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How correctional facilities can achieve healthcare accreditation

National and state accreditations help verify the quality of healthcare providers within the walls of jails and prisons


In this Sept. 12, 2012, file photo, Dr. David Mathis, visits with an inmate in the hospital unit at the California Medical Facility in Vacaville, Calif.

AP Photo/Rich Pedroncelli, File

By Steve Epple, C1 Contributor

Achieving accreditation in any profession provides objective verification that a company has met accepted standards in its industry. National and state accreditations are extremely critical for those providing healthcare within the walls of jails and prisons.

A framework to ensure optimal patient outcomes

Armor Correctional Health Services (Armor) is committed to meeting the standards set by the National Commission on Correctional Health Care (NCCHC), the independent accrediting agency that establishes the quality level of healthcare provided to inmates in a correctional facility.

NCCHC standards provide a framework to ensure that evidence-based systems, policies and procedures are in place to produce the best patient outcomes. NCCHC accreditation is validation of professional excellence in the correctional healthcare industry. Meeting these rigorous standards benefits the patient, the healthcare provider and the community at large as most inmates will be released back into our communities.

First steps toward accreditation

Facilities and organizations that seek accreditation for the first time may find the process challenging, even daunting.

Critical to success is a committed staff of caregivers, a strong partnership with corrections, and knowledgeable, experienced leadership to work with the NCCHC.

The NCCHC sets forth 59 standards for health services in jails. The Commission labels 39 standards as essential and 20 as important. The standards are divided into seven sections:

  • Governance and administration;
  • Health promotion, safety and disease prevention;
  • Personnel and training;
  • Ancillary healthcare services;
  • Patient care and treatment;
  • Special needs and services;
  • Medical-legal Issues.

In order to achieve or maintain national accreditation, a site must attain a score of 100% of essential standards and no less than 85% of important standards.

The accreditation survey should be viewed as an opportunity for site caregivers to objectively verify the good care patients are receiving. Proper organization, a properly trained staff and proper documentation to support the standards are all essential to provide correctional healthcare within national standards.

Presenting your organization’s information

Prior to a site’s initial survey, the NCCHC sends the organization an 80-page electronic self-survey designed for the organization to outline how it meets the standards. Additionally, the lead NCCHC surveyor contacts the Health Service Administrator (HSA) – the individual overseeing the facility’s healthcare delivery system – approximately one month prior to the site visit to go over the process and request certain items for review.

Surprisingly, many healthcare providers do not understand how to best present their organization’s information and practices. Site policies and procedures should not be complicated and should outline how the site meets the requirements for the respective standard. For example, at Armor, we emphasize to our HSAs and supervisors the importance of making a file for each standard and reviewing all the compliance indicators for that standard. Moreover, we encourage regular review at staff meetings.

It is also important to include your client (warden/sheriff’s office) in the survey process as much as possible. This helps to ensure information is accurate and deadlines are met.

Typically, there are two or three members on an NCCHC survey team scheduled to be on site for two or three days. However, the size of the facility will determine the number of days on site and the size of the team needed to complete the survey. The survey team holds an entrance and exit conference with key personnel.

During the accreditation process

During the accreditation process, the surveyors:

  • Carefully review health records and site-specific policies and procedures;
  • Tour the facility;
  • Conduct interviews with healthcare staff, correctional staff and inmates/patients.

It is important to assign one or more of the healthcare staff to work alongside the physician surveyor to assist with navigating health records (whether paper or electronic). The lead surveyor will spend a good portion of the time with the HSA reviewing policies and procedures.

During the exit conference, the team will review standards and discuss preliminary findings. They do not, however, make the decision on accreditation. The lead surveyor will submit a report to the NCCHC for review by the accreditation committee. The committee will decide whether to accredit, accredit upon verification, defer, or deny. After the initial NCCHC accreditation, re-accreditation is done every three years.

Recently, the Minnehaha Sheriff’s Office, in conjunction with Armor, achieved accreditation at the Minnehaha County Jail for the first time.

About the author
Steve Epple is the regional vice president at Armor Correctional Health Services.