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

Performance Standard 6D: Performance Improvement

Peer Review 5-ACI-6D-03 (Ref. 4-4411)

(MANDATORY) A documented peer review program for all health care prac- titioners/providers and a documented external peer review program will be utilized for all physicians, psychologists, and dentists every two years. Comment : The credentialing and privileging process is an integral part of assuring the competence of the providers for the inmate patients they treat. This should be routine every two years with an ability to have an immediate review if problems of practice arise. Immediate reviews are serious and only should be permitted by a careful decision of the most senior physician responsible for the system or in- stitution. A mechanism for patient care complaints, observations by other health services providers, security, or other nonmedical providers should be established so that the responsible physician can call a panel of independent physicians to re- view the practice and practice patterns of the physician on whom the complaint(s) has (have) been made. The investigation and its findings are confidential in most states by statute. The responsible physician should receive the report, take indi- cated action, and be prepared to demonstrate to the auditors, within the confines of confidentiality, the process, process indicators, and the actions available (for example, termination of the physician, required education in an area, prohibition against seeing a type of disease entity without another physician, and so forth). It is important that the auditors appreciate that the process is real and meaningful and that peer review is not simply a paper trail without substance.

Protocols : Written policy and procedure. Written agreements or contract.

Process Indicators : Signed agreements or contracts. Peer review reports.

Staffing 5-ACI-6D-04 (Ref. 4-4412)

The facility uses a health care staffing analysis to determine the essential po- sitions needed to perform the health services mission and provide the defined scope of services.A staffing plan is developed and implemented from this anal- ysis. There is an annual review of the staffing plan by the health authority to determine if the number and type of staff is adequate. Comment : Adequate staffing is based on variables such as facility size and config- uration, location, and offender type. The staffing analysis is used to determine the types and numbers of staff needed to provide a defined scope of services (medical, dental, mental health, and infirmary).

Protocols : Written policy and procedure. Health care staffing analysis.

Process Indicators : Staffing plan. Documentation of annual review.

Adult Correctional Institutions, Fifth Edition 211