Independent review of clinical health

services for prisoners

Robert B. Greifinger

Robert B. Greifinger is a
Consultant Physician at
John Jay College of
Criminal Justice, City
University of New York,
New York, USA.

Abstract
Purpose The purpose of this paper is to describe the parameters for the development of performance
measurement of the quality of medical care behind bars, drawing from widely-published free-world
clinical guidelines and aspects of care that are unique to the criminal justice arena.
Design/methodology/approach One way to help assure that prisoners receive timely and
appropriate health care is through independent review of health care services, to identify strengths of
programs and opportunities for improvement. This is a quality of medical care assessment. When done
in a systematic way, this has the potential to reduce risk of harm and enhance the personal health of the
prisoner and improve the public health. Independent external review provides the best opportunity
to identify and remedy opportunities for improvement. External can mean wholly independent or
corporate, that is, review by agency staff that has no vested interest in the findings at the individual
facility. Recently, the methodology for assessment of the quality of medical care in the community has
blossomed, yet there is little guidance on how to adapt this methodology to the prison setting.
Findings This paper introduces a prison-oriented method for assessing clinical performance. To the
extent possible, the author cites references to the scientific basis for the recommendations. Where there
is no science, the author relies as much as possible on consensus, and in a few cases resorts to
wisdom and experience, as unreliable as this might be. This is a conceptual paper with a viewpoint.
Originality/value The paper provides guidance on reducing risk of harm and promoting improved
health and health care for prisoners.
Keywords Prisons, Health care, Service delivery, Performance measurement,
Clinical quality assessment, Prisoner health care
Paper type Conceptual paper

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;

measurable deterioration in function (including organ function);

death; or

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

INTERNATIONAL JOURNAL OF PRISONER HEALTH

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 lions 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 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

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 lions 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 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

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;

equipment;

medication formulary;

housing, including segregation and specialized units;

nutrition and medical diets;

policies and procedures;

chronic care guidelines;

nurse assessment tools;

health and custody staff training;

medical autonomy;

privacy;

research;

credentialing;

restraints;

throughcare;

analysis of complaints and responses; and

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.

VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 143

Methodology
If you cant measure it, you cant 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 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 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.

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

About the author

Robert B. Greifinger, MD, is a Consultant Physician who focuses on improvements in the
quality of health services for adults and juveniles behind bars. Robert B. Greifinger can be
contacted at: bob@rgreifinger.com
(The Appendix follows overleaf.)

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints

VOL. 8 NO. 3/4 2012 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 145

Appendix

Table AI Suggested clinical performance measures for internal or external review

1. Suicide screening (NCCHC, 2008; P-E-02, P-G-05 and Appendix C; Hoge et al., 2009; ACA 2004 4-ALDF-4C-32)
Sample: 25 randomly selected mental health screens that address suicide risk
Item no.
Measure
1
Is an acceptable suicide risk management screening instrument used?
2
Do all individuals identified as needing mental health services receive a full mental health
evaluation and treatment, where appropriate?
3
Are prisoners assessed to be suicidal placed on suicide watch and treated by mental health
professionals?
Note
All screeners and all staff in direct contact with inmates should receive training regarding suicide
in inmates. Training logs should be kept for all contact staff
2. Health assessment (NCCHC, 2008; P-E-04; ACA 2004 4-ALDF-4C-24, 4-ALDF-4C-25)
Source
Inmates arriving during recent period, at least two weeks prior to review, to allow for evaluation of
timely follow-up
Sample
Ten chosen at random
Item no.
Measure
1
Is the initial screen complete within 12 hours of booking?
2
PPD placed during medical screening, if applicable, and read within 48-72 hours, or if PPD is
positive by history, chest X-ray is ordered and read?
3
Was there timely follow-up for significant findings of acute and chronic conditions?a
4
Complete health evaluation: vital signs, adequate medical and behavioral health history, physical
examination by licensed MD/PA/NP/RN within 14 days of booking, except patients with HIV,
diabetes, dialysis, asthma (on daily meds), and other chronic illness will be seen within 48 hours?
3. Sexually transmitted infections (CDC, 2010)
Sample: Ten patients with each condition, identified from laboratory logs
Item no.
Measure
1
Do patients with a positive test for syphilis receiving appropriate Rx (based on CDC or other
relevant guidelines) within three days of timely lab report?
2
Do patients with a positive test for gonorrhea receiving appropriate Rx (based on CDC or other
relevant guidelines) within three days of timely lab report?
3
Do patients with a positive test for chlamydia receiving appropriate
Rx (based on CDC guidelines) within three days of
timely lab report?
4. Intake evaluation pregnant women (Stern et al., 2010; NCCHC, 2008; P-G-07; ACA 2004 4-ALDF-4C-13)
Sample: 10 most recent pregnant women, in custody $30 days
Item no.
Measure
1
Is a pregnancy test performed on females aged 10-54 during intake screening or prior to initiation
of any medication regimen or X-ray?
2
Was an OB/GYN consult ordered within seven days?
3
Are pregnant patients seen by OB/GYN within 30 days?
4
Are pregnant patients screened for HIV, STI, and viral hepatitis?
5
Is hepatitis B vaccine offered?
6
Are prenatal vitamins prescribed?
5. Urgent care (NCCHC, 2008; P-A-01, P-E-07; ACA 2004 4-ALDF-4C-03, 4-ALDF-4D-03)
Sample
Ten urgent care visits by inmates with potentially serious complaints that occurred one to three
weeks prior to review. Common potentially serious complaints include chest pain, abdominal
pain, seizure, vomiting, skin infection, diabetic complications, etc.
Item no.
Measure
1
Timely and appropriate evaluation by nursing staff, depending on the nature of the complaint?
2
Care within the scope of staff members license?
2
Vital signs documented during nurse assessment?
3
Timely referral to a licensed independent practitioner, where appropriate?
4
MD/PA/NP assessment and plan documented, where appropriate
6. Evaluation of care provided prior to visit in hospital emergency department, for ambulatory sensitive conditions (NCCHC,
2008; P-E-12)
Sample
Within the past six months, 12 patients sent to ER with ambulatory sensitive conditions, such as
seizure, alcohol and/or substance withdrawal, skin or deep tissue infections, diabetic
ketoacidosis, abdominal pain,
or chest pain
(continued)

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Table AI
Item no.
1
2

Measure
Is there an outbound progress note?
From the progress notes and other medical records (including requests for care prior to the
ER trip), there are no indications that earlier intervention might have prevented deterioration to the
point of need for ER/hospital care? If yes, describe. (This element may require physician review.)
3
Is there an inbound progress note detailing ER/hospital findings and recommendations?
4
Have these recommendations been followed? If not, is there documentation of the rationale for
not following the recommendations?
7. Medication administration records
Sample
Visual scan of the records
Item no.
Measure
1
Percentage of undocumented (blank) spaces in the medication administration books?
2
Assess percentage of refusals/no shows (on three consecutive days or three consecutive doses
and/or 50 percent of doses missed within seven days, including psychotropic medications) with
medical record documentation that ordering practitioner was informed and
follow-up/counseling?
3
Estimate percentage of patients on self-administered medication?b
4
In the medical record area, number of months of MARs not filed in individual medical records?
8. Continuity of medication (Greifinger, unpublished)
Sample
Ten patients with initial intake orders for chronic medications with time urgency, such as HIV
medications, coumadin, psychotropic medication, diabetes medication, or new prescriptions for
antibiotics (psychotropic medication must be part of the sample)
Cross-check date of first dose with order date in the medical record
Item no.
Measure
1
Period of time from completion of intake screening to the ordering of medications less than 24
hours?
2
Period of time from order to first dose less than 24 hours?
9. Diagnostic services and specialty care access (NCCHC, 2008; P-D-05; ACA 2004 4-ALDF-4C-06)
Sample
Ten specialty patients chosen at random
Item no.
Measure
1
Documented time urgency on order?
2
Accomplished within 45 days of order or within ordered timeframe, e.g. return in 90 days?
3
Documented re-evaluation of patient for deterioration each 30 days in excess of time urgency on
order?
3
Clinician acknowledgement and report in medical
record within seven days?
10. X-rays (Greifinger, unpublished)
Sample
From X-ray log, ten consecutive cases from during the six months prior to review, most recent first
Item no.
Measure
1
X-ray performed within time ordered by clinician?
2
Documentation noted in medical record if X-ray is abnormal?
3
Clinician acknowledgement?
4
Report in medical record within seven days?
11. Chronic disease registries (NCCHC, 2008; P-G-01)
Sample
Ten patients on chronic disease medications, such as hypertension, diabetes, asthma, HIV,
elevated lipids
Item no.
Measure
1
Are patients monitored regularly for their chronic conditions?
2
Are patients seen at the prescribed frequency?
12. Chronic disease: diabetes (NCCHC guideline for diabetes; NCCHC, 2012b)
Sample
Ten patients with diabetes chosen at random
Item no.
Measure
1
Blood sugar on intake?
2
Seen for chronic care within seven days of illness identification?
3
Baseline HA1c performed within 30 days of intake or within past three months
4
Measurement of lipids and blood pressure; prescription for aspirin, as clinically indicated?
5
Documented degree of control (goal,7.0); strategy to attain diabetes control documented if
above goal?
6
Flu vaccine annually, in season (1 October-15 February) or documented refusal in chart?
7
Documented pneumococcal vaccine or documented refusal in chart?
13. Chronic disease: asthma (NCCHC Guideline for Asthma; NCCHC, 2012a)
(continued)

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Table AI
Sample
Item no.
1
2
3

Ten patients with asthma chosen at random

Measure
Seen in CCC within 14 days of illness identification?
Peak flow at initial history and physical and within the past three months?
Followed chronic disease guideline, such as determined severity, medication consistent with
severity, documented degree of control? (may require physician review)
4
Influenza vaccine annually, in season
(1 October-15 February)?
14. Chronic disease: seizure disorder (Greifinger, unpublished)
Sample
Ten patients with seizure disorder chosen at random
Item no.
Measure
1
Appropriate neurological history at physical examination?
2
Seen in for chronic condition within 14 days of illness identification?
3
Serum drug levels performed every three months until stable, then every six months, where
indicated?
4
Treatment plan established, including orders for bottom bunk, where appropriate?
15. Chronic disease: HIV (National Institutes of Health, 2012)
Sample
Ten patients with HIV chosen at random
Item no.
Measure
1
Documented HIV by laboratory or prior medical records?
2
CD4 and viral load within three months from prior records or ordered and performed within 14
days of admission?
3
Seen by HIV certified or otherwise competent MD or mid-level within 14 days of above order?
4
Antiretroviral treatment considered and documented?
5
Followed chronic disease guideline within 30 days of problem identification?
6
Influenza vaccine annually, in season (1 October-15 February) or documented refusal in chart?
7
Documented pneumococcal vaccine, by history or given within 30 days or documented refusal in
chart?
8
Chest X-ray within 72 hours of problem identification, if not already done?
16. Chronic disease: hypertension (NCCHC Guideline for Hypertension; NCCHC, 2012c)
Sample
Ten patients with hypertension chosen at random
Item no.
Measure
1
Blood pressure reading noted at intake?
2
Patient seen within 14 days of illness identification?
3
Blood pressure . 140 systolic or . 90 diastolic: treatment or plan will be initiated within 14 days
of identification?
4
Followed chronic disease guideline, including baseline laboratory testing?
17. Anticoagulant medication (Greifinger, unpublished)
Sample
All inmates on anticoagulants with a narrow therapeutic index, within the past year, up to ten
Item no.
Measure
1
Is an INR log is maintained?
2
INRs are performed at the frequency ordered by the practitioner?
3
Results are documented on the log and in the medical record and acknowledged by the
practitioner?
4
Dosing is adjusted, where medically appropriate?
18. Abnormal involuntary movement (Hoge et al., 2009)
Sample
Ten patients, chosen at random, on first- or second-generation antipsychotic medication, such as
chlorpromazine, haloperidol, thioridazine, olanzapine, aripiprazole, quetiapine, risperdone, and
ziprazadone
Item no.
Measure
1
Abnormal involuntary movements assessed and documented at baseline (the initiation of
antipsychotic treatment in the facility)?
2
Reassessments performed and documented, at a minimum, every six months, regardless of
whether a first- or second-generation antipsychotic medication is prescribed?
3
A standardized assessment tool, such as the AIMS, is employed?
19. Monitoring for lithium toxicity (Hoge et al., 2009)
Sample
Ten patients on lithium, chosen at random
Item no.
Measure
1
Pretreatment workup includes history and physical examination, evaluation of kidney function
(creatinine and blood urea nitrogen), thyroid function tests, complete blood count, and
pregnancy testing for female patients?
(continued)

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Table AI
2
3

Trough lithium level drawn ten days after beginning treatment?

Trough lithium level drawn every three months at a minimum, even if there have been no dosage
changes and the levels have been stable?
4
Monitored trough levels after any dosage change, within ten days?
5
Thyroid and kidney functions checked each quarter for six months (twice), thereafter, yearly
unless greater frequency is clinically indicated?
6
Affirmative statement in progress notes that indicate labs, evaluation for presence of side effects
and toxicity, and other clinically relevant data?
20. Monitoring valproic acid levels (Hoge et al., 2009)
Sample
All patients currently on valproic acid (depakote, depakene), up to ten records
Item no.
Measure
1
Prior to initiation: complete blood count; liver function; pregnancy test, in females?
2
Monitoring of labs: liver function every six months for one year, annually thereafter?
3
Trough levels checked within 30 days of any change in dose?
4
Affirmative statement in progress notes that indicate labs, evaluation for presence of side effects
and toxicity, and other clinically relevant data?
21. Antipsychotic medication: monitoring for metabolic syndrome (Hoge et al., 2009)
Sample
Ten patients on antipsychotic medication, chosen at random
Item no.
Measure
1
Weight checked at baseline, then monthly for three months, then quarterly thereafter?
2
Body mass index calculated at least quarterly?
3
Lipid profile at baseline, 12 weeks, and every five years thereafter?
4
Fasting blood sugar at baseline, 12 weeks, and then annually? (in facilities where fasting blood
sugars cannot be assured, A1c hemoglobin is a viable alternative)
5
Vital signs initially, at two months, then quarterly?
22. Mental health treatment planning (Hoge et al., 2009)
Sample
Ten patients, selected randomly, on mental health caseload, including all patients on
psychotropic medication
Item no.
Measure
1
Clinical assessment, treatment, and follow-up plan documented
2
Treatment plans periodically updated?
23. Throughcare (NCCHC, 2008; J-E-12, J-E-13; ACA 2004 4-ALDF-4C-23 4-ALDF-4D-27)
Sample
Ten most recent discharges or transfers
Item no.
Measure
1
Was a transfer summary completed prior to release?
2
Is there proper documentation of the receipt of a supply of the medication three days for
transfers and 14 days for releases?
24. Dental care (NCCHC, 2008; P-A-01, P-E-02, P-E-04, P-E-06; ACA 2004 4-ALDF-4C-20)
Sample
Ten records from recent schedule of patients seen by a dentist
Item no.
Measure
1
Was patient screened for symptoms during the intake process?
2
Was patient evaluated within 48 hours of request?
3
Clinical note describes findings, diagnosis, treatment and plans?
4
Patient scheduled for follow-up treatment as recommended?
25. Credentialing (NCCHC, 2008; P-C-01; ACA 2004 4-ALDF-4D-05)
Sample
Ten credentialing files from all licensed health care professionals, chosen at random
Item no.
Measure
1
Validation of current license (and controlled substances authority for physicians, if applicable)?
2
Validation of current license?
3
Validation of current license (and controlled substances authority for dentists, if applicable)?
4
Validation of current license (and controlled substances authority for all licensed mental health
positions, if applicable)?
26. Complaints and grievances (NCCHC, 2008; P-A-06, P-A-11)
Sample
Facilitys periodic grievance analyses, with underlying data (grievances and responses)
Item no.
Measure
1
Does a review of grievances reveal possible barriers to care or repetitive concerns that could
affect clinical care? If so, does the facility use this information to implement change?
2
Assess percentage appropriately addressed within five working days
27. Mortality review (Hayes, 2007; NCCHC, 2008; P-A-10; ACA 2004 4-ALDF-4D-24)
Sample
All in-custody deaths, including those in hospital, within the past two years
Item no.
Measure
(continued)

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Table AI
1
2
3

Multidisciplinary review within 30 calendar days?

Follow-up review when autopsy and toxicology reports are available?
Assessment as to whether the medical response was appropriate on the day of death or transfer
to the hospital?
4
Assessment as to whether earlier intervention was possible and whether that would have
changed the outcome?
5
Analysis of ways to improve patient care, independent of the cause of death, if applicable?
6
For suicides only, was there a psychological autopsy?
28. Medical recordkeeping practices (NCCHC, 2008; P-H-01, P-H-04)
Sample
Ten records reviewed on inmates with chronic disease
Item no.
Measure
1
Identifying informationc
2
Current problem listd
3
Receiving screen and health assessment forms
4
Progress notese
5
Clinician orders for medication, signed
6
Medication administration records
7
Lab and diagnostic reportsf
8
Flow sheets
9
Consent, refusal, and release of information forms
10
Results of specialty consultations and referralsf
11
Discharge summaries from ED and hospitalizations
12
Special needs treatment plan, where applicable
13
Immunization records, where applicable
14
Date and time of each encounter
15
Integrated medical, dental, and mental health record
16
Timely filing, within 72 hours
17
Consolidated medical recordg
18
Content organized for easy retrieval
19
Electronic health record (EHR) password protected, by individual
20
Integrated health information with EHR, where applicableh
Limited language proficiency assistance (Greifinger unpublished)
Sample
Five to ten prisoners within the population who have very 29 limited local proficiency. Determine
through medical records examination if any accommodation has been made during medical
encounters, intake, and mental health encounters for appropriate interpretation
Item no.
Measure
1
Has the provision of interpretation been properly recorded, including interpreter number or
name?
2
Are there any indications that medical or mental health services have not been performed or were
delayed due to language barriers?
3
Are there any indications that correctional staff or other prisoners were used as interpreters, in
non-emergent circumstances?
4
Are sick call slips available in the major languages spoken by the prisoner population at the
facility?
5
Is there documentation that patient education was provided in the prisoners preferred language?
30 Treatment of disability i
Sample
Five to ten prisoners within the population who have a disability that requires special medical
treatment. Determine through medical record examination if appropriate treatment and
accommodation was given
Item no.
Measure
1
Is the disability prominently noted in the file, along with any needed accommodations?
2
Was the inmate assessed for assistance with activities of daily living (ADL)?
3
Were appropriate special orders entered (e.g. lower bunk, assistive device, meal, etc.)?
4
Was ADL assistance provided?
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)

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