By Jaime Shimkus

It’s the holy grail of health care: improved quality of patient care at reduced expense. Highly desired yet difficult to achieve, this goal is in the sights of jails and prisons everywhere. At the Orleans Parish Criminal Sheriff’s Office, this “grail” is now in their grasp.

Over the past five years, while the jail’s inmate population was burgeoning, staff were being added to meet the new demand, and pharmaceutical costs were skyrocketing, the health services department managed to cut its annual budget from nearly $14 million to less than $11 million.

At the same time, ambitious—and successful—programs were established to enhance quality improvement, infection control, utilization review, staff training and other areas.

Who’s the crusader behind this quest? An internal medicine specialist who, before taking a three-month moonlighting job at the jail, had never worked in corrections. R. Demaree Inglese, MD, was fresh out of the Air Force medical school and had experience primarily as a clinician with some administrative responsibilities.

The sheriff at the time noted his enthusiasm, long hours and initiative in reforming trouble spots such as infection control. When the three months were up, the sheriff asked him to stay on as medical director.

“I told him absolutely not. I had other career plans,” says Inglese, who now is not only medical director but also health services administrator. Finally he agreed, but only with the provision that he’d have carte blanche to rebuild the department as long he delivered in cutting the budget.

Reinventing the Wheel
Looking back at the experience, Inglese says, “I didn’t look at other jails so I had no template. That’s what’s both good and bad about our program. We reinvented the wheel with every program we developed.”

While acknowledging that this approach wasted some time, he did find it helpful to draw on his experience in the Air Force—and his colleagues there. One of his first steps was to replace most of the jail physicians, mainly “moonlighting residents and part-time subspecialists,” with a cadre of new graduates a year behind him at the Air Force.

Why were they willing to follow his career path? Inglese targeted highly motivated doctors with public health and public service interests and offered lucrative terms: a salary competitive with the private sector, and a weekdays-only schedule. Because it operates 24/7, the department uses an emergency medicine group practice to cover evenings and weekends.

Now, Inglese says, “Our patient population has access to young, enthusiastic physicians at the cutting-edge of their field,” noting that many of them also teach at the medical schools at Tulane University and Louisiana State University.

Among the specialties represented by the 12 full-time staff physicians are family practice, various internal medicine subspecialties, ENT, general surgery, ob/gyn and orthopedics.

This staffing plan is key to cost containment, says Inglese. That’s because it enables high quality on-site care, continuity of care, preventive medicine, high formulary compliance, low turnover and many other positive practices.

Dedicated to Quality
The quality improvement mission at OPCSO’s health services department is so central that it has become a discrete unit with four dedicated staff members. It has several components.

Every inmate grievance triggers a process of investigation and resolution, with corrective action taken as needed. Similarly, all communications from family members and other concerned parties about inmates’ health care are logged and, if it is a complaint, investigated.

In the provider peer review program, 5% of all sick call visits are reviewed to assess both quality of care and issues such as resource utilization (e.g., STAT lab tests).

Another main QI task is to track the specialty clinics to, for example, measure referral waiting times. In addition, a compliance officer conducts monthly audits of the medical and specialty clinics. These exhaustive audits cover not only “clinical” concerns such as charting, but also virtually every aspect of operations, from general sanitation to narcotics counts.

In each of these QI task areas, detailed periodic reports are used to monitor trends, guide improvement efforts and track progress.

Finally, the department provides an inmate advocate who handles out-of-the-ordinary situations such as, for example, when an inmate needs an orthotic device, or requests special accommodations to donate an organ to a family member.

Quality Pays
Two other ways to foster good quality of care are to control infectious disease aggressively, and to ensure that staff are well-trained. OPCSO has excellent programs in both areas.

In sum, Inglese says, these measures have helped lower health care costs to $5 per inmate per day, vs. $10 or $12 in the average large jail. Yet the ultimate goal remains foremost: Patients receive superb care.

— About the author: Jaime Shimkus is NCCHC’s publications editor. To contact her, e-mail jaimeshimkus@ncchc.org.