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The Latest Column
Questions are from the latest Standards Q&A column, posted in December 2017.
Dates for Compliance With 2018 Standards
My facility is due for a reaccreditation survey in 2018. Will we have to be in compliance with the 2018 Standards for Health Services?
It depends on when the facility is due for a survey. The anticipated release date for the 2018 Standards is April 21. Facilities have approximately six months to transition to the new set of standards. While exceptions may be granted, a general guide is this: If your survey is scheduled for between January 1 to July 31, the 2014 Standards will be used. For surveys in August, September or October, facilities will have the choice of being surveyed under the 2014 or 2018 Standards. Beginning November 1, all surveys for jails and prisons will be conducted under the 2018 Standards. Depending on the date of application, facilities that are applying for initial accreditation in 2018 will likely be surveyed under the new standards.
Accredited Health Care Companies?
We would like to identify accredited correctional health care companies for reference purposes. Can NCCHC provide such a list?
NCCHC does not accredit any kind of company (such as health care contractors, electronic health records vendors or pharmacies), states or agencies. Rather, NCCHC accredits individual correctional facilities for compliance with the relevant Standards for Health Services. The accreditation is awarded to the facility itself for its established system of health care delivery and demonstrated compliance with the requirements of the standards.
Quality Improvement Studies
In P-A-06 Continuous Quality Improvement Program and compliance indicator #4 states, “When the committee identifies a health care problem from its monitoring, a process and/or outcome quality improvement study is initiated and documented.” Please explain what is meant by the term “study” and what evidence is required to meet this indicator.
A study is a process of reviewing an identified problem—either a facility problem or a patient clinical care problem—and setting thresholds, conducting a baseline study, developing and implementing a corrective plan and restudying the problem to assess the effectiveness of the corrective action plan.
Process studies focus on facility problems. For example, if problems with the chronic care program are identified, baseline studies might look at how you identify chronic care patients, how you schedule them for clinics, whether any security escort problems cause delays and how documentation is kept. An outcome study on the same subject might focus on whether the chronic care inmate’s symptoms are actually decreasing or at least are not worsening as a result of the care. Typically, process studies answer the question “Is what we are doing effective and efficient?” and outcome studies answer the question “Are our patients getting better?”
The evidence would be documentation of the studies themselves that contain all parts of a study (see compliance indicator #2 and the definitions of process and outcome quality improvement studies). A word of caution: Be sure that the CQI program is actually identifying problems and finding solutions. Often, routine monitoring of correctional health care processes is presented as a study and does not meet the intent of the standard.