Spotlight on the Standards

Clinical Performance Enhancement Made Clear

The Clinical Performance Enhancement standard (C-02), introduced in the 2003 edition of the prison and jail Standards for Health Services, was one of the most difficult to articulate. Now that it has been implemented, it is turning out to be one of those standards most often misunderstood.

While the NCCHC standards are not clinical performance standards per se, the expected outcome of compliance is provision of health care that not only meets constitutional requirements but also conforms with community standards. The NCCHC standards are based on the assumption that correctional health care providers practice their clinical skills as they would in any other health setting.

With that in mind, the NCCHC standards revision committee saw this new standard as a push to the correctional health care system to focus on clinical skills and practice at least once per year. It is an opportunity to pause, step back from the day-to-day demands of treating, and concentrate on quality practice issues with an experienced and understanding colleague.

In contrast to a healthy continuous quality improvement program, which raises red flags when a provider is not practicing according to usual expectations, the performance enhancement process is an opportunity to spotlight the professionalism and currency of clinical care.

The name chosen for this standard, the definitions used to clarify intent and the compliance indicators all were the result of much discussion by the revision committee.

The standard itself is succinct—“A clinical performance enhancement process evaluates the appropriateness of all primary care providers’ services”—as is its statement of intent: “to enhance patient care through peer review of the clinicians’ practice.”

To clarify intent, three definitions are provided: Clinical performance enhancement is the process of having a health professional’s work reviewed by another professional of at least equal training in the same general discipline. Primary care providers are all licensed practitioners providing the facility’s primary care including medical physicians, psychiatrists, dentists, midlevel practitioners (i.e., nurse practitioners, physician assistants), and PhD-level psychologists. Finally, primary care is defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Meeting the Intent
Despite these efforts at clarification, a number of accredited facilities and those seeking accreditation are engaging in practices that may be worthwhile in themselves but do not satisfy the intent of this standard.

For example, an annual performance evaluation most often is done by a supervisor who focuses on administrative matters such as completion of work and compliance with attendance rules. Unless the supervisor is a clinician of equal or better qualification in the same discipline and the evaluation also includes a review of clinical practice, the typical performance evaluation does not meet the intent of this standard.

In all cases, the reviewer should first inspect some treatment records and then provide a written evaluation and recommendations, if any. Ideally, the two parties will meet face-to-face, though a phone call may suffice. Exchange of written materials is less desirable but could work well in the hands of experienced professionals. At minimum, a written report is forwarded to the provider, who signs the evaluation to acknowledge the feedback.

Beyond that, two criteria must be met. First, the reviewer must be in the same general discipline as the provider being reviewed—for example, both are dentists or both are psychiatrists. Second, the reviewer has received the same or a higher level of training—e.g., an MD reviewing other MDs or midlevel practitioners; a PhD-level psychologist reviewing PhD-level psychologists.

Review of the responsible physicians, dentists and psychiatrists generally is conducted by corporate or system-level medical directors, dental directors or mental health coordinators. Where there are two or more providers in the same discipline, mutual reviews are fine. While it would be great for midlevel providers to be reviewed by a midlevel colleague, for purposes of this standard physicians are considered to be in the same discipline because of the unique relationship between physicians and PAs/NAs.

What of the lone provider in a facility? This is one of the “target staff” for this standard: the provider who is often isolated both professionally and geographically.

So what should be done when there is only one physician or psychiatrist? Possibilities include contacting a community physician or psychiatrist in private practice or a state medical school to provide such services, or, for those in remote facilities, use of a university telemedicine program.

If limited remuneration to offer the reviewer is a problem, perhaps the correctional care provider might give a lecture at a professional meeting, provide evaluation services for a hospital provider, or cover for a weekend for the reviewer. After record reviews are completed, there might be nothing better than dinner during which the two professionals can discuss findings and share experiences. In drafting the standard, the revision committee hoped that encouraging professionals to reach out to community colleagues for these reviews would establish lines of communication and professional sharing.

Other Considerations
Another common area of confusion relates to documentation. How much is needed? How much must be shared with the surveyors?

From a supervisory standpoint, clinical performance reviews are confidential communication. However, documentation is worthwhile only if it contains sufficient information to be able to understand any problems noted and follow up on any corrective actions recommended.

From an accreditation standpoint, while it would be ideal if the surveyors could review the evaluation report, only the following basic information must be shared: the names of reviewee and reviewer, title or position of the reviewer, the review date and confirmation that the findings were shared with the provider being reviewed. If corrective actions were recommended, a statement as to whether such actions were taken must be noted.

(This article first appeared in the Spring 2004 issue of CorrectCare.)

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