Policies and Procedures - National Commission on Correctional Health Care
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Policies and Procedures

A-05 Policies and Procedures (essential)

The facility has a manual or compilation of policies and defined procedures regarding health care services that address each applicable standard in the Standards.

Policies and procedures are essential to outlining a facility’s mission and providing clarity when dealing with correctional health care issues. An up-to-date, accurate manual is an important reference for new and established health staff alike.

A Manual That Follows NCCHC Standards

Standard A-05 in all five of NCCHC’s Standards manuals outlines the requirements for policies and procedures and requires that a manual or compilation address each applicable standard, including all compliance indicators. Whether establishing a manual for the first time or updating a current manual, the first step is to determine which policies already exist, which policies exist but need revision, and which policies need to be developed. We recommend that each policy be cross-referenced with the appropriate NCCHC standard(s), although the policies don’t need to be placed in the same order as the standards.

As policies are developed, there may be one policy that addresses multiple standards or several policies that address one standard. Facilities need not develop policies for standards that are not applicable (e.g., Infirmary Care when the facility does not have an infirmary).

Specificity Counts

Imagine being a new employee at a facility and opening up a policy and procedure manual that is very generic. How helpful would that be in the learning process? Employees need guidance that is specific to the correctional health care that is being delivered in the facility in which they work. This is especially true for systems that have multiple facilities. For example, sick call in the main facility may be conducted in the clinic, whereas in the satellite, nurses may go to exam rooms located in each housing area. In case of a mass disaster, triage areas may be different in the main facility than in a satellite. Therefore, the standard requires that health care policies and procedures are site specific. While correctional systems or corporate third-party providers may have policies that apply to all facilities, addenda for each facility should be included when specificity is required.

When addressing compliance indicators in each standard, it is important to expand on areas when necessary. For example, a policy that addresses the emergency response plan should not just list the compliance indicators verbatim. Each component of the plan should be specifically outlined: “The responsibilities of health staff are…; the procedures for triage are…” and so forth.

No Conflicts, Please

While most correctional health-related policies are developed by the responsible health authority (RHA), it is permissible to use policies promulgated by custody staff to complete or augment the health services policy and procedure manual. It is not necessary to write duplicate policies if the custody policy includes all components of a particular standard.

However, if policies on the same topic exist in both the custody and health care manuals, it is important that they do not conflict. Let’s continue using the emergency response plan as an example. If the emergency response plan for health staff is to set up a triage area in the hall between A Pod and B Pod but the custody policy indicates that triage will be conducted in a court holding area, then the plans are in conflict. Similarly, if the custody policy on restraints indicates that health staff monitor the restrained inmate every 15 minutes but the health services policy indicates monitoring every hour for these individuals, then the policies conflict. The RHA should ensure that other policies for custody, kitchen, industries or corporate do not conflict with health care policies.

Approval Process

As policies and procedures are developed, an approval process is required. Each policy and procedure in the health care manual should be reviewed at least annually and revised as necessary under the direction of the RHA. Documentation of this review can be done by inserting a signed and dated declaration at the beginning of the manual stating that the policies and procedures have been reviewed and approved. Or each policy can be signed individually. While it is important that key staff review and approve the policies and procedures, at a minimum, the signature of the facility’s RHA and responsible physician should be present to signify annual review and approval. Policies included in the manual that are not promulgated by health services should have authorizing dates and signatures but do not need signatures from the RHA and responsible physician.

Availability of the Manual

The standard intends to ensure that policies and procedures are written and accessible to staff. Having the only manual locked away in an administrator’s office is not useful and should be avoided. Manuals should be stored in a place that is readily accessible to health staff. Facilities may have one or more binders or have the policies available electronically on a shared drive. Facilities that have electronic policies and procedures should consider having at least one printed manual to ensure the manual is accessible in the event of a power failure.

Finally, the RHA should ensure that actual practice matches the newly developed or revised policies and procedures. Staff training may be a component of ensuring that practice matches the written word. When properly developed, the policy and procedure manual will be a useful tool to staff as they carry out the facility’s mission.

[This article first appeared in the Spring 2017 issue of CorrectCare.]