By Roberta E. Stellman, MD, CCHP
Posted on September 29, 2010 – Oftentimes a correctional system or facility does not think to hire a medical consultant until matters have deteriorated to the point that a legal challenge to the health care system has been initiated or obtained. At that point, the county or state authorities may be willing to allocate funds in order to obtain an independent review by an outside physician. A focused system review can be helpful, but I would argue that better results can be obtained if an expert consultant is retained with an ongoing active role to protect and insure that quality health care is being delivered as stipulated by the contracts with the medical, dental, mental health and pharmacy providers. Most of my comments in this article will be more applicable to jails than prisons because these are usually free standing agencies that lack the central office of health services resources present in most state correctional systems. When hiring a consultant, the facility should look for a medical expert in correctional medicine. This professional should possess substantial clinical experience, a solid knowledge base of NCCHC standards, correctional experience with awareness of the interactions between the medical and custody disciplines, the nature of penal confinement (especially segregation), an operational understanding of the principles of total quality management, continuous quality improvement and quality assurance, a knowledge of community statutes pertaining to medical practice and mental health commitment / guardianship and forced medication, and a dedication to chart review and data organization.
I will briefly describe how I see the role of such a consultant. However, all my comments and suggestions can be applied to the health services program as a whole. Granted, there are many models of consultation and, given the system and circumstances, different methods apply. I will attempt to convey the approach I find most useful and successful, but first will describe the orientation and mind set consultants need in order to drive a system to success.
1. Remember who you are serving. The consultant is a representative of the public entity providing the jail or prison services. Your reviews can result in the health care provider being financially penalized depending on contractual liquidated damages.
2. Be a familiar presence. It is not the consultant’s job to displace on-site medical leadership because the facility has already contracted for that service with the providers; however, the consultant must be a familiar presence at the facility.
Depending on the size of the facility, the consultant may be sufficiently effective by being on-site for one to two days a month for a mega jail, and perhaps a couple of hours per month for small to medium sized facilities. Larger mega jails might require three to five days per month for the most effective outcomes.
3. Be an external medical director as well as a helpful colleague and mentor. You need to be an authority on how the service is designed and how it operates. The consultant works collaboratively with the leadership of the institution and strives to be integrated into the health services operations of the facility. A solid and trusting relationship with the superintendent, sheriff, county manager, and others is essential in order for the providers and custody officials to perceive the consultant as a valued asset (with authority conferred to them by the facility director). The consultant should be a resource to the facility as well as to the health care providers. Although your allegiance is to the facility, you cannot be effective unless the health care leadership regards you as a reasonable and helpful professional resource. You must also be capable of working collaboratively with them in the development of clinical processes and policies consistent with community practice and professional ethical codes.
An essential function of the consultant is protecting the uniformity of policies, processes and medical record forms. The consultant should act as a clearing house and make recommendations to the facility director for approval and implementation of those items. Too often, jails hire contract health care services and those companies bring their own policies and procedures to the facility. I would recommend that the facility own their policies and all template forms that are entered into the medical record. Only then can the institution ensure uniformity and consistency in the nature of the service, regardless of which provider is successful in winning the contract.
The consultant should also review any proposal by the vendor to implement new systems of care and review all CQI efforts. In the long run, the consultant will become the institutional memory of the evolution of the service and its delivery systems since providers and leadership personnel come and go. This leads to the next suggestion.
4. Help develop and implement the institution’s health care mission and vision.
5. Participate in mortality and morbidity reviews. Oftentimes, site staff looks at sentinel events from the limited view of the medical interventions performed during the occurrence. A consultant can help bring a bird’s eye view or systems perspective which is truly the critical purpose of the multidisciplinary mortality review committee.
6. Develop an auditing tool to assess performance regarding areas such as staffing, the timeliness and adequacy of processes (e.g., sick call requests and intake), chronic care clinics, emergency care, off-site referrals, infectious disease management, timely referral and assessment by psychiatry and mental health, mental health input into the disciplinary process, and presegregation assessments by medical and mental health. For psychiatry, one must also monitor involuntary treatments as well as suicide prevention, seclusion and restraint processes.
7. Do not be involved directly in personnel management or the denial of care requests. These are issues for the private company’s managers and are not the role of a consultant to the facility.
The consultant’s role is really multifaceted and designed to aid the public agency in its review and management of multimillion dollar contracts. The cost of a consultant can be pennies on the total health care dollars expended; roughly equivalent to 1.0 -1.5 % of the total contract. Yet it can mean the difference between inconsistent or even chaotic health care services versus exemplary ones. Most importantly, it is the inmates who ultimately benefit the most from the presence of an effective, independent consultant and improved health care operations.
Dr. Stellman is an SCP member and psychiatrist who currently consults to correctional systems. Readers may reach her at roberta.stellman@gmail.com.
