HomeMy WebLinkAboutClinical Performance EnhancementIdaho
Department of
Correction
Standard
Operating
Procedure
Title:
Clinical Performance Enhancement
Page:
1 of 5
Control Number:
401.06.03.013
Version:
4.0
Adopted:
11-09-1998
Pat Donaldson, chief of the Management Services division, approved this
document on 04/27/2015.
Open to the public: Yes
SCOPE
This standard operating procedure (SOP) applies to all Idaho Department of Correction
(IDOC) health care services staff, offenders, contract medical providers and subcontractors.
Revision Summary
Revision date (04/27/2015) version 4.0: Periodic review to include administrative updates:
New/current SOP format
Changed approval from Education Treatment & Reentry to Management Services
division
TABLE OF CONTENTS
1. Introduction ....................................................................................................................... 3
2. Review Requirements ...................................................................................................... 3
3. Elements of the Clinical Performance Enhancement Review ......................................... 3
4. Tracking Requirements .................................................................................................... 4
5. Compliance....................................................................................................................... 4
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBER 401
Clinical Services and Treatment
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures for
clinical performance enhancement for the purpose of evaluating the appropriateness of all
health care provider services.
Control Number:
401.06.03.013
Version:
4.0
Title:
Clinical Performance Enhancement
Page Number:
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Idaho Department of Correction
RESPONSIBILITY
Health Authority
The health authority is responsible for:
Monitoring and overseeing all aspects of health care services, and
The implementation and continued practice of the provisions provided in this
SOP.
When health care services are privatized, he will also be responsible for:
Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all health care-related
requirements provided in respective contractual agreements, this SOP, and in
National Commission on Correctional Health Care (NCCHC) standard P -C-02,
Clinical Performance Enhancement. (See section 5 of this SOP.)
Contract Medical Provider
When health care services are privatized, the contract medical provider is responsible
for:
Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
Ensuring that all aspects of this SOP and NCCHC standard P-C-02 are
addressed by applicable contract medical provider policy and procedure;
Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all health care-
related requirements provided in this SOP, NCCHC standard P-C-02, or as
indicated in their respective contractual agreement(s); and
Ensuring all applicable contract medical provider policy, procedure, and forms
are submitted to the health authority for review and approval prior to
implementation.
Nothing in this SOP shall be construed to relieve the contract medical provider(s) of any
obligation and/or responsibility stipulated in respective contractual agreements.
Facility Medical Director
The facility medical director and facility health authority (or designees) will be jointly
responsible for:
Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-C-02
are accomplished as required; and
Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP.
Control Number:
401.06.03.013
Version:
4.0
Title:
Clinical Performance Enhancement
Page Number:
3 of 5
Idaho Department of Correction
Facility Health Authority
The facility health authority and facility medical director (or designees) will be joint ly
responsible for the duties described in the section above.
GENERAL REQUIREMENTS
1. Introduction
Clinical performance enhancement (as defined) does not include program supervision
performed by management (i.e., health authority, facility medical director, o r director of
nursing services) and may be conducted by contracting with an independent entity that is
not employed by the contract medical provider.
2. Review Requirements
Individual
Individual case reviews may be done on selected cases such as:
Unusual incident cases;
Cases with significant morbidity; and
Selected high costs.
Offender grievances shall be reviewed for any relevant pattern that may lend itself to
improving medical practices.
All cases involving death shall be reviewed by the facility medical director.
Peer
All health care provider services shall be reviewed by his peer within 90 days of hire and
at least annually thereafter. The goal is to:
Encourage learning from peers;
Enable self-regulation of health care providers as a group;
Provide a m ethod of standard evaluation;
Ensure consistent quality of care; and
Maintain a high quality of practice standards among all qualified health
professionals.
All peer reviews shall remain confidential.
Annual
The facility medical director (or designee) shall meet with all health care providers to
discuss clinical performance enhancement reviews and chart reviews on a fixed annual
schedule. The schedule shall be forwarded to the health authority in advance of an y
scheduled meetings to allow the health authority the opportunity to attend.
3. Elements of the Clinical Performance Enhancement Review
At a minimum, the clinical performance enhancement review shall contain the following
elements:
The name of the individual being reviewed;
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401.06.03.013
Version:
4.0
Title:
Clinical Performance Enhancement
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Idaho Department of Correction
The name and credentials of the person conducting the review;
The date the review was conducted;
Confirmation that the review was shared with the health care provider; and
A summary of the findings and any corrective actions taken, if any.
4. Tracking Requirements
A log or other written record that provides the names of health care providers and the dates
of their most recent reviews shall be maintained on-site by the facility medical director.
These logs and records shall be made available for review to the health authority.
5. Compliance
Compliance with this SOP and all related department-approved protocols will be monitored
by the health authority (or designee) by using various sources to include: this SOP, clinical
practice guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct one (1) audit per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider and IDOC policy and procedures, applicable NCCHC
standards, and the review of a minimum of 15 individual records .
DEFINITIONS
Clinical Performance Enhancement: The process of having a qualified health
professional’s work reviewed by another qualified health professional who has at least equal
training in the same general discipline (e.g., when the highest ranking physician conducts
reviews on lower ranking physicians).
Contract Medical Provider: A private company under contract with the Department to
provide comprehensive medical, dental, and/or mental health services to the in carcerated
offender population.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Health Authority: The Department employee who is primarily responsible for overseeing or
managing the Department’s medical and mental health services. The health authority is
commonly referred to as the health services director.
Health Care Provider: Health care practitioners are clinicians trained to diagnose and treat
patients.
Primary Care: General medical care that (1) is provided to an offender without referral from
another qualified heath professional, and (2) focuses on preventive care and treatment of
routine injuries and illnesses.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons , Standard P-C-02, Clinical Performance Enhancement
Control Number:
401.06.03.013
Version:
4.0
Title:
Clinical Performance Enhancement
Page Number:
5 of 5
Idaho Department of Correction
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