The Oregon Department of Corrections plans to comprehensively restructure its troubled health services unit to improve health care for inmates and working conditions for staff, agency officials announced Tuesday.

The pledge comes after years of mismanagement in the unit that bred a toxic work atmosphere among medical providers and substandard care for inmates suffering from ailments of all kinds, from asthma to genital herpes, cancer to traumatic head injuries.

Last December, the state entered a $250,000 contract with the Falcon Group, a consulting firm that specializes in corrections health care, to complete a comprehensive review of the agency’s delivery system, including policies, practices and the quality of care.

The firm delivered 67 findings and key recommendations to address a level of care that it described as fragmented, disorganized and inefficient, according to the report released Tuesday. Among the priorities:

  • Overhauling the internal panels of medical providers, called Therapeutic Level of Care Committees, who determine whether inmates can see outside specialists; giving providers more discretion regarding referrals; and allowing a range of clinical requests to be referred to outside providers without committee approval.  
  • Centralizing scheduling of such visits to address the backlog of needed outside medical trips and hiring more staff to transport inmates to appointments.
  • Prioritizing the implementation of an electronic health records system to organize paper health records that are currently sparse and fragmented, and, according to the report, are undermining safety and quality of care.
  • Establishing a Department of Innovation to oversee data collection, analysis, routine audits and performance improvement within Health Services.
  • Conducting a comprehensive staffing analysis and addressing immediate staffing needs at specific prisons. The report pointed to staffing issues at Oregon State Correctional Institution in Salem, the Two Rivers Correctional Institution in Umatilla, and the Deer Ridge Correctional Institution in Madras.
  • Revising medical grievance procedures to promote rapid informal resolution with inmates and ensure clinicians respond to issues.
  • Exploring the feasibility of creating secure treatment units in off-site hospitals; establishing a neuro-cognitive unit or skilled nursing facility inside the prison system; and replacing the Oregon State Prison with a purpose-built health care facility.
  • Develop an internal and external plan to improve communications between the workforce and inmates, to convey the intention and progress toward improvements throughout the agency, and provide updates to legislative, media and community members.

The agency, which oversees health care for some 12,000 incarcerated individuals across 12 prisons, has faced a growing number of lawsuits from inmates alleging substandard care and conscious indifference to their suffering, and paid millions of dollars in settlements. It has seen staff defections, whistleblower complaints and a 2024 report by an outside accreditation nonprofit that reported a backlog of 600 health care appointments and other deficiencies in the treatment of women incarcerated at the Coffee Creek Correctional Facility.

Media investigations, meanwhile, have documented deep-seated problems within the unit. The Oregonian/OregonLive reported in February that more than half of Oregon’s prison doctors were on paid administrative leave, had been fired or resigned in the past year.

The agency fired its two top administrators earlier this year after an outside investigator delivered a scathing report that questioned the competence Warren Roberts, the unit’s chief medical officer, and his boss, Joe Bugher.

Michael Reese, director of the agency, said in a news release Tuesday that department was committed to improving the quality, accessibility and efficacy of care for inmates and that the report would serve as a strategic guide for prioritizing actions. The agency plans to take the next four months to assess the report and develop an action plan to be carried out under an incoming assistant director of health services.

—Ted Sickinger is a reporter on the investigations team. Reach him at 503-221-8505 or tsickinger@oregonian.com

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