Continuous Quality Improvement


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NCCHC’s standards for jails and prisons require that health record reviews be done under the guidance of the responsible physician or designee (A-06 Continuous Quality Improvement Program). Could you provide guidelines as to the number of health records to be reviewed each month and how the review should be conducted?

These systematic reviews of the health record use a standardized form or audit tool to determine whether specific elements related to the quality of care provided are adequately documented. Although the standards are silent on the number of charts to be reviewed, a generally accepted guideline is 5% to 10% of the average daily population. Specific areas for review should be selected each month (e.g., documentation, access to care, chronic diseases), and criteria should be developed to evaluate each area.

The intent of the standard is that facilities have a continuous quality improvement program to monitor and improve the health care delivered. Health record reviews are only one component of the overall CQI program.

— From CorrectCare Volume 33, Issue 3, Summer 2019


As the health service administrator of a large jail, I have been asked to develop a continuous quality improvement program as we prepare for NCCHC accreditation. Can you give me some guidelines on where to start?

It is good to hear that you are preparing for NCCHC accreditation. A continuous quality improvement program (standard A-06) is essential as you make changes in your system. However, you may already have some of the elements of a CQI program in place, but you may not be thinking of them as CQI.

For example, does your facility have a grievance process for health care complaints? If someone is keeping track of the grievances, you may be noticing a pattern that could indicate an aspect of your services that needs improvement. Are you receiving environmental inspection reports? Do the same issues keep appearing in the reports? Are you noticing inmates from a particular housing area presenting at sick call with similar complaints? This could indicate that either a contagious condition is spreading in that unit or something in the environment is causing the problem.

Many of the ordinary, day-to-day activities of a facility, including monitoring compliance with NCCHC standards, fit nicely into a CQI program. Other areas that could be monitored in the CQI program are high-risk, high-volume, problem-prone aspects of the various services provided: medical, dental, mental health, pharmacy, food service, disaster readiness, etc. Just keep in mind that CQI is more than just monitoring. You are looking for areas to improve (i.e., areas that are falling below threshold levels). Those areas could be turned into the CQI process or outcome studies that are required in standard A-06.

— From CorrectCare Volume 33, Issue 1, Winter 2019


Our question relates to A-06 Continuous Quality Improvement Program, compliance indicator #4. We understand that we need to conduct process or outcome studies. Can you explain the difference in the two types of studies and what evidence is required to meet this indicator.

A study is a process of reviewing an identified problem to assess potential causes. A CQI study is one in which a facility problem is identified, a baseline study is completed, a corrective action plan is developed and implemented, and the problem is restudied to assess the effectiveness of the corrective action plan. Subsequent corrective action is documented and evaluated to see if the intervention was effective in addressing the problem.

Process studies normally answer the question “Is what we are doing effective and efficient?” They focus on implementation of policies and procedures (usually involving more than one category of staff) and the effectiveness of those processes. For example, examining your chronic care procedure might involve looking at how you identify chronic care patients, how you schedule them for clinics, whether security escort problems cause delays, how documentation is kept and so forth. Process studies often focus on timeliness and efficiency.

Outcome studies answer the question “Are our patients getting better?” or determine whether the expected outcomes of patient care were achieved (degree of control is a helpful consideration). Looking again at chronic care, an outcome study might focus on whether the chronic care patients’ symptoms are actually decreasing or at least are not worsening as a result of the care.

Documentation for these studies must address all components listed under compliance indicator #2, including the established thresholds, and all components outlined in the definitions of process and outcome studies.

— From CorrectCare Volume 31, Issue 2, Spring 2017


We have a jail system that consists of a main jail and a satellite about three miles away. This satellite is primarily used for intake and receiving. The health staff at the satellite does mass disaster drills at the main site, and process and outcome studies are also done at the main site. Both sites do man-down drills. Is this sufficient or does the satellite need to do mass disaster drills and CQI studies, as well?

The two standards in question are A-06 Continuous Quality Improvement Program and A-07 Emergency Response Plan. The intent of the CQI standard is that a facility uses a structured process to find areas in the health care delivery system that need improvement and that when such areas are found, staff develop and implement strategies for improvement. This includes doing the same for the satellite facilities. The number of process and outcome studies depends on the ADP of the satellite facility.
The intent of the Emergency Response Plan standard is that a facility protects the health, safety and welfare of inmates, staff and visitors during emergencies. Satellite facilities must be included in this process, as well. One mass disaster drill must be conducted annually in the satellite facility so that over a three-year period, each shift has participated. If full-time health staff are not assigned to a particular shift, that shift is exempt from drills. If there are no full-time health staff, drills are not required. The number of mass disaster drills that must be conducted in the satellite facility depends on the staffing plan.
— From CorrectCare Volume 27, Issue 3, Summer 2013


Our jail is changing to a new pharmacy and we want to make sure that changing this vendor does not affect patient outcomes or the expected standard that patients would continue to receive their medications as ordered by the physician for their treatment plan. Can we use this study for one of our outcome studies as required by J-A-06 Continuous Quality Improvement Program?

This is a great CQI study topic, but it sounds like it is best classified as a process study (and can certainly be used as such to meet J-A-06). Remember that outcome studies examine whether patients’ conditions are improving under the care provided. From what you describe, you are assessing the pharmacy delivery system—a process. The “outcome” of the patient receiving ordered medications is part of a process and is not a clinical outcome. We have seen CQI outcome studies on topics such as the effect of valproic acid administration on the rate of violence among mentally ill inmates, monitoring to reduce hemoglobin A1c levels and degree of control in hypertensive patients. Keep up the good work on monitoring whether patients receive ordered medication as part of their continuity of care.
— From CorrectCare Volume 25, Issue 3, Summer 2011