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The Latest Column
Questions are from the latest Standards Q&A column, posted in August 2019.
Can We Earn Three Accreditations? Sure!
Our jail is accredited by NCCHC for health services and a survey is scheduled for our opioid treatment program. We know that NCCHC also offers a mental health accreditation. Is this an additional accreditation that our facility can attain?
First, thank you for participating in NCCHC’s accreditation program for health services and soon-to-be for OTP. Yes, we do offer mental health accreditation for facilities that have a more robust mental health program in place. It is based on the 2015 Standards for Mental Health Services in Correctional Facilities. The survey for this program can take place at the same time as the surveys for health services and/or the OTP, or it can be conducted at a separate date or time. Facilities that attain all three types of accreditation will be awarded NCCHC’s Pinnacle Recognition.
Health Record Review: How, and How Many?
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.
Customized Policies and Procedures
Our facility is about to contract with an organization to provide health services. The contractor has its own policies and procedures that we would be using. Will we meet the requirements of standard A-05 if we use the contractor’s policies and procedures, or must we develop our own?
You may use the contractor’s policies and procedures only if they meet your facility’s unique needs. For example, the policies and procedures must address infirmary-level care if your facility houses these types of patients and they must address prenatal care if it houses female inmates. In other words, if the policies and procedures are to perform their function of providing guidance to staff, they must be tailored to fit the needs of your facility and to address each applicable NCCHC standard.