Professional Documents
Culture Documents
Independent Review of Clinical
Independent Review of Clinical
Introduction
Independent of varying laws and national standards, prisoners are entitled to timely access
to a reasonable level of medical, dental, and mental health care for their serious medical
needs. A serious medical need is a valid health condition that, without timely medical
intervention, will cause:
B unnecessary pain;
B measurable deterioration in function (including organ function);
B death; or
B substantial risk to the public health (Greifinger, 2006).
The United Nations (1990) maintains that prisoners have a right to the highest attainable
level of health and care that is the equivalent to the health services available in their country,
regardless of their legal situation. But we know that care behind bars does not always meet
these expectations. As a result, prisoners suffer.
DOI 10.1108/17449201211285012 VOL. 8 NO. 3/4 2012, pp. 141-150, Q Emerald Group Publishing Limited, ISSN 1744-9200 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 141
Patient safety is part of a larger concept known as quality of medical care, which can be
defined as ‘‘the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes.’’ Patient safety is the avoidance of errors of either
omission or commission in the planning or execution of health care interventions. Based on
this definition, the lion’s share of quality of medical care rests within the realm of patient safety.
International agencies, governments, and organizations publish principles and/or
standards for health care behind bars. Among many others, these include the United Nations,
World Health Organization, and the World Medical Association. In the USA, organizations such
as the National Commission on Correctional Health Care (NCCHC), the American Public Health
Association, the American Psychiatric Association, and the American Correctional Association
(ACA) have developed and revised correctional health care standards. These standards are, for
the most part, about patient safety[1]. Independent authors and organizations have also
published on the elements of patient safety that deserve particular attention in prisons (NPPS;
The Physician Practice Patient Safety Assessment, 2006; WHO CCPSS, 2007; National Quality
Forum (NQF), 2009; Stern et al., 2010; Greifinger et al., 2010).
This paper focuses on performance measurement of health services practices that have the
greatest potential to improve patient safety through the reduction of risk of harm. It is designed
to assess the health services in a correctional facility. It is also an adjunct to prudent standards
and practices known to reduce risk of harm (Stern et al., 2010; Greifinger et al., 2010).
The methods and elements described herein apply to quality of clinical care assessments,
as many facility assessments do not address the quality of clinical care. Instead, they look
only at structure and process. Examples of structure include the policies and procedures,
staffing, facilities, and medical records. Examples of process include the timing and the
elements of screening, health appraisal, sick call, and medication management.
Focus
While structure and process are important elements for evaluation, they do not provide a
sufficiently broad picture of the care that is actually delivered to patients in an individual
facility. For example, a timely health appraisal on a prisoner that identifies an acute or chronic
condition is not predictive of whether the care for the identified problem is addressed
adequately; a five-minute response time to a patient who collapses after vomiting blood
does not predict whether the emergency condition might have been avoided by timely care
prior to the event.
Measurement of outcome (such as mortality rates and rates of preventable infections) would
fit the bill, but meaningful outcome measurement is too difficult to accomplish in small
populations. In the health care community, outcome performance measurement is done with
process measures that have demonstrated evidence that harm can be prevented. There are
a wide variety of clinical performance indicators, based on hard epidemiological evidence,
that are known to reduce risk of harm. For example, the laboratory measurement of A1c
hemoglobin in patients with diabetes and CD4 þ counts and viral load in patients with HIV
are predictors of better control and fewer, preventable complications of these diseases;
pregnancy testing and prenatal care are predictors of better pregnancy outcomes; AIMS
testing is a predictor of lower morbidity from antipsychotic medication; and laboratory
monitoring of patients on coumadin and lithium are predictors of fewer adverse
consequences of these medications.
There are high-risk situations that are unique to corrections, however, where there may not
be hard evidence of improved outcome. But there is experience and, generally, consensus
that specific interventions reduce the risk of harm. Examples of these include self-critical,
multidisciplinary mortality review; timely urgent care; management of patients on hunger
strike; and suicide risk assessment.
The elements described in his guide should be customized to the expectations set for each
country or criminal justice agency, keeping in mind the principles of timely access to an
appropriate level of care and equivalence to care available in the community. The locally
j j
PAGE 142 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012
Patient safety is part of a larger concept known as quality of medical care, which can be
defined as ‘‘the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes.’’ Patient safety is the avoidance of errors of either
omission or commission in the planning or execution of health care interventions. Based on
this definition, the lion’s share of quality of medical care rests within the realm of patient safety.
International agencies, governments, and organizations publish principles and/or
standards for health care behind bars. Among many others, these include the United Nations,
World Health Organization, and the World Medical Association. In the USA, organizations such
as the National Commission on Correctional Health Care (NCCHC), the American Public Health
Association, the American Psychiatric Association, and the American Correctional Association
(ACA) have developed and revised correctional health care standards. These standards are, for
the most part, about patient safety[1]. Independent authors and organizations have also
published on the elements of patient safety that deserve particular attention in prisons (NPPS;
The Physician Practice Patient Safety Assessment, 2006; WHO CCPSS, 2007; National Quality
Forum (NQF), 2009; Stern et al., 2010; Greifinger et al., 2010).
This paper focuses on performance measurement of health services practices that have the
greatest potential to improve patient safety through the reduction of risk of harm. It is designed
to assess the health services in a correctional facility. It is also an adjunct to prudent standards
and practices known to reduce risk of harm (Stern et al., 2010; Greifinger et al., 2010).
The methods and elements described herein apply to quality of clinical care assessments,
as many facility assessments do not address the quality of clinical care. Instead, they look
only at structure and process. Examples of structure include the policies and procedures,
staffing, facilities, and medical records. Examples of process include the timing and the
elements of screening, health appraisal, sick call, and medication management.
Focus
While structure and process are important elements for evaluation, they do not provide a
sufficiently broad picture of the care that is actually delivered to patients in an individual
facility. For example, a timely health appraisal on a prisoner that identifies an acute or chronic
condition is not predictive of whether the care for the identified problem is addressed
adequately; a five-minute response time to a patient who collapses after vomiting blood
does not predict whether the emergency condition might have been avoided by timely care
prior to the event.
Measurement of outcome (such as mortality rates and rates of preventable infections) would
fit the bill, but meaningful outcome measurement is too difficult to accomplish in small
populations. In the health care community, outcome performance measurement is done with
process measures that have demonstrated evidence that harm can be prevented. There are
a wide variety of clinical performance indicators, based on hard epidemiological evidence,
that are known to reduce risk of harm. For example, the laboratory measurement of A1c
hemoglobin in patients with diabetes and CD4 þ counts and viral load in patients with HIV
are predictors of better control and fewer, preventable complications of these diseases;
pregnancy testing and prenatal care are predictors of better pregnancy outcomes; AIMS
testing is a predictor of lower morbidity from antipsychotic medication; and laboratory
monitoring of patients on coumadin and lithium are predictors of fewer adverse
consequences of these medications.
There are high-risk situations that are unique to corrections, however, where there may not
be hard evidence of improved outcome. But there is experience and, generally, consensus
that specific interventions reduce the risk of harm. Examples of these include self-critical,
multidisciplinary mortality review; timely urgent care; management of patients on hunger
strike; and suicide risk assessment.
The elements described in his guide should be customized to the expectations set for each
country or criminal justice agency, keeping in mind the principles of timely access to an
appropriate level of care and equivalence to care available in the community. The locally
j j
PAGE 142 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012
customized elements can be made into a toolkit so that reviewers (generally nurses) can
collect and quantitatively analyze the data. Physician review, where medically appropriate,
can be done remotely through exchange of pertinent medical record information. The
expected performance for most measures is 90 percent. Performance on some measures
is expected to be 100 percent, such as self-critical mortality review, follow-up on
consultant/hospital recommendations, monitoring of patients on anti-coagulant medication,
and continuity of antiretroviral medication.
This guide looks at more than 30 areas of correctional health care where the most serious harm
is likely to result for inmates if they are not properly or thoroughly screened, evaluated, and
treated. The measures address high-volume/high-risk situations where good performance
reduces risk to patients and reduces liability for facilities and health care staff. This guide
provides a mechanism for reviewers to assess performance quantitatively, by facility, and
allows comparative analysis of a facility to aggregate data. Once the data are analyzed,
remedies can be identified and monitored over time.
During the past 25 years, the author has reviewed the health care in several hundred police
lock-ups, detention centers, and prisons and I have seen reports on countless facilities by
other reviewers. This is a summary of a method to review the clinical care within a prison, for
quality and timeliness. It is not a comprehensive guide to the investigation of comprehensive
health services. For example, this summary does not include attention to other critical areas
(structure and process issues) that might be included in a comprehensive review, such as:
B sanitation;
B equipment;
B medication formulary;
B housing, including segregation and specialized units;
B nutrition and medical diets;
B policies and procedures;
B chronic care guidelines;
B nurse assessment tools;
B health and custody staff training;
B medical autonomy;
B privacy;
B research;
B credentialing;
B restraints;
B throughcare;
B analysis of complaints and responses; and
B others.
Every element of each performance measure included in this guide should be viewed as
an individual risk factor. Poor performance on any element of any measure can pose risk of
harm. Therefore, the aggregation of data and the calculation of an overall score should
be avoided. For example, there are four elements in the chronic disease measure for asthma.
If a facility scores 100 percent on the first three elements and zero percent for influenza
vaccine, its score is not 75 percent. The score is zero percent for influenza vaccine, which
poses a significant risk of harm. This indicates that the medical care may be deficient and
even harmful for patients and falls short meeting expectations for care. Clinical performance
measurement should help evaluators focus on specific opportunities for improvement and
head off problems before they lead to pain, suffering, serious injury, and/or death of prisoners.
j j
VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 143
Methodology
If you can’t measure it, you can’t manage it (Anonymous, not attributable).
To address aspects of care that pose the most risk of harm and to be fair to the governance
and health care staff of the facility, I do focused reviews of medical records, selected from
data bases that should be maintained by the facility, either written or electronic. These
include practitioner appointment calendars, chronic care registry, medication administration
records, mortality reviews, and outside trips for emergency, specialty, diagnostic, or hospital
care. The individual records are selected according to risk. For example, patients with
chronic disease and patients sent for outside care for ambulatory sensitive conditions, such
as diabetic ketoacidosis, seizures, or cellulitis.
The measures described in Appendix 1 are proxy measures. That is, there is an implicit
assumption that good clinical performance on aspects of care that pose the most risk of
harm can be generalized. This may not be correct. Qualitative analysis of the results of the
performance measurement or analysis of other data may reveal further opportunities for
improvement. This then is an opportunity to refine the measures and the version of the toolkit
developed for individual facilities.
Performance measurement is a quality management tool. It is not research. Thus, to the extent
that the focused reviews are selected randomly within each category, a sample of ten to
12 records is typically sufficient to identify if there may be an opportunity for improvement.
If performance is good, this is sufficient. If performance falls below expectations, in any area,
performance should be assessed on a larger sample, such as 20 records. The sample for
assessment of suicide screening, intake assessment, and comprehensive health assessment,
might need to approach 25 records to obtain an adequate sample to form conclusions.
The measures described in Appendix 1 should not be limited to external review. Internal
quality management programs should integrate clinical performance measurement as
part of the regular self-critical analysis seeking opportunities for improvement. Quality
management programs should include performance measurement for risk reduction and
prevention of harm.
Note
1. Many of the references cited in this article are US-based. In other nations, the relevant standards
should be substituted, where appropriate.
References
Centers for Disease Control and Prevention (CDC) (2010), MMWR, 17 December, Vol. 59, RR-12,
available at: www.cdc.gov/std/treatment/2010/ (accessed 20 September 2011).
Greifinger, R.B. (2006), ‘‘Health care quality through care management’’, in Puisis, M. (Ed.), Clinical
Practice in Correctional Medicine, 2nd ed., Mosby, St Louis, MO, p. 512.
Greifinger, R.B., Stern, M.F. and Mellow, J. (2010), ‘‘Patient safety in correctional settings’’, available at:
http://patientsafetyincorrectionalsettings.com/ (accessed 14 July 2012).
Hayes, L.M. (2007), ‘‘Reducing inmate suicides through the mortality review process’’, in Greifinger, R.B.
(Ed.), Public Health Behind Bars: From Prisons to Communities, Springer, New York, NY, pp. 280-91.
Hoge, S.K., Greifinger, R.B., Lundquist, T. and Mellow, J. (2009), ‘‘Mental health performance
measurement in corrections’’, International Journal of Offender Therapy and Criminology, Vol. 53 No. 6,
pp. 634-47, Abstract, available at: www.ncjrs.gov/App/Publications/abstract.aspx?ID ¼ 251100
(accessed 14 July 2012).
National Institutes of Health (2012), ‘‘Adult and adolescent guidelines for HIV 2012’’, available at: www.
aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID ¼ 7; ACA 2004 4-ALDF-4C-18 http://
aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0/ (accessed 14 July 2012).
NCCHC (2008), Standards for Health Services in Prisons, National Commission on Correctional Health
Care, Chicago, IL.
j j
PAGE 144 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012
NCCHC (2012a), ‘‘NCCHC guideline for disease management, asthma’’, available at: www.ncchc.org/
resources/guidelines/Asthma2011.pdf (accessed 14 July 2012); ACA 2004 4-ALDF-4C-19.
NCCHC (2012b), ‘‘NCCHC guideline for disease management, diabetes’’, ACA 2004 4-ALDF-4C-19
available at: www.ncchc.org/resources/guidelines/Diabetes2011.pdf (accessed 14 July 2012).
NCCHC (2012c), ‘‘NCCHC guideline for disease management, hypertension’’, ACA 2004
4-ALDF-4C-19, available at: www.ncchc.org/resources/guidelines/Hypertension2011.pdf (accessed
14 July 2012).
NQF (2009), ‘‘Safe practices for better healthcare’’, available at: www.qualityforum.org/Publications/
2009/03/Safe_Practices_for_Better_Healthcare%e2%80%932009_Update.aspx
Stern, M.F., Greifinger, R.B. and Mellow, J. (2010), ‘‘Patient safety: moving the bar in prison health care
standards’’, American Journal of Public Health, Vol. 100, November, pp. 2103-10.
The Physician Practice Patient Safety Assessment (2006), available at: www.mgma.com/pppsahome/
United Nations (1990), ‘‘Basic principles for the treatment of prisoners’’, Adopted and proclaimed by
General Assembly Resolution 45/111 of 14 December, United Nations, New York, NY.
WHO-CCPSS (2007), ‘‘World Health Organization Collaborating Center for patient safety solutions of
healthcare providers and systems’’, available at: www.who.int/patientsafety/newsalert/issue2/en/
index.html
Further reading
AHRQ CAHPS: Agency for Healthcare Research and Quality Consumer Assessment (n.d.), available at:
https://www.cahps.ahrq.gov/default.asp
AHRQ PSI: Agency for Healthcare Research and Quality Patient Safety Indicator (n.d.), available at:
www.qualityindicators.ahrq.gov/psi_overview.htm
HEDIS: Healthcare Effectiveness Data and Information Set (n.d.), available at: www.ncqa.org/tabid/
1044/Default.aspx
j j
VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 145
Appendix
j j
PAGE 146 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012
Table AI
j j
VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 147
Table AI
j j
PAGE 148 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012
Table AI
j j
VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 149
Table AI
Notes: aA significant finding is a condition that, without timely intervention, could lead to deterioration in function, pain, death, or risk to the
public health; bthis is a measure of efficiency; many inmates can safely self-administer a wide variety of medications, e.g. medications for
chronic conditions and over-the-counter medications; the higher the proportion, the more time nursing staff has for other duties; cinmate
name, ID number, date of birth, gender; dmedical and mental health diagnoses and treatments; known allergies; efor all encounters, with
documentation of significant findings, diagnoses, treatments, and dispositions, preferably SOAP format; facknowledged and dated;
g
records from prior stays incorporated; hincorporation of information that arrives on paper into the EHR; ian individual is considered to
have a ‘‘disability’’ if s/he has a physical or mental impairment that substantially limits one or more major life activities, has a record of such
an impairment, or is regarded as having such an impairment (www.ada.gov/q%26aeng02.htm (accessed 14 July 2012)
j j
PAGE 150 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 8 NO. 3/4 2012