Outcome-based health care accreditation: management tool of the future.
Accreditation is a term many are familiar with, but just what is it and what is its significance? While accreditation is widely viewed as an evaluation that takes place at a single point in time, it is actually a process. Like all processes, accreditation covers multiple facets. Of the lesser known is its use as a management tool In the correctional arena, several aspects of the outcome-based accreditation process enable the correctional manager to make decisions about the cost-effectiveness and challenges of a program, thereby making it an excellent management tool. Accreditation is used in such a capacity and offers many benefits to correctional administrators.
Just like any evaluation, the accreditation of a correctional facility or programs is most effective if it is conducted by an outside source, which tends to be more balanced and impartial than one from within. When accreditation is performed in this way, it demonstrates that at least minimum standards are being met and ensures stakeholders--be they the legislature, the contract manager, the facility director, employees or the court system--that a given facility is being run properly.
However, because stakeholders are apt to have different, and sometimes contrasting, views, some challenges can be expected. One group of stakeholders, for example, may be focused on getting tough on crimes and offenders, while another may believe that incarceration, by its very nature, is inhumane. Yet another group, generally represented by various media outlets, may not have any strong feeling one way or the other, but seeks out and publicizes the most sensational aspects of incarceration and detention, regardless of whether those incidents are representative of a facility or system as a whole. While the accreditation process may not alter the ingrained views of stakeholders, by opening the inner parts of a system to scrutiny from an outside "expert," it can allay and defuse some of the debate between stakeholders and provide important information about how things are and how things need to be changed.
The corrections field is one of the few professions that has opened itself to scrutiny. With the exception of those organizations in the medical field, which are typically obligated to be accredited, most professions are not required to endure an accreditation process, but rather are evaluated on the peer level. The only time any other organization such as this undergoes scrutiny from the public is when it has demonstrated some level of misconduct and is then investigated. With both medicine and corrections, however, there is a prospective evaluation of performance judged against a series of accepted professional standards.
In fact, for privatized corrections, many of the successful bidders must maintain correctional accreditation to continue their contracts. Accreditation establishes that the facility is providing services at the level of quality for which the customer has contracted, and in so doing, offers the customer a greater degree of assurance.
While other monitoring tools can be applied in both the private and public sectors, outcome-based accreditations permit the evaluation of quality-specific program delivery in a fashion that has been unheard of up until now. It also permits trending of data and making data-driven decisions on particular kinds of care.
Realizing Higher Standards
In a traditional accreditation process, the processes, efforts, output and attempts were each measured, and specific items were determined to be either present or absent. For example, a survey might ask if HIV inmates have access to care and if the ones who are being cared for are receiving a combination drug therapy. While this type of evaluation measures the constitutional requirement for access to care and can determine if the community standard care is being delivered, it provides no information about the quality of that care.
On the other hand, an outcome-based measurement will reveal the results of the activity by measuring conclusions rather than output, accomplishments rather than effort, successes rather than attempts, and outcomes rather than processes. In the HIV example just mentioned, the only items measured were the processes--the access to care and the inmates' receipt of a therapeutic drug cocktail. If an outcome-based measurement were applied, in addition to some of the same basic inquiries, it would also ask the agency to analyze the data in such a way that real data-driven decisions would be able to be made.
This represents a significant change from the "old-fashioned" way. Previously, accreditation could be granted based on standards such as a goal statement, a performance standard, and expected practice, protocols and process indicators. Now, however, the requirement is that an evaluation of an outcome be made.
It is important to understand the definition of outcomes as they are applied in the accreditation process. Simply stated, outcomes are measurable events, occurrences, conditions, behaviors or attitudes that describe the consequence of the program activities. Outcomes can be expressed in a variety of ways. They can be expressed numerically as a rate, such as the frequency of an occurrence over time; as a ratio (or in other forms of prevalence), which, for example, would compare the number of HIV inmates with the total number of inmates in the facility (average daily population); or as proportions, which compare a part with a whole, such as the number of grievances found in favor of an inmate compared with the total number of inmates.
The following is an example of outcome measures: Standard 1HC-1A-14 states that there must be a written plan to address the management of HIV infection. The plan includes procedures for the identification, surveillance, immunization (where applicable), treatment, follow up and isolation (where applicable) of the infected inmate. In the past, accreditation could be granted on the mere presence of the plan and some assurance that the plan was being implemented. For instance, one could see that some inmates were on a multiple drug regimen for HIV treatment. However, the new outcome-based measurements require an analysis of the consequences of the effort--not just that the effort was being made--which serves as a far more valuable piece of information.
Not only are these outcome-based measurements more effective in the short term, but also in the long term. For instance, because the manager knows the costs of providing services, an analysis of cost trends can determine factors such as if the cost is increasing or decreasing, whether the outcome is improving, if the expense is worth the outcome and whether a manager can accept a lesser outcome at a significantly lesser expense. Both facility administrators and health care providers help reach a decision regarding these matters. Ultimately, though, the administrators of the state or facility make the decision by appropriating the funding for the activity.
Uncovering Data-Driven Information
The first audit of any outcome-based accreditation not only ensures that performance is at an acceptable level, it also indicates that the outcomes the facility achieves are at an acceptable level. With each subsequent audit--and each preparation for an audit--a different set of trends is revealed.
For instance, the HIV example discussed earlier determined only whether inmates with HIV would receive a multiple drug treatment regimen consistent with their medical condition. That scenario only indicates if a process had been put into place and whether it was being followed, but provides no information about whether the process is effective or what conditions could improve effectiveness.
However, because outcome measures require that additional information be analyzed, in this same example, the process would entail that all inmates with HIV have their viral loads controlled. The outcome measurement then would be the number of inmates with their viral loads controlled, divided by the number of inmates with HIV.
One of the advantages of this type of measurement is that it provides relevant data not only on the degree of effectiveness, but also on what can be done to make the process more effective and what can be eliminated. How is this accomplished? Consider the following scenario based on the previous example:
In the first year, only half of the inmates achieve an undetectable viral load on a combination drug therapy cocktail. The medication cost inclusive of the keep-on-person delivery system is $10,000 per year, per inmate. If this 50 percent level of undetectable is unacceptable, directly observed therapy can be initiated. Medication costs would then remain the same, but administration costs would increase by $200 per year, per inmate for a total of $10,200.
In preparation for the interim accreditation report, it is noted that now 95 percent of the inmates with HIV have a 95 percent undetectable rate. Because this is a good result, the facility continues this for approximately one year. When the legislature requests additional cost cuts, the health services department is asked to devise a plan. One potential solution is to merge self-administered therapy and directly observed therapy. Most of the inmates are on self-administered therapy with only the most recalcitrant on directly observed therapy. Now, 84 percent have an undetectable viral load rate, but nursing costs have decreased by $170 per inmate, per year. It now costs $10,030 to achieve an 84 percent undetectable viral load.
At this point, several questions must be answered. First, is 84 percent acceptable and is it acceptable at the savings of $170 per year, per inmate with HIV? In addition, is it worth $170 to move from 95 percent undetectable to 84 percent undetectable?
Of course, it is certainly worth $200 to move from 50 percent to 95 percent undetectable. (This does not include the humanitarian goal that was achieved.) Studies have demonstrated that for most systems, inmates without the severe complications of HIV are much less expensive to treat than those with significant complications, and there is the added security benefit of having fewer unaccounted for drugs on the compound. Clearly, the initial decision was well worth it, as it saves money in the long run and eases security's burden.
Arriving at a conclusion for the second question is more complicated and must be answered by the individual facility administrator. Whether it is more cost effective in the long run to move back to 95 percent at a cost of $170 per HIV inmate and whether that cost will be offset by higher costs in caring for the complications of HIV depends on the average length of stay and the average level of inmates with HIV in the facility.
The bottom line is that without performance-based outcome measures, one does not have the data necessary for making the inquiry. The questions, in fact, cannot even be posed without the data from the outcome measurements. By capturing outcome measurements, the administrator is in a position to note trends and uncover the cost of the outcome and adjust the outcomes predicated on a scientifically valid cost/outcome analysis. This leads to a data-driven system, which represents a substantial improvement from the past. Previously, prior to collecting outcome data and converting it to numerical equivalents, correctional management was based solely upon observation and comparison of processes. Now, by using outcome-based accreditation measurements, for the first time, the manager of a facility or program has the real capacity to make data-driven decisions and note the results of those decisions in an analytical way.
David L. Thomas, M.D., JD, is professor and chair of the Department of Surgery, and professor and chair of the Division of Correctional Medicine at Nova Southeastern University in Fort Lauderdale, Fla. He is also former chair of the Commission on Accreditation for Corrections for the American Correctional Association. Elizabeth F. Gondles, Ph.D., works nationally on correctional health care issues and has done extensive work on viral hepatitis in correctional settings. She is president of the Institute for Criminal Justice Health Care and serves as the health care adviser to the president of ACA.
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|Author:||Thomas, David L.; Gondles, Elizabeth F.|
|Date:||Dec 1, 2004|
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