Continuous Quality Improvement Program

Idaho
Department of
Correction

Standard
Operating
Procedure

Operations
Division

Operational
Services
Control Number:
401.06.03.006
Version:
2.2
Page Number:
1 of 7
Adopted:
11-12-1998
Reviewed:
6-11-2012

Title:
Continuous Quality Improvement Program

This document was approved by Shane Evans, director of the Education,
Treatment, and Reentry Bureau, on 6/11/12 (signature on file).
Open to the general public: Yes
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBE R 401
Clinical Services and Treatment
DEFINITIONS
Standardized Terms and Definitions List
Contract Medical Provider: A private company or other entity that is under contract with
the Idaho Department of Correction (IDOC) to provide comprehensive medical, dental,
and/or mental health services to the IDOC’s incarcerated 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.
Health Authority: The Idaho Department of Correction (IDOC) employee who is primarily
responsible for overseeing or managing the IDOC’s medical services. (The health authority
is commonly referred to as the health services director.)
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish a program to ensure
facilities use a structured process to find areas in the healthcare delivery system that need
improvement and implement strategies for improvement.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers and subcontractors .
RESPONSIBILITY
Health Authority
The health authority is responsible for:
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• Monitoring and overseeing all aspects of healthcare services; and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare 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, and ensuring compliance with healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
National Commission on Correctional Health Care (NCCHC) standard P-A-06,
Continuous Quality Improvement Program . (See section 5 of this SOP.)
Contract Medical Provider
When healthcare 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 NCCHS standard P-A-06 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 healthcare -
related requirements provided in this SOP, NCCHC standard P-A-06, 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.
Note: 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 will be responsible for:
• Overseeing the continuous quality improvement (CQI) process and ensuring that
events such as acute care hospital admissions, medical emergencies, and
deaths are reviewed routinely;
• Completing monthly reviews of patient healthcare records , documenting the
reviews on approved forms, and maintaining the completed reviews on-site for
review by the health authority; and
• Deciding (in conjunction with the facility health authority) whether or not
corrective action is necessary based on the findings of the monthly reviews.
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Facility Health Authority
The facility health authority will be responsible for:
• Ensuring healthcare services staff responsible for the CQI program are
appropriately trained in CQI principles and processes to adequately perform their
duties;
• Providing CQI program staff with additional training opportunities needed to
enhance their skills;
• Preparing and submitting continuous quality improvement (CQI) meeting minutes
to the health authority;
• Ensuring CQI meeting minutes provide sufficient detail (e.g., identify the
problems, solutions agreed upon, person(s) responsible for corrective action and
the timeframe for carrying out the corrective action) to guide future decisions;
• Deciding (in conjunction with the facility medical director) whether or not
corrective action is necessary based on the findings of his monthly reviews.
• Preparing a narrated report (on a quarterly basis) and submitting the report to the
health authority by the last day of the month following the end of the quarter (e.g.,
If the quarter ends on March 31, the report would need to be submitted by the
last day of April).
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-A-06
are accomplis hed as required.
Table of Contents
General Requirements .............................................................................................................. 3
1. The Basic Continuous Quality Improvement (CQI) Program ............................................. 4
Monthly Requirements .................................................................................................. 4
Annual Requirements ................................................................................................... 4
2. The Comprehensive Continuous Quality Improvement (CQI) Program ............................ 5
Quarterly Requirements ................................................................................................ 5
Annual Requirements ................................................................................................... 5
3. CQI Studies ......................................................................................................................... 6
4. Medical Audit Committee (MAC) Meetings ........................................................................ 6
5. Compliance ......................................................................................................................... 7
References ................................................................................................................................ 7
GENERAL REQUIREMENTS
The quality of the delivery of healthcare services in the IDOC will be monitored through CQI
activities, which include program reviews, inquiries regarding stakeholder satisfaction, and
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assessments of the relationship of healthcare services to other areas of offender
management.
When new correctional facilities are constructed, the health authority reviews the mission of
the facility in the context of NCCHC standard P-A-06 to determine if the new facility is
required to es tablish a c omprehensive CQI program, or whether a basic CQI program is
appropriate.
1. The Basic Continuous Quality Improvement (CQI) Program
The basic CQI program was designed for the following:
• Monitoring the fundamental aspects of a facility's healthcare system through one
Process Quality Improvement Study and one Outcome Quality Improvement Study,
and
• Reviewing physicians’ clinical charts.
Note: Both studies are meant to identify areas in need of improvement and bring about
remedial actions or strategies . See section 3 for further information.
The following facilities have an average daily population of 500 or less and are therefore
required to have a basic CQI program:
• South Boise Women's Correctional Center (SBWCC);
• East Boise Community Work Center (EB-CWC), (shall be conducted by SBWCC);
• North Idaho Correctional Institution (NICI);
• Correctional Alternative Placement Program (CAPP) facility; and
• St. Anthony Work Camp (SAWC).
Monthly Requirements
Each month, the facility medical director (or designee) shall conduct physician clinical
chart reviews of at least five percent (5%) of all patient healthcare records.
Annual Requirements
To assess the effectiveness of the program, each year the facility medical director (or
designee) shall conduct a review of the following areas:
• Access to care,
• Receiving screening,
• Health assessment,
• Continuity of care,
• Emergency care and hospitalizations, and
• Adverse patient occurrences , including all deaths .
Note: CQI studies , m inutes from administrative and/or staff meetings, and other
pertinent written materials shall also be used to assess the effectiveness of the program .
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2. The Comprehensive Continuous Quality Improvement (CQI) Program
A Comprehensive CQI Program includes the following:
• A Multidisciplinary Quality Improvement Committee,
• Monitoring of the areas specified in the compliance indicators,
• An annual review of the effectiveness of the CQI program,
• Two (2) Process Quality Improvement Studies , and
• Two (2) Outcome Quality Improvement Studies .
Note: Both studies are meant to identify areas in need of improvement and bring about
remedial actions or strategies. See section 3 for further information.
The following facilities have an average daily population of 500 or more and are therefore
required to establish a Multidisciplinary Quality Improvement Committee:
• Idaho Maximum Security Institution (IMSI);
• Nampa Community Work Center (NCWC), (shall be conducted by IMSI);
• Idaho State Correctional Institution (ISCI);
• South Idaho Correctional Institution (SICI);
• SICI Community Work Center (SICI-CWC), (shall be conducted by SICI);
• Idaho Correctional Institution-Orofino (ICI-O);
• Pocatello Women's Correctional Center (PWCC);
• Idaho Falls Community Work Center (IF-CWC), (shall be conducted by PWCC); and
• Idaho Correctional Center (ICC).
Quarterly Requirements
On at least a quarterly basis, the Multidisciplinary Quality Improvement Committee shall
meet to design quality improvement monitoring activities, discuss the results, and
implement corrective actions .
Note: The Committee is a group of healthcare services staff members from various
disciplines (e.g., medicine, nursing, mental health, dentistry, healthcare records,
pharmacy, laboratory).
The results of the quarterly CQI studies are discussed at the monthly Medical Audit
Committee (MAC) meetings. (See section 4 for further details.)
Annual Requirements
To assess the effectiveness of the program, each year, the facility medical director (or
designee) shall conduct a review of the following areas:
• Admission evaluations,
• Sick call services,
• Chronic disease management,
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• Infirmary care,
• Nursing services,
• Pharmacy services,
• Diagnostic services,
• Dental services,
• Disaster drills,
• Environmental inspection reports,
• Inmate grievances, and
• Infection control practices.
3. CQI Studies
There are two (2) types of CQI studies:
• Outcome Quality Improvement Study–Examines whether expected outcomes of
patient care were achieved.
• Process Quality Improvement Study–Examines the effectiveness of the healthcare
delivery process.
In addition to the Outcome and Process Quality Improvement Studies, the subjects studied
may be selected from ideas or concerns raised by staff, offenders or others, and quality
assurance studies or from the review of grievances, audits, program reviews, or other
reports.
The method used to conduct the CQI studies should involve representatives from the
various disciplines that have an interest or responsibility for the subjects selected.
The format for reporting CQI studies shall include the following areas:
• How the topic was selected,
• Question to be analyzed,
• Methodology,
• Findings,
• Plan for improvement,
• Implementation, and
• Outcome.
4. Medical Audit Committee (MAC) Meetings
The MAC shall meet on a monthly basis. The purpose of the MAC is to bring together
contract medical provider staff and IDOC staff to discuss medical and offender issues within
the facility.
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5. Compliance
Compliance with this SOP and all related IDOC -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 two (2) audits per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider, IDOC policy and procedures, applicable NCCHC
standards, and the review of a minimum of 15 individual records.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons , Standard P-A-06, Continuous Quality Improvement Program
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