Perf-Based Stds, Adult Corr. Inst. 5th ed March 2021

Part 6: Healthcare

6B. - PERFORMANCE STANDARD: STAFF TRAINING The provision of health services should be done in a professionally acceptable manner including the requirement that all staff be ade- quately trained and qualified and can demonstrate competency in their assigned duties. (1) Number of health care staff with lapsed licensure or certification during a twelve (12) month peri- od divided by Number of licensed or certified staff during a twelve (12) month period. (2) Number of new health care staff during a twelve (12) month period that completed orientation training prior to undertaking their job divided by Number of new health care staff during the twelve (12) month period. (3) Number of occupational exposures to blood or other potentially infectious materials in the past twelve (12) months divided by the number of employees. (4) Number of direct care staff (employees and contractors) with a conversion of a TB test that indi- cates newly acquired TB infection in the past twelve (12) months divided by the number of direct care staff tested for TB infection in the past twelve (12) months during periodic or clinically indi- cated evaluations. Health Authority OUTCOME MEASURES:

5-ACI-6B-01 (Ref. 4-4380)

(MANDATORY) The facility has a designated health authority with responsi- bility for ongoing health care services pursuant to a written agreement, con- tract, or job description. Such responsibilities include: • establish a mission statement, which defines the scope of health care services • develop mechanisms, including written agreements, when necessary, to assure that the scope of services are provided and properly monitored • develop a facility’s operational health policies and procedures • identify the type of health care staff needed to provide the determined scope of services • establish systems for the coordination of care among multidisciplinary health care providers and • develop a quality management program The health authoritymay be a physician, health services administrator, or health agency.When the health authority is other than a physician, final clinical judg- ments rest with a single, designated, responsible physician. The health authority is authorized and responsible for making decisions about the deployment of health resources and the day-to-day operations of the health services program. Comment : The health authority and health services administrator may be the same person. The responsibility of the health authority includes arranging for all levels of health services, assuring the quality of all health services, and assuring that of-

196 Adult Correctional Institutions, Fifth Edition