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

Performance Standard 6D: Performance Improvement

6D. - PERFORMANCE STANDARD: PERFORMANCE IMPROVEMENT Health care services are evaluated and continually improved. OUTCOME MEASURES: (1) Number of problems identified by quality assurance program that were corrected during a twelve (12) month period divided by the number of problems identified by quality assurance program during a twelve (12) month period. (2) Number of high-risk events or adverse outcomes identified by the quality assurance program during a twelve (12) month period. (3) Number of offender suicide attempts in the past twelve (12) months divided by average daily popu- lation (4) Number of offender suicides in the past twelve (12) divided by average daily population. (5) Number of unexpected natural deaths in the past twelve (12) months divided by Total number of deaths in the same reporting period. (6) Number of serious medication errors in the past twelve (12) months. Quarterly Meetings

5-ACI-6D-01 (Ref. 4-4408)

The health authority meets with the facility or program administrator at least quarterly and submits quarterly reports on the health services system and health environment, and submits plans to address issues raised. Comment: Minutes of the quarterly administrative meetings may be used to meet the requirements for a quarterly report. The report should address topics such as the effectiveness of the health care system, a description of any environmental fac- tors that need improvement, changes effected since the last reporting period, and, if needed, recommended corrective action. The health authority should report imme- diately any condition that poses a danger to staff or offender health and safety.

Protocols : Written policy and procedure.

Process Indicators : Documentation of meetings. Quarterly reports. Interviews.

4-4409

Deleted January 2016

Adult Correctional Institutions, Fifth Edition 209