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

Part 6: Healthcare

Goals and Objectives 5-ACI-6D-08 (Ref. 4-4422)

The medical program has established measurable goals and objectives that are reviewed at least annually and updated, as needed.

Comment : None.

Protocols : Written policy and procedure. Written long-range goals and policies. Format for periodic review and reporting. Bylaws and constitution. Budget and planning documents. Administrative manual.

Process Indicators : An annual report. Board meeting minutes. Documentation of an annual review. Monthly and quarterly reports.

5-ACI-6D-09 (Ref. 4-4423)

There is an internal system for assessing the achievement of goals and ob- jectives and that documents findings. Program changes are implemented, as necessary, in response to findings. Comment : Operations and programs should be implemented as outlined in the pol- icies and procedures. An audit system providing timely and periodic assessment of the various agency operations will reveal the degree of compliance. The internal administrative audit should exist apart from any external or continuing audit con- ducted by other agencies.

Protocols : Written policy and procedure. Internal monitoring system and forms. Inspection forms.

Process Indicators : Completed inspection or internal audit reports. Documentation of corrective actions taken.

5-ACI-6D-10 (Ref. 4-4424)

Each policy, procedure, and program in the health care delivery system is re- viewed at least annually by the appropriate health care authority and revised, if necessary.

Comment : None.

Protocols : Written policy and procedure.

Process Indicators : Documentation of annual review. Documentation of any nec- essary revisions.

214 Adult Correctional Institutions, Fifth Edition