Patient Safety: Moving the Bar in Prison Health Care Standards

Abstract

Improvements in community health care quality through error reduction have been slow to transfer to correctional settings. We convened a panel of correctional experts, which recommended 60 patient safety standards focusing on such issues as creating safety cultures at organizational, supervisory, and staff levels through changes to policy and training and by ensuring staff competency, reducing medication errors, encouraging the seamless transfer of information between and within practice settings, and developing mechanisms to detect errors or near misses and to shift the emphasis from blaming staff to fixing systems. To our knowledge, this is the first published set of standards focusing on patient safety in prisons, adapted from the emerging literature on quality improvement in the community.

In Geneva, more than a half century ago, at the First Congress on the Prevention of Crime and the Treatment of Offenders, the United Nations took the first substantive step toward setting minimal standards for the quality of health care delivered to individuals in custody.¹ Currently in the United States, the field is dominated by standards formulated by 3 organizations: the American Public Health Association (APHA)²; the National Commission on Correctional Health Care (NCCHC),³ which drew on the work of the APHA and the American Medical Association⁴; and the American Correctional Association (ACA).⁵

These standards have set the bar at an elemental level, trying to ensure the most basic of human rights for prisoners, including access to care. No data have been published on the effectiveness of these standards in improving health care conditions that were prevalent prior to the 1970s and 1980s. NCCHC promotes its accreditation as a tool for improving patient safety⁶ (as does ACA, more indirectly⁷). Many prisons and jails voluntarily seek accreditation (or, when contracting for services, require their vendors to do so); it is thus reasonable to infer that many correctional administrators believe NCCHC's claim.

Does an institution's adoption of any of the existing sets of standards, by itself, ensure that its patients will be safe? We were unable to find high-quality evidence to answer this question. However, in our anecdotal experience, lapses in quality of care occur at accredited institutions—albeit less commonly than at nonaccredited institutions. At least 1 source of the continuing danger to patients lies in institutions’ failure to address patient safety with the same vigor with which it is being addressed in the community.

Reason's well-known treatise on human error was published in 1990.⁸ Over the next decade, critical evidence slowly began to emerge that the health care system was not immune to the kinds of human error Reason described.^9–12 The landmark publication of the Institute of Medicine's To Err is Human pulled much of this evidence together under a framework largely informed by Reason's error model and shone an intense light on patient safety.¹³ Subsequent publications from the Institute of Medicine and the World Health Organization depicted a problem with the broader quality of health care and began to lay out a foundation for addressing safety and quality challenges.^14–16 This attention prompted the formulation of several patient safety guidelines and standards by various organizations, including the Agency for Healthcare Research and Quality,¹⁷ the National Quality Forum,¹⁸ the National Committee for Quality Assurance,¹⁹ the Institute for Safe Medication Practices,²⁰ and the World Health Organization.²¹

In the research literature, far less attention has been directed toward patient safety in correctional settings than it has been in the community. Current correctional standards address patient safety, and new ones, such as NCCHC's patient safety standard,³ that incorporate Institute of Medicine concepts have begun to emerge and are an important step. However, such efforts do not yet encompass the depth and breadth of the larger community's patient safety movement. If improvements to patient safety are needed in the community at large, the same need surely exists in correctional health care.

One barrier to a more rapid spread of the patient safety movement to correctional settings is that standards designed for the community setting may not translate seamlessly to correctional health systems. Although health care is essentially the same no matter where it is practiced, practice inside prisons is significantly different from practice in the community. Not only is the content of some standards inappropriate to the correctional environment (e.g., timely return of patient phone calls), the sheer number of existing community standards is overwhelming.

We perceived a need for (1) selection of a limited number of community standards that, at this point in the evolution of prison health care, are needed most urgently, and (2) tailoring of these standards to the correctional environment. Consistent with suggestions by the Institute of Medicine^13,15 and the World Health Organization^21,22 that nongovernmental professional organizations can play a role in bringing about change, we developed quality-of-care standards (with a focus on patient safety) from the consensus of a group of correctional health care experts in the United States.

METHODS

We convened a series of 4 roundtable meetings in 2006 and 2007 at John Jay College in New York, New York, to discuss development of tools for improving the quality of correctional health care. Because we had no outside funding, most participants in these roundtables were representatives of large, private correctional health care contractors who paid their own way to the meetings. The success of these meetings prompted John Jay College to seek support for 2 symposia that would include public-sector correctional health care leaders. The Langeloth Foundation funded the public–private symposia, with 23% of the funds contributed by private vendors and 1% by John Jay College. The first symposium (described here) addressed patient safety, and the second addressed challenges in contracting for correctional health care services.

Participants

We selected participants for the invitational symposium on patient safety for their experience and wisdom on big-picture issues in correctional health care. A broad range of national experts (19 men and 11 women) were selected (by R. B. G., with advice from other authors) to participate.

The group comprised 14 executives (some of them physicians) who were employed by private correctional health care providers and who had worked together in other, similar forums; 7 correctional health care leaders employed in the public sector, of whom 5 were medical directors of state correctional agencies; 4 independent correctional heath care consultants; 3 academic researchers; and 2 attorneys who were executives of organizations active in prisoner advocacy. Sixteen of the 30 participants were physicians; the others had graduate degrees in law, psychology, nursing, or public health.

Development of Candidate Standards

We used the following 6 guiding principles for recommending standards:

1. Standards should not reiterate existing correctional health care standards.

2. Standards may derive from the general medical care literature but should be tailored to corrections. Where standards existed in the literature, we preferred them to new ones, because those already published were more likely to be based on evidence. This helped align our efforts with those in the general medical community. Where necessary, we modified existing standards to ensure their relevance to corrections. For example, during our deliberations of a standard regarding timely response to e-mails and phone calls from patients (the Physician Practice Patient Safety Assessment²⁰), we replaced “e-mails and phone calls” with “written messages,” the typical way for incarcerated patients to communicate health care needs to health care staff.

3. The focus should be on patient safety rather than on a broader set of quality indicators. Published definitions of quality and safety are diverse, but the consensus is that safety is a subset of quality. After a careful review of the quality and safety literature (M. F. S. and R. B. G., unpublished data, 2009), we decided to adopt a very broad definition of safety derived from that literature: freedom from preventable adverse events. An adverse event results in unintended harm to the patient by an act of commission or omission resulting from medical management (not from the underlying disease or condition of the patient). Harm is the degree to which health services for individuals fail to achieve desired health outcomes, as determined by the patient. This definition of patient safety is so broad that the notions of safety and quality overlap almost completely. This overlap simplified our effort to focus on patient safety.

4. The term “standard” (in contrast, for example, with “indicator”) should be defined liberally. Numerous measures to assess safety (and quality) are cited in the literature. One framework has measures of appropriateness of care (i.e., did the benefits of the intervention outweigh the risks?) and measures of adherence to professional standards, which are further subdivided into quality indicators (usually measured as continuous variables, e.g., the percentage of eligible patients receiving screening mammography) and practices (usually measured as binary variables, e.g., whether an organization includes patient safety in its written goals).²³ A different framework distinguishes between prevalence measures (e.g., the number of people with diabetes in a year), utilization measures (e.g., the number of trips to the emergency room for diabetes-related problems in a year), standards (e.g., 85% of patients with diabetes must have a hemoglobin A1c test annually), and true quality measures (e.g., the percentage of patients with a diagnosis of diabetes who had 2 or more hemoglobin A1c tests in the past 12 months²⁴). Although we recognized that our definition of the term standard was broad, we considered a metric patterned after any of these structures to be worthy of consideration.

5. Standards should meet content criteria such as validity and importance. Standards needed to satisfy preestablished content requirements (M. F. S. and R. B. G., unpublished briefing paper sent to members of expert panel prior to conference, 2009). (The details of these requirements can be found in Appendix A, available as a supplement to the online version of this article at http://www.ajph.org.)

6. The initial focus should be on standards for adult prisons. Correctional medicine is practiced in 3 environments: jails (predominantly pretrial detention), prisons (primarily housing convicted felons), and juvenile detention facilities. Although these environments have many similarities, their differences warranted focusing on a single one. We focused on prisons for this first set of standards because we believed they would have the greatest and most rapid effect there. Indeed, the population of juvenile facilities is much smaller than those of prisons and jails, and the United States has only 52 administrations for prisons, but thousands for the management of county and city jails.

We reviewed the following existing sets of standards: Prevention Quality Indicators,²⁵ Inpatient Quality Indicators,²⁶ Patient Safety Indicators,¹⁷ 2009 Healthcare Effectiveness Data and Information Set,¹⁹ Safe Practices for Better Healthcare–2009 Update: A Consensus Report,¹⁸ and Physician Practice Patient Safety Assessment.²⁰ From these we culled 73 standards that met our criteria. We also proposed 7 new measures, 1 for tracking emergency department visits and others patterned after disease-specific measures in the Prevention Quality Indicators, including measures for cellulitis and seizures, because these conditions are prevalent among adult prisoners.

We sent our 80-item correctional health care safety measure draft checklist to members of the expert panel 2 weeks prior to the symposium, along with 2 briefing papers written for the symposium, 1 on correctional patient safety in general and 1 on patient safety for female prisoners. For each candidate measure on the checklist, the experts received the working title, a full definition, and, where applicable, the source of the measure and the full text from that original source. The experts were asked to rank each measure in order of importance on a 3-point Likert scale: (1) critically important measure that should be adopted early by prison systems; (2) important but less critical measure, whose implementation could and should be postponed until highest-priority items are implemented; and (3) either not an important measure or implementation could wait until a system has implemented standards ranked 1 and 2.

We sought to determine, prior to the symposium, the level of consensus on each item, so that discussion could focus more on issues for which we found less initial agreement. (The consensus process used for arriving at the final set of standards presented here is discussed in more detail in Appendix B, available as a supplement to the online version of this article at http://www.ajph.org.)

RESULTS

Responses to the presymposium review of the 80 candidate measures were received from 23 (77%) of the experts. Degree of consensus was calculated from the modal frequency (number of respondents choosing the most common response divided by the total responses). After examining the responses, we determined high consensus to be a modal frequency of 68% or more; moderate consensus, 50% to 67%; and low consensus, 49% or less. We found high consensus among these respondents on 29 (36%) of the proposed standards, moderate consensus on 30 (38%), and low consensus on 21 (26%).

During symposium deliberations, participants achieved high consensus on 75 of the 80 candidate items. Five drew moderate or low consensus: provision of translated medication information for non-Anglophone patients, maintenance of a list of permitted procedures, maintenance of a list of procedures clinicians are privileged to perform, establishment of a voluntary system of near-miss reporting, and requirement that clinicians have patients describe back (teach back) instructions.

Group deliberation led to the introduction of 5 additional standards (4 new standards and 1 original standard that was split into 2). As the symposium progressed, a new model for priority ranking emerged to replace the original Likert scale. Rather than recommending 3 tiers of measures for implementation, the experts opted for 2 tiers, a higher-priority tier (corresponding to the original Likert score of 1, 47 of the final measures), and a lower-priority—but still important—tier (corresponding to a consolidation of the original Likert scores 2 and 3, 13 measures). The 5 items receiving moderate or low consensus were assigned to the lower-priority tier. The panel also agreed to delete 25 proposed standards. Thus 60 standards survived the process as consensus recommendations.

Following the day-long symposium, the list of all standards discussed (tier 1, tier 2, and deleted) was sent to the panelists for final review and comment. Tables 1 and 2 show the surviving standards in tiers 1 and 2, respectively.

TABLE 1.

Tier 1 Proposed Standards for Patient Safety in Prisons: Patient Safety Behind Bars, John Jay College of Criminal Justice, New York, NY, 2009

Short Title	Proposed Safety Measure	Source(s)
Access to and availability of care
Access to prenatal care	Pregnant females receive prenatal care within first trimester or within 14 d of incarceration.	HEDIS
Access to postpartum care	Postpartum females receive care within 7 wk of delivery.	HEDIS
Culture of safety
Culture of safety from the top	Practice has a written statement in appropriate governing document emphasizing patient safety as a priority.	NQF 1
Active safety leadership by chief pharmacist and chief nurse	Chief pharmacist and chief nurse have active role on administrative leadership team and are accountable for medication management systems performance and patient safety related to nursing, respectively.	NQF 9; 18
Preventable adverse event reporting	System is in place for reporting of all preventable adverse events (events in which a preventable error led to patient harm). Examples include (but are not limited to) patient receiving wrong medication and having an adverse reaction, development of a pressure sore in an infirmary patient, wrong patient receiving an invasive procedure, and patient suffering a preventable fall.	PPPSA 33.1; NQF 4
Action taken on all reported errors (preventable adverse events and near misses)	System is in place to analyze and address all reported errors.	PPPSA 33.3; NQF 4
Shift from employee remediation to system improvement	System is in place to assure that when a preventable adverse event is discovered, practice addresses it in a framework (e.g., Just Culture26,27) that seeks first to discover and fix what is wrong not who is wrong; punishing an individual reserved for those instances where there is willfulness on the part of the individual rather than a system problem. System includes appropriate policies, staff training, and executive monitoring of staff sanctions.	PPPSA 33.3; NQF 4
Grievance response and review	All grievances, formal and informal, are addressed by health care personnel. System is in place to analyze and address system issues.	PPPSA 33.11
Personnel
Staff trained on patient safety	Human factors and key principles of error reduction (e.g., standardization, use of constraints, redundancy) are reviewed with all health staff during orientation and during each performance evaluation.	PPPSA 33.13; PPPSA 32.5
Patient safety is everyone's job	Organization has written statements in the documents appropriate in that organization (e.g., governing documents, ethics statement, job description, post orders) reflecting, for health and custody personnel, each staff member's responsibility in patient safety, including roles in team and error reporting.	PPPSA 33.8; 33.9
Staff fatigue and burnout	Systems are in place to monitor unscheduled leave use.	PPPSA 33.18
Staff vacancy	Systems are in place to monitor ease of recruitment and retention (e.g., turnover rate, vacancy rate, agency use to fill positions).	…
Adequate nursing staffing	Staffing plan exists, is adequately funded, is monitored.	NQF 9
Annual competency assessment of nonproviders	Practice maintains system to annually assess nursing and support staff competency appropriate for services and procedures they perform, including devices and associated protocols/guidelines. Competency with their use is verified before they are permitted to use device or train others.	PPPSA 32.3
Annual competency assessment of providers	Identical to previous standard, but applicable to physicians, nurse practitioners, and physician assistants.	PPPSA 32.4
Medication management
Up-to-date medication list	Complete medication history (including over-the-counter medications) is obtained and documented on every patient when change in medication, change of primary practitioner, or change in level of care (e.g., to and from infirmary or community hospital) occurs.	PPPSA 29.1; 29.9; WHO-CCPSS
Medication list available	Medication list is available to all professional staff caring for patient at time of care.	PPPSA 29.13
Medication references	Up-to-date, standardized medication reference resource is available to all prescribers at the point of prescribing.	PPPSA 29.1; 29.9
Medications in pregnancy	All female patients of childbearing age have documented negative pregnancy test or other notation before medications known to be teratogenic or contraindicated in pregnancy are prescribed.	PPPSA 29.12
Computerized practitioner order entry system	Prison has this system.	PPPSA 29.5; NQF 16
Medication properly labeled	All medications kept by patients on their person show patient name and number, prescriber, medication name, strength, dose, frequency, number of pills or time frame, lot number, date dispensed, expiration date.	PPPSA 29.15
Medication list to patient on release	Patients provided up-to-date list of all medications they are receiving on release.	PPPSA 29.3
Handling of medications for external use	External medications (e.g., benzoin, podophylline) labeled “For External Use Only” and separated from internal-use medications in all storage areas.	PPPSA 29.8
Handling of multidose injectables	All multiple-dose vials of injectable medications (e.g., lidocaine, dexamethasone, prochlorperazine, vitamin B12) labeled with date opened and include date on which unused product will be discarded (no later than 30 d after opening).	PPPSA 29.14
Check expiration dates	All medications, reagents, and other products that expire are routinely checked (at least quarterly) by designated staff member and are discarded once expired.	PPPSA 29.11
Transitions and communication
Critical info read back	For verbal or telephone orders or for telephonic reporting of critical test results, communication is verified by having receiving person record and read back completely.	NQF 13
Dangerous abbreviations	Staff may not use abbreviations on list of prohibited abbreviations, acronyms, symbols, and dose designations.	NQF 13
Correct patient name on tests	Standardized policies, processes, and systems are in place to ensure accurate labeling of radiographs, laboratory specimens, and other diagnostic studies, so that the right study is labeled for the right patient at the right time.	NQF 13
Specialist consultation timeliness	Internal and external consultations with specialists (employee or contractor, on-site or off-site) are completed within time frame ordered. If the primary care practitioner modifies date needed, the new date determines whether consultation is completed on time.	…
Specialist consultation followed	Consultant recommendations are followed or a documented clinical rationale from primary care practitioner is provided if they are not.	…
Test and consultation tracking	Tests are tracked when sent outside the prison (what sent, where, when, when expected back, action taken if results are overdue); when results are received, they are seen by appropriate clinician and posted to medical record. Mechanism exists to report critical results, even in absence of requestor (e.g., vacation, after hours).	PPPSA 30.2; PPPSA 30.4
Nonmedication reconciliation	Nonmedication information (e.g., allergies, mobility limitations, language or communication limitations, and other disabilities) is reconciled whenever patient transitions from 1 primary provider or health care setting to another (e.g., infirmary to general population, prison to community, prison to hospital, prison to another prison).	WHO-CCPSS
Patient involvement
Informed consent	When written informed consent is obtained, it is by a clinician credentialed to order the intervention and contains explanation of risks and alternatives and patient describing back to the clinician key information he or she heard, in his or her own words.	PPPSA 34.5; NQF 5
Informed refusal	Any written refusal of treatment is an informed refusal and is only obtained (at a time interval appropriate to the intervention) by clinicians privileged to order or refer for the intervention. Excludes noncritical single refusals of staff-administered medications.	…
Patient-tailored decisions	Care plans take patient's social environment (e.g., work, release plan) into account.	PPPSA 34.3
Health-adjusted correctional environment	Correctional environment is adjusted to special health needs of inmate (e.g., adding air conditioning).	…
Interpreters	Interpretation services are available for clinical encounters, interpreters should be qualified/certified, and should not be custody staff or other prisoners except in emergencies.	PPPSA 34.7
Patient notification of results	Results of tests are communicated to patient within 2 wk of receipt; practice confirms and documents that patient received results.	PPPSA 30.7
Obtain advance directives	Practitioners seek advance directives for patients admitted to an infirmary who do not already have such directives.	…
Advance directives available	For those with advance directives, written documentation of patient's preferences is prominently displayed in medical record.	NQF 6
Specific conditions
Chronic disease registry	Practice maintains chronic disease registry, either free standing or within an electronic health record.	PPPSA 34.2
Access to care after acute mental health problem	During a recent period (can be any relevant period chosen by system, typically 1 y), percentage of patients discharged from a prison acute mental health care bed getting follow-up visit with mental health staff within 1 d of discharge.a	HEDIS
Hand hygiene	Organization complies with category I recommendations in the CDC's hand hygiene guidelines.29	NQF 19; WHO-CCPSS
Chronic disease monitoring	The following nationally accepted guidelines are followed for chronic disease management: guidelines published by NCCHC, correctional consensus psychiatric guidelines,30 and all patients receiving certain high-risk medications for ≥ 180 d receive appropriate lab test monitoring annually (or more often if clinically indicated).b	HEDIS
Warfarin monitoring	All patients on warfarin tracked for appropriate International Normalized Ratio levels.	PPPSA 29.4; NQF 29
Pressure sore prevention	Written protocols in place for prevention and management of pressure sores among nonambulatory patients.	AHRQ PSI
Pregnancy and methadone	Patients admitted who are pregnant and opioid dependent, including methadone maintenance, will receive adequate opioid dosing to prevent withdrawal during pregnancy.	…

Note. AHRQ PSI = Agency for Healthcare Research and Quality Patient Safety Indicator¹⁷; CDC = Centers for Disease and Prevntion; HEDIS = Healthcare Effectiveness Data and Information Set¹⁹; NCCHC = National Commission on Correctional Health Care; NQF = National Quality Forum Safe Practices for Better Healthcare¹⁸; PPPSA = The Physician Practice Patient Safety Assessment²⁰; WHO-CCPSS = World Health Organization Collaborating Center for Patient Safety Solutions.²¹ Tier 1 standards were designated by an expert panel as highest priority for adoption by prison systems. Ellipses indicate new proposed standards not derived from existing ones.

^aThe panel chose not to prescribe the threshold percentage that systems should achieve. Rather, at this early point in the use of patient safety standards in corrections, members felt systems should be at liberty to establish their own thresholds. They hoped that over time systems would gradually raise their own threshold or that as this standard was adopted by accreditation or professional organizations, these organizations would set a threshold.

^bFor patients taking angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, digoxin, or diuretics, the following are monitored: serum potassium, serum creatinine, and blood urea nitrogen; for patients taking carbamazepine, phenobarbital, phenytoin, or valproic acid, the serum concentration of the drug is monitored.

TABLE 2.

Tier 2 Proposed Standards for Patient Safety in Prisons: Patient Safety Behind Bars, John Jay College of Criminal Justice, New York, NY, 2009

Short Title	Proposed Safety Measure	Source(s)
Patient involvement
Patient satisfaction	The practice periodically gathers and analyzes data from patients regarding their safety concerns.	AHRQ CAHPS
Patient instructions	Patients are asked to describe back to the clinician information they heard, in their own words, to help the clinician clarify any instructions.	PPPSA 34.6; NQF 5
Culture of safety
Employee support after errors	A system in place to ensure that after serious harm caused by system failure or unintentional human error, the involved caregivers (clinical providers, staff, and administrators) receive just treatment, respect, compassion, supportive emotional care, and the opportunity to fully participate in event investigation risk identification, and mitigation activities that will prevent future events.	PPPSA 33.7; NQF 8
Near-miss reporting	A system is in place for voluntary, anonymous reporting of all near misses and for analysis and implementation of changes as appropriate.	PPPSA 33.2; NQF 4
Personnel
List of permitted procedures	Up-to-date list of permitted procedures is maintained and is accessible to all staff.	PPPSA 31.1
List of privileged operators	A list of who may perform what procedures is compiled and is updated annually.	PPPSA 31.5
Staff surveyed on patient safety	A survey (core items should be standardized nationally) of health care staff is conducted annually to measure the penetration of patient safety concepts into the culture and is reported to leadership.	NQF 2
Staff trained on team-based care	Leadership and care delivery personnel receive ongoing training on how to function as a team (including members of the custody staff) in activities closely related to patient safety (e.g., functioning in an emergency and suicide prevention).	NQF 3; PPPSA 33.2
Staff trained on health literacy	All health care staff that interact with patients are trained to recognize and manage health literacy issues.	PPPSA 33.19
Medication management
Vaccine log	All vaccines are documented in a log that contains the name of the vaccine, lot number, expiration date, patient name, dose, and date administered.	PPPSA 29.16
Medication device maintenance	All devices used in medication delivery (e.g., nebulizer, glucometer, intravenous pump) are standardized, maintained annually, and covered by protocols for use.	PPPSA 33.21
Medication information translation	Up-to-date, useful written information about medications is available to non–English-speaking patients in their language.	PPPSA 29.2
New medication in-service	When a new medication is added to the prison formulary, prescribers are educated about its use from reliable, nonpharmaceutical sources.	PPPSA 32.1

Note. AHRQ CAHPS = Agency for Healthcare Research and Quality Consumer Assessment of Healthcare Providers and Systems³¹; NQF = National Quality Forum Safe Practices for Better Healthcare¹⁸; PPPSA = Physician Practice Patient Safety Assessment.²⁰ Tier 2 standards were designated by an expert panel as important but less critical, whose implementation could and should be postponed until tier 1 items are implemented.

Of the 25 items the panel decided to delete from the candidate standards, 4 were considered to be adequately addressed by existing national correctional health care standards. An additional 4 standards were found to be either duplicates of, or easily folded into, other standards under consideration. A standard requiring the correctional health care operation to be transparent with patients and family following an adverse event was felt not to have a direct effect on patient safety and therefore was not part of the group's task.

Panelists relegated 2 standards for further work: a pilot-tested survey instrument should be developed before instituting a standard requiring a correctional health care organization to regularly survey patients regarding their concerns for patient safety, and consensus about types of treatment should be achieved before recommending access to drug abuse therapy. The participants agreed that additional attention was most needed regarding continuation of opiate maintenance therapy in nonpregnant individuals. They therefore requested that a work group be convened, from among the symposium attendees and other experts, to address this topic.

Most of the disease-specific standards, 9 in all, were deleted. The discussion indicated that their deletion did not reflect their lack of importance to the panelists, but rather stemmed from various factors, such as lack of consensus about whether they were the most important conditions, a desire to concentrate on global system issues rather than specific diseases, a belief that many systems already monitor their performance related to the clinical issues in these 9 standards as part of their continuous quality improvement efforts, and a concern that for those systems that do not already monitor such performance, the potential magnitude of improvements in patient safety from adopting these 9 standards (compared with the standards retained in the final set) was not great enough to justify the difficulty and cost of collecting data required to implement the standard, especially in systems lacking electronic health records.

The remaining 5 standards recommended for deletion were considered by the experts as not unimportant but as less urgent than were the retained candidate standards. The deleted standards were (1) a system is in place to monitor the literature of patient safety in correctional organizations; (2) all prescriptions carry the clinical indication; (3) patients are provided with an up-to-date list of all medications they are receiving, whether the medications are staff-administered or kept on their persons; (4) patients' participation is actively sought in decisions regarding their own care; and (5) patients have access to their medical records (without cost if no copies are made).

DISCUSSION

Our consensus process created a unique set of prison-specific standards focusing on patient safety. Candidate standards were drawn from several respected evidence-based standards sets currently in use in the community. The final standards were chosen and adapted from the candidate standards by a representative group of experts in correctional health care deliberating in person. This group recommended 47 standards for immediate and 13 standards for subsequent implementation.

Prison health care standards promulgated by respected organizations (e.g., the World Health Organization, NCCHC, ACA, and APHA) are already in widespread use. At their core, these standards, like those we propose, focus on patient safety as our group defined it. The science of patient safety has grown in the past 2 decades. Revisions of existing standards, such as NCCHC's patient safety standards, are a step toward embracing that science. Our proposed set extends that effort, bringing more of the newer community-based safety standards into the correctional setting.

Although most of our proposed standards cover new domains, some are similar to existing standards. Where similarities exist, our proposals extend or more strongly emphasize patient safety or systems improvement. For example, an NCCHC standard (end-of-life decision making) and 2 of our standards (obtain advance directives and have advance directives available) address end-of-life decision making and care. They differ in that the NCCHC standard focuses more on ensuring that prisoners are permitted to execute advance directives and preserving their rights in the process, consistent with constitutional requirements for access to care; our standards build on this by focusing more on ensuring that advanced directives are actively sought by health care staff and that the directives are prominently displayed, helping to ensure that the care plan is executed as planned.

Another example involves the NCCHC standard on grievance management (grievance mechanism for health complaints) and our similar standard (grievance response and review). The focus of the former is on ensuring that medical needs of individual patients are met (although the standard suggests that grievances can be part of a quality improvement program); the latter focuses on translating lessons learned into system change.

Limitations

Our identification and selection of experts did not follow a random or a formal process, but rather depended on the following factors: recommendation by other national experts, successful participation in previous similar efforts, willingness and availability, and our attempt to achieve a cross section of representatives of public and private delivery systems, patient advocacy, industry, and academia. Not all experts in the field were included.

The majority (60%) of the participants were representatives of private contractors. The involvement of these individuals stemmed, in part, from the history of the series of panels that preceded the symposium. Most of the support for the earlier panels came from industry. As a result, we had a convenient pool of experts who supported ongoing dialogue and had proved their effectiveness during previous consensus roundtables. Their presence helped moderate expectations to keep them practical and achievable. However, it is possible that their majority presence influenced the final product by emphasizing financial interest over patient need.

Conclusions

Despite the limitations, we intend for this set of standards to stimulate constructive dialogue among health care and custody professionals on how to improve the quality of health care in adult prisons by further embracing the developments in patient safety of the past 2 decades. We hope that NCCHC, ACA, and APHA will consider these proposed standards as possible additions to their current standards. They could be introduced en masse or gradually; they could also be offered as voluntary standards. Individual penal institutions and systems may also identify and adopt individual standards that resonate with their situation and needs.

Increasing the workload of correctional health care systems, many of which are overburdened and fiscally constrained, will not be easy, which informed our choice of a tiered approach. But even adoption of a single proposed standard, if it marginally improves patient safety, may help close the quality chasm.