Spotlight on the Standards

The Award of Accreditation: For Facilities Only

Let’s eavesdrop on a recent meeting of NCCHC’s health services accreditation committee. Deliberations for the Harrison County Jail are over, and the committee is ready to announce its decision.

“And accreditation is awarded to...”
“Chavez Cor-Med, the health service contractor at the Harrison County Jail?” “No.”
“The Stanley Mental Health Services provided at the Harrison County Jail?” “No.”
“The county health staff who work at the Harrison County Jail?” “No.”
“The Harrison County Jail?” “Yes!”

Correctional Facilities Only
NCCHC often receives questions such as the following:
• My company developed electronic medical records software for corrections. Can we have it accredited?
• The state DOC central office has revised all health policies and procedures to meet NCCHC standards. Can this system be accredited?
• We are a community health services company and will begin to work in jails. Can we be accredited?

In each case the answer is “no.” NCCHC awards accreditation only to individual facilities as a whole, not to products, systems or providers. To understand why, it is useful to consider what NCCHC aims to achieve with health services accreditation.

Standards at the Core
Accreditation affirms that a facility is in compliance with 100% of the relevant essential standards and at least 85% of the relevant important standards. By definition, then, compliance is determined by the outcomes. Outcomes cannot exist in the abstract. They occur only as a consequence of the actual care given to inmate-patients at a specific facility.

The term relevant refers to the version of the Standards for Health Services being used (there are separate versions for jails, prisons and juvenile facilities); its currency (editions now in effect are 2003 for the jail and prison Standards and 2004 for the juvenile Standards); and whether a particular standard is applicable to the facility (for example, standards regarding pregnancy do not apply in an all-male facility).

Essential and important refer to the NCCHC classification of individual standards. This is an artificial designation in the sense that every standard could be considered critical in one way or another.

However, as noted in the manuals’ introductory sections, the essential standards relate more directly to the inmates’ “health, safety, and welfare” and to the “critical components of a health care system,” such as receiving screening and health assessment.

Important standards tend to be related to health services but under the jurisdiction of the correctional authorities (e.g., exercise, diet, personal hygiene), or may be introduced for the first time in a new edition, or may reflect best practice recommendations beyond the basics.

The standards’ format is meant to make explicit the expected outcomes. To determine what these outcomes are, it is best to start with the first sentence of a standard’s Discussion. This is the intent, or the “why” of the particular standard.

Turning to the Standard itself, the “what” is explained. Next, the Compliance Indicators specify the usual way (“how”) in which compliance is achieved. Like two sides of a coin, the Standard and Compliance Indicators need the other to fully address the requirements. But it is possible to achieve the intent in a unique way without meeting every compliance indicator.

Every Department Plays a Role
Standards are grouped into nine sections (“A” through “I”). Review of these sections makes it clear why accreditation can be awarded only to a facility as a whole.

Governance and Administration (section A) sets the organizational and management parameters within which health care services are provided. This involves all of the facility’s respective authorities—correctional, medical, mental health and any other specialized services. Health service policies and procedures must spell out respective responsibilities and confirm the unique roles of each component, as well as define the specific health care protocols. In all but issues of medical autonomy, health staff are subject to the correctional authority’s regulations.

Section B, Managing a Safe and Healthy Environment, addresses infection control practices not only of health services but also of areas under the correctional authority’s control (e.g., environmental cleanliness, food operations, ectoparasite control). In an accredited correctional facility, health staff play a role analogous to a public health department in the community.

While most Personnel and Training (C) standards pertain specifically to health staff, the roles of correctional staff and inmate-workers as they relate to health services also is addressed. This includes orientation issues so that correctional and health staff understand and respect each other’s skills and tasks, as well as health training for correctional staff, who are most likely to first notice a need for health interventions.

The Health Care Services and Support (D) and Health Promotion and Disease Prevention (F) sections delineate the roles of various departments that support medical, mental health and substance abuse services. Without appropriate equipment, supplies and space, professional health care cannot occur. Guidance on healthier lifestyles is often provided by facility program staff or community volunteers or organizations such as Alcoholics Anonymous.

The sections of Inmate Care and Treatment (E) and Special Needs and Services (G) also address critical times when correctional and health staff must work together to identify and meet inmates’ significant health needs. Among these are the intake process and receiving screening, prompt response to emergency and routine health needs, health requirements of those in segregation, identification of and interventions with the suicidal inmate, and discharge planning for those with significant health needs. Without coordination and cooperation among departments, health staff cannot provide professional and effective services.

Health Records (H) standards focus primarily on the requirements for documentation and protection of confidential health information. However, unless correctional staff respect the confidentiality issues, the professionalism of health services could easily be compromised.

In Medical-Legal Issues (I), the standards address issues of consent and refusal, which can be among the most difficult to resolve. In potentially explosive interventions such as restraint and seclusion (whether initiated by security or health staff) and forced emergency psychotropic medication, safety for all can be ensured only by clearly established lines of authority, knowledge of what is expected by all parties, and mutual communication and cooperation. Without this, the health services outcome cannot be met.

Cake for All
Although health staff take the lead, all facility departments must work together to achieve compliance with the standards, either directly or indirectly. Thus it is the facility that is accredited, and it is the warden or superintendent who receives the complimentary accreditation pin and the framed certificate of accreditation.

(This article first appeared in the Summer 2005 issue of CorrectCare.)

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