Addressing quality health care in the correctional setting.

Quality is hard to define, but correctional health care professionals are able to recognize the attributes of a quality health care program when they see one. The simplest correctional health care program, as well as the most complex correctional health care delivery system, can project the essence of quality by providing health care to offenders in an organized and systematic manner, which is supported by research-based practices and the proactive monitoring of the health care being provided by using problem-solving methods. How does a quality health care program evolve in corrections? This is a complex question, because correctional health care is a dynamic and unique business. The quality management process of a health care delivery system is especially challenging in a correctional facility.

Health care in the correctional setting is provided in a controlled managed-care environment by medical, nursing and auxiliary staff. A major difference for correctional health care providers from that of community health care providers is that the central and primary mission of the correctional setting is public safety and confinement, not health care. The focus of the correctional setting's mission, thus, becomes maintaining security.

When the concept of confinement and public safety is explored in its totality, is when the legal obligation and vital necessity of providing health care becomes part of maintaining custody. In the correctional setting, care and custody become the model of the correctional environment. Correctional health care practice occurs in a wide berth of unique programs throughout the county, with many different scenarios existing. Yet, with all the different health care programs, there is a common thread. That is the American Correctional Association's performance-based standards, which include an expectation for a quality management process that is used to measure the quality of the health care being provided in the correctional setting.

Quality management is an ongoing process, not an event. ACA's Standards for Adult Correctional Institutions, Fourth Edition, presents a comprehensive mandatory standard (4-4410) that provides a framework for internal review and quality assurance. This standard allows administrators of each correctional health care delivery system the opportunity to develop a meaningful and useful quality management program to measure and monitor the unique attributes of their health care delivery system. Once implemented, the standard provides administrators the tools to evaluate individual correctional health care systems or programs.

The Correctional Quality Health Care Process

The framework of the correctional health care quality management system as specified by ACA standards is based on a system of documented internal reviews and statistical gathering designed by each system's health authority. The basic components of quality and internal review standard (4-4410) include the following:

     A multidisciplinary team of corrections professionals and/or
     correctional health care professionals. This team participates in
     quality review, improvement or assurance activities and committee
     meetings. The activities of the quality improvement
     multidisciplinary team include the collecting, tending and analysis
     of data, which are unique and meaningful to each individual
     facility. The analysis of the data produces a systematic planning,
     intervening and reassessment of the quality and performance of the
     correctional health care program. The quality improvement team's
     activities and documentation of activities should support an
     evaluation of the defined data, which will result in the effective
     maintenance of offender access to health care, the improved quality
     of offender health care and better use of resources, all while
     maintaining public safety and security of the institution.

     The onsite monitoring of the health care program's performance
     outcome measures. This includes but is not limited to: chart
     reviews by the responsible physician or designee, which include the
     investigation of complaints and the quality of the health care
     record; the review of prescribing practices and the administration
     of medication practices by a responsible physician; the systematic
     investigation of complaints and grievances regarding offender
     health care; and the development and monitoring of corrective
     action plans when improvement opportunities occur.

     The review of all offender deaths that occur in custody. Particular
     attention to suicide offender deaths or suicide attempts by
     offenders should be made. Any communicable disease or illness
     outbreaks should be reviewed for the implementation of a corrective
     action plan. A retrospective review of these types of cases can
     provide meaningful intervention activity to protect offenders and
     staff while improving the health care delivery system.

     The corrective action plan. This includes designing and
     implementing measures to address and resolve important problems or
     concerns that are identified in the data collection review and
     analysis phases of the quality improvement process. The basic
     problem-solving methodology is employed when developing a
     corrective action plan.

     The re-evaluation of problems and concerns unique to each
     individual health care delivery system. Such reevaluation will
     determine objectively whether the corrective measures implemented
     in the corrective action plan have achieved and sustained the
     desired results.

     The results of the internal review activity of the
     multidisciplinary quality improvement committee. The results should
     reflect and be incorporated into the organization's educational and
     training activities.

     The maintaining and documenting of quality improvement. This is
     essential to quality management activities. The recommendation is
     that the recording of meetings and activities occur through
     committee minutes. Reports and minutes can be facilitated by
     regular participation of the facility or program administrator,
     health care administrator and responsible physician. Consider
     having a physician as the quality management program supervisor.

     The preparation of a quarterly report. Compiled and issued by the
     quality improvement committee, the report provides to the health
     care administrator, health care authority, facility administrator
     or program administrator the findings of internal review activities
     and quality management programming.

The entire process of quality management and internal review needs to include provisions ensuring that records of internal review activities comply with the legal requirements on confidentiality of records.

ACA Performance-Based Standards Enhance Quality Performance

The quality activities of a correctional health care program should include a close review of the health care section (E) in Standards for Adult Correctional Institutions, Fourth Edition. The goal of that section is to provide appropriate and necessary health services and care for offenders. This is the same goal for a quality correctional health care program. The performance standard identified is that offenders have unimpeded access to a continuum of health care services so that their health care needs, including prevention and health education, are met in a timely and efficient manner.

Thirty-six outcome measures are designed for statistical gathering, review and evaluation of health care programming. These outcome measures will allow individual health care delivery systems a mechanism to review and safeguard the facility's performance in meeting the outlined goal related to unimpeded access to health care. Analysis of this data on a quarterly basis will provide the quality review committee guidance in developing corrective action plans. Individual comparison data can provide and identify trends and issues unique to the health care delivery program. The inclusion of the outcome measures into the quality improvement activities of a correctional health care delivery program will provide the documentation necessary to maintain a fluid, ongoing quality system.

Statistical analysis identifies issues and trends that may or may not produce the need for intervention. But once an improvement opportunity is identified, a root cause analysis can be beneficial. A root cause analysis may include human factors, equipment factors, controllable environmental factors, uncontrollable external factors, leadership or institutional culture, and information management issues. Improvements to reduce risk and improve health care should ultimately be implemented.

Creating a Quality Correctional Health Care Culture

In addition to setting up a correctional health care delivery framework based on ACA's standards, a good leader--someone to carry out the task at hand and motivate those involved in the process of quality management and review--is essential.

Leaders should promote effective team functioning when developing a quality management program. A multidisciplinary team needs clear objectives when designing corrective action plans from emerging problem identification and effective problem solving. Leaders should anticipate the unexpected; risk is always emerging but not always foreseeable.

Also, leaders should create a learning environment. Alert, well-trained clinicians and health care providers are crucial to the success of a quality correctional health care program.

Finally, leaders should enhance awareness to quality issues--acknowledge that systems are fallible and risk is inherent to complex systems. Analysis and review of the entire system and corrective action plan implementations will redirect the correctional system toward the improvement of quality in the health care program.

Conclusion

Quality management in correctional health care is a dynamic and fluid process that can be achieved by using ACA's standards and performance-based outcomes as a framework.

Quality becomes an institutional objective. The risk of failure is inherent in complex systems. The primary mission of corrections is not health care but public safety and security. Parameters regarding this primary mission need to be intertwined with the health care delivery system's quality management program. A keen astuteness to this aspect of providing health care will always be necessary. Quality is everyone's responsibility.

Quality can be addressed using the ACA model in the smallest correctional health care program as well as the largest complex correctional health care systems. Quality improvement activities need to keep the primary mission of security and public safety in the forefront. An institutional culture that promotes quality improvement activity is essential to the correctional health care delivery system.

Table 1. Quality Assurance and Internal Review Continuum

Assessment Phase:
  * Statistical gathering
  * Review of complaints and systematic investigation of grievances
  * Chart reviews regarding the quality of the medical record
  * Review of prescribing practices
  * Review of centennial events

Identification of Concerns:
  * Problem-solving and goal-setting

Corrective Action Plan Development:
  * Actual intervention to enact changing policy and procedures
  * Incorporating findings of internal review activities into education
    and training activities

Evaluation/Re-Evaluation of the Corrective Action Plan:
  * Maintaining records
  * Quarterly reports
  * Maintaining legal requirements of records and patient
    confidentiality
  * Redesigning planned interventions and/or evaluating if the desired
    outcome has been achieved

Kathleen Bachmeier, RN, M.S., is director of medical services for the North Dakota State Penitentiary in Bismarck.