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Spotlight on the Standards
The
Accreditation Survey Report and Compliance Findings
Like each NCCHC-accredited
facility, our accreditation program uses continuous quality
improvement activities to further its mission: the support and
improvement of quality health care services in correctional
settings. Each revision of the Standards for Health Services
gives us an opportunity to review the various outcomes of the
accreditation program and make it better.
The
accreditation survey report itself can be viewed as an outcome.
After all, the report summarizes on-site findings about
standards compliance at a facility, outlines corrective action
required, makes recommendations for growth and development of
health services, and documents a facility’s subsequent
response to compliance issues.
In our own CQI
effort, NCCHC examined how well the survey report format and
contents serve the purposes for which they are intended.
Survey
Report: Who Is the Reader?
The survey report is
written for the person legally responsible for the facility and
is presented in a format that is usable to health staff.
However,
correctional and health professionals bring different
perspectives and expectations when they review the report and
apply its findings. For example, the correctional administrator
wants to know how the facility’s health services compare to
national norms and why issues raised are important. Health care
staff seek validation of their work, and also need details of
any compliance issues to be addressed.
If health
services are contracted to a third-party provider, the
contractor will add survey findings to its internal quality
improvement process. In turn, the facility’s contract monitor
will look to verify that contract obligations are met. Although
the confidential reports are for the facility and its health
staff (unless the facility directs otherwise), administrators
can use the reports to demonstrate that the level of care
provided meets constitutional requirements.
Report
Format: Achieving Goals
The survey report format
has evolved over the years to meet the needs of its varied
readers and to reflect revisions to the standards. In our latest
quest to do even better, we asked whether a format change could
enhance readers’ grasp of the functioning of a health services
program.
We factored in
feedback and questions from customers (administrators and health
staff at accredited facilities) and other report users;
professionals attending our seminars; lead surveyors, who write
the reports; and accreditation committee members, who use the
reports to make accreditation decisions. Good feedback has
helped us to refine the report, for example with a finer balance
between highlighting positive findings and corrective action
needed.
We will begin
using the new format for survey reports completed in June 2004,
and expect to complete the piloting phase by year-end.
Anatomy of
the Report
The revised
report has four sections: (1) Executive Summary; (2) Facility
Profile, a concise description of facility size, organization
and functioning; (3) Survey Profile, detailing the parameters of
the on-site survey; and (4) Survey Findings and Comments.
The one-page
Executive Summary distills the essence of the survey findings
and accreditation decisions. It enables readers to readily
discern overall compliance via a list of standards that are not
applicable for this facility and those for which compliance
criteria are not met.
Compliance with
individual standards is assessed in Section 4, which is divided
into the nine major categories of standards. Each category
begins with a note on the role that it plays in the health
services system and then provides succinct details on how the
facility addresses its standards.
Delving deeper,
the individual standard assessments note whether the standard
has been met and highlight areas handled particularly well.
In cases of
partial compliance or noncompliance, citations refer as
applicable to the intent of the standard and to the relevant
“compliance indicators,” a new feature of the 2003 Standards
that explains the usual way compliance is achieved. Required
corrective action is spelled out. If such action is needed, the
facility’s subsequent documentation will later be added to the
report.
Key Changes
The most substantial
change is the new finding of partial compliance with a standard.
Now each standard can be assessed in one of four ways:
• Compliance:
Requirements for the standard are met, the intent of the
standard is met, no corrective action is required.
• Partial
compliance: One or more compliance indicators are not met, or
corrective action is required. The accreditation committee will
assess the impact of the missed indicator(s) on overall
compliance with the intent of the standard.
•
Noncompliance: None of the indicators are met and/or the intent
of the standard is not met, and corrective action is required.
•
Nonapplicable: The facility cannot address the issue due to the
nature of its population or functioning. For example, in an
all-male facility, the standard addressing care of the pregnant
inmate is nonapplicable.
The partial
compliance finding was added because it often reflects the true
picture at many facilities: Parts of a standard’s requirements
are met but one or two aspects are not. In such cases, a
judgment of noncompliance can be disheartening. Partial
compliance acknowledges current achievement while noting changes
required for full compliance. In some cases, “partial”
status may be deemed acceptable by the accreditation committee,
as when the facility meets the standard’s intent without
strict adherence to every indicator.
As before,
accreditation requires satisfactory performance on all
applicable essential standards and at least 85% of applicable
important standards.
Another notable
addition is the Executive Summary, described above.
To aid
understanding of the report, definition keys are present
throughout and parenthetical explanations provide context that
will be helpful to the nonhealth professional. Further, the
grouping of descriptive and positive comments under the nine
standards categories gives the reader a better perspective from
which to judge overall health service functioning.
Assessing
Outcome
We anticipate that
accreditation survey report users will find that the new format
aids their understanding of standards interrelatedness,
expectations for compliance, desired outcomes, and specific
concerns and remedies.
Still, as with
any good CQI process, the format remains open to refinement. We
welcome your reactions and look forward to feedback.
(This article first appeared in the
Winter 2004 issue of CorrectCare.)
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Do you have a question about the NCCHC standards for health services?
Contact us at:
Standards Q&A
National Commission on Correctional Health Care
1145 W. Diversey Pkwy.,
Chicago, IL 60614
Phone (773) 880-1460 • Fax (773) 880-2424
E-mail info@ncchc.org
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