ACA Correctional Health Care Standards - Looking Forward.
The decisions being made by clinical and correctional decision-makers are more complex and difficult than ever before. Correctional health care has been described as a huge jigsaw-puzzle with many interconnecting and interdependent pieces. Access standards, disease management, quality improvement, security controls, staffing issues and legal requirements represent just a few of the critical issues in building a quality correctional health care system.
So, where does a correctional agency or correctional health care provider turn for guidance and assistance in putting all the pieces of the puzzle together? The answer is the American Correctional Association (ACA). Health care standards have been an integral part of ACA accreditation programs since their creation in the 1970s.
In 1989, ACA published its first health care-specific program -- Certification Standards for Health Care Programs. In addition to health care standards, this program included standards on safety and emergency procedures, sanitation, security and control, training and staff development, and fiscal and personnel procedures. Several facilities continue to maintain certification in this program. Through various forums, ACA's membership has become more aware of correctional health care issues and the need to better evaluate the performance of correctional health care operations.
In 1999, ACA's senior leadership responded to the concerns of its membership and committed to a major revision of the Certification Standards for Health Care Programs. A health care task force was formed and charged with updating existing health care standards and developing a new health care program based on contemporary correctional health care practices. The health care task force is comprised of prominent health care and corrections professionals from a variety of clinical and correctional disciplines. Key members of the health care task force include three state medical directors, a correctional nurse, a clinical psychologist, the director of a large state correctional system, a correctional health services administrator, a senior federal sector representative, a corrections consultant, an infectious disease specialist and the sheriff of a large metropolitan area. When completed, the new manual program will be titled Standards for Correctional Health Care Programs.
Another endeavor for the task force was for the new correctional health care program to be developed as a performance-based standards model. Performance-based standards are a growing trend in both the public and private sectors. The federal Government Performance and Results Act was instrumental in setting an example and requires all federal agencies to develop a set of performance measures to evaluate whether they have achieved their missions and goals. Other organizations and businesses were encouraged to follow the government's lead and to embrace similar performance-based models. Performance-based standards are not unique to ACA accreditation programs and currently are being used in various formats by other accreditation organizations. However, they are relatively new to the health care setting.
ACA formally endorsed performance-based standards several years ago and already has revised Standards for Adult Community Residential Services to include performance-based standards. Both the performance-based standards model and the traditional process-oriented standards model require an evaluation of policy, procedures and practice. In addition, several of the elements in each model are essentially the same even though they have different names. The major difference between the two models is that performance-based standards require the analysis of outcome measures (essentially data elements), which are used to determine an organization's overall performance.
Outcome measures are distinct from program activities. For example, counting the number of tuberculin skin tests given to offenders is not an outcome measure (it is a process indicator), but measuring the incidence of positive readings or diagnosed TB in the offender population is an outcome measure. Similarly, counting the number of consultations or referrals ordered by a primary care provider is a process indicator, while measuring the number of consultations or referrals that actually occurred is an outcome measure. When trended, outcome measures can be used (over time) to help a facility determine how well it is meeting short- or long-term requirements and goals. Outcome measures are not intended to create facility or industrywide benchmarks and, by design, they make no attempts to address the financial or human resource requirements of a facility. Outcome measures essentially are "report cards," that evaluate the overall impact and effectiveness of compliance with a particular standard or group of expec ted practices.
Outcome measures are a key element of performance-based standards and they deserve much discussion. However, another element of ACA's forthcoming Standards for Correctional Health Care Programs deserves equal attention. Approximately 100 expected practices were drafted by the health care task force after a detailed review of existing correctional health care-related standards. Many standards were revised, consolidated, deleted or added. Expected practices now reflect contemporary correctional health care practices and truly are the "core' of Standards for Correctional Health Care Programs. Expected practices are the "little pieces" of the big correctional health care puzzle. When connected (followed), they bring a correctional health care program together.
Standards for Correctional Health Care Programs will soon be available to correctional agencies that desire a stand-alone accreditation of their health care programs or a specialized accreditation to complement ACA's facilitywide accreditation award. When part of a combined audit, Standards for Correctional Health Care Programs will supercede the health care standards in other program manuals. It is anticipated that at least two health care professionals will spend at least three days auditing the new program, regardless of whether it is a combined or stand-alone health care audit. For very large health care operations, such as medical or mental health centers, additional auditors may be used. Approximately 100 health care auditors already have been chosen to perform these specialized audits. They represent a variety of health care disciplines and include representation from physicians, nurses, mental health practitioners, health services administrators and dentists. Many of these auditors already are partic ipating as members of ACA audit teams. Standards for Correctional Health Care Programs is a logical and timely addition to ACA's standards and accreditation program and demonstrates the organization's responsiveness to the needs of its membership.
Keith Midberry is a former regional manager for ACA's Standards and Accreditation Department.
Elements of process-oriented standards from Adult Correctional Institutions, Third Edition:
Standard: a required condition, a specific number, a requirement that a process or policy and procedure be in place.
Example: written policy, procedure and practice designate the conditions for periodic health examinations of inmates.
Primary Documentation: the written guidelines specifying what will be accomplished and how it will be done.
Example: written policy and procedures; physical exam forms.
Secondary documentation: the backup materials that demonstrate that written policies and procedures are being implemented; the "tracks" or "footprints."
Example: completed physical exam forms.
Elements of performance-based standards from Standards for Correctional Health Care Programs:
Performance standard: what is to occur; defines essential condition to be achieved; represents a state of being, not an activity.
* Offenders have unimpeded access to a continuum of health care services.
* Health care services are evaluated and continually improved.
* Offenders are treated fairly and their rights are not violated.
Outcome measures (data): effectiveness; measurable evidence compared over time; indicates improvement or sends up red flag; collected continuously, analyzed periodically; expressed as ratios, rates or percentages.
* Number of offender specialty consultations completed during a 12-month period; number of specialty consultations ordered by primary health care providers during a 12-month period.
* Number of problems identified by internal review that were corrected during a 12-month period; number of problems identified by internal review during a 12-month period.
* Number of offender grievances related to unfair treatment or rights violations found in favor of the offender during a 12-month period; number of offender grievances related to unfair treatment or rights violations during a 12:month period.
Expected practices: how to accomplish the standard (the means to an end): actions that produce the desired outcome, what we think is necessary to gain compliance (not necessarily the only way to do so); best thinking of the field (previously called standards).
* Offenders who need health care beyond the resources available in the facility, as determined by the responsible physician, are transferred under appropriate security provisions to a facility where such care is available. There is a written list of referral sources for emergency and routine care that is reviewed and updated annually.
* Monthly statistical reports are prepared and include, at a minimum, the utilization of health care services by category, referrals to specialists, prescriptions written, laboratory/X-ray tests completed, infirmary admissions (If applicable). off-site hospital admissions, serious illnesses/injuries, deaths and off-site transports.
* There is a system for resolving offender grievances relating to health care disputes.
Protocols: a written framework or instructions that guide implementation. i.e., policies and procedures, post orders, training curriculum, formats for logs and forms, handbooks, facility diagrams. etc. (previously called primary documentation).
* Written policy and procedures; referral/consultation forms.
* Written policy and procedures; statistical report forms.
* Written policy and procedures; grievance report forms.
Process Indicators: evidence that practices are actually (and properly) being implemented and documentation that can be periodically and continuously analyzed; tracks or footprints that allow management to monitor ongoing operations. i.e., logs, records, measurements, observation, interviews (previously called secondary documentation).
* Health record; completed referral/consultation forms; transportation log; interviews.
* Documentation of monthly statistical reports.
* Grievance records; interviews.