Administrative Meetings and Reports

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During an accreditation survey, do surveyors expect to see our statistics separated into appointments, sick call, pharmacy refill, etc., or is the total number of patient visits each day adequate?

Standard A-04 Administrative Meetings and Reports requires that statistical reports of health services are made at least monthly. Because they should be used to monitor trends in health care delivery, various categories of information should be collected. We recommend that the reports contain statistics such as service volume, incidence of certain illnesses, infectious disease monitoring, access, timeliness of health services and follow-up, missed appointments, emergency services and hospital admissions, referrals to specialists, deaths and grievances. Simply reporting the total number of patient visits each day would not be adequate to capture these specific trends. Monitoring areas such as these may help with staffing plans, space and equipment needs and facility comparisons when indicated.

— From CorrectCare Volume 32, Issue 3, Summer 2018

 
 

Do the standards require someone from mental health to attend the administrative meetings? Right now, our health services administrator goes, but we want to know if mental health should be going as well.

If mental health operates under a separate structure than that of medical, then the designated responsible mental health clinician or designee should also attend the administrative meetings according to standard A-04 Administrative Meetings and Reports. A designated mental health clinician refers to a psychiatrist, psychologist or psychiatric social worker who is responsible for clinical mental health issues when mental health services at the facility are under a different authority than the medical services, according to standard A-02 Responsible Health Authority.

On the other hand, if medical and mental health staff report to the same authority, then only the responsible health authority or the RHA’s designee is required by the standard to attend. Usually, the health services administrator or the responsible physician is the RHA or serves as the designee. The intent is that there is joint monitoring, planning and problem resolution by the facility’s health and correctional administrators.

The standard also intends that all health staff, including medical, dental and mental health, are kept informed about facility operational issues and receive current information on all aspects of the institution’s health care delivery.
— From CorrectCare Volume 26, Issue 3, Summer 2012