assistant Toxicologist II qualify under the Society of Forensic Toxicologist guidelines to manage the toxicology laboratory.

The Budget Analyst states:

• Membership in the Society of Forensic Toxicologists is not at issue;

• The ability of the Toxicology Laboratory to become accredited and the proper management and oversight of the facility is at issue; and,

• NAME states, as does the Society of Forensic Toxicologists, that the Toxicologist responsible for managing and supervising the laboratory, should hold a doctorate degree from an accredited institution with a chemical, toxicological or pharmaceutical science as a major subject with four years experience in forensic toxicology, or be a toxicologist certified by the American Board of Forensic Toxicologists.

We wish to thank the staff of the Medical Examiner"s Office, Department of Administrative Services, Department of Public Health, District Attorney, Public Defender, City Attorney and Police Department for their assistance and cooperation during this management audit. Without their assistance, our task would have been much more difficult.

Respectfully submitted,

Harvey M. Rose

Budget Analyst

c:
President Kaufman
Supervisor Bierman
Supervisor Brown
Supervisor Katz
Supervisor Leal
Supervisor Medina
Supervisor Newsom
Supervisor Teng
Supervisor Yaki
Supervisor Yee
Clerk of the Board
Controller
Mayor Brown
Steve Nelson, Director of Administrative Services
Boyd Stephens, Chief Medical Examiner
Louise Renne, City Attorney
Terence Hallinan, District Attorney
Jeff Brown, Public Defender
Sandra Hernandez, Director of Health
Fred Lau, Chief of Police
Ricardo Hernandez, Public Administrator/Public Guardian
Steve Agostini
Stephen Kawa
Ted Lakey