How States Fortify Prison Health Care Quality Monitoring Systems

This is the ninth analysis in a series examining how health care is funded and delivered in state-run prisons, as well as how care continuity is facilitated upon release.

Quality monitoring has become an increasingly powerful tool to improve health care systems, including in prisons, where high-stakes treatment is routinely needed. A first-of-its-kind report by The Pew Charitable Trusts details whether and how states monitor the quality of care they provide. This analysis builds on those findings, offering practical examples that policymakers and administrators can reference to inform their own policies and programs.

Codified requirements can provide clarity for what shape a system should take and can bolster consistency amid personnel changes. For example, in Texas, legislation requires its Correctional Managed Health Care Committee, a cross-stakeholder division of the Texas Department of Criminal Justice that addresses costs and operational challenges, to establish a procedure for monitoring quality. The department must provide the results of this monitoring and any corrective action plans to the committee and the Texas Board of Criminal Justice, which also oversees the department. In turn, the committee is required to submit a quarterly report with data on expenditures and health care utilization and patient acuity to the governor and the legislature. The committee is also required by the statute to share “quality assurance statistics and data, to the extent permitted by law” with the public.

Nevada has taken a different tack, promulgating an administrative regulation that established a “Medical Quality Management Program,” described as a “structured process to monitor and improve health care delivery to inmates.” The state convenes administrative and frontline facility-level committees to collect and review data to measure the “effectiveness of the health care delivery system in the institution and if expected outcomes in patient care are achieved.”

States can also benefit from making data accessible to legislators and public stakeholders. In 2006, after finding that California had not provided a constitutional level of medical care to incarcerated individuals, a federal court appointed an independent body known as a receiver to take over that care. The receiver, working through a nonprofit corporation that manages medical care until responsibility is fully returned to the state, has taken several steps to revamp operations, including implementing a system for monitoring and improving care quality. One feature of this system is a monthly online dashboard that tracks performance indicators against benchmarks and goals across a range of domains, such as access to care, patient outcomes, and utilization and cost.

Consolidating both facility- and statewide-level data, the dashboard is meant to provide “information that can be used to improve the performance and value of health care services and patient outcomes.”

California Correctional Health Care Services Dashboard

The receiver’s office conducts periodic reviews of processes and services it considers to be “high risk, high volume, high cost, or problem-prone” and targets areas for improvement. Then it reports tri-annually on progress made, informed, in part, by data posted in the dashboard.

Based on data from the dashboard and other sources, as of April 2018, the California Department of Corrections and Rehabilitation had demonstrated sufficient progress to regain control of health care in about half of its facilities.

Finally, continuous quality improvement—commonly referred to as “CQI”—is a structured process practitioners use to enhance health care services by identifying problems, implementing and monitoring corrective actions, and assessing their effectiveness. Activating a recurring feedback loop wherein strengths and weaknesses can be identified, analyzed, and addressed helps staff ensure that quality monitoring systems meet their ultimate objectives.

Illinois’ policy, according to a copy provided to Pew researchers in 2016 by the state’s Department of Corrections, is intended, in part, to “assure ongoing, systematic evaluation of offender care practices, professional or clinical performance, and offender care services.” The policy requires studies of discrete processes and outcomes, review of medical records for treatment protocol compliance, examination of critical incidents (e.g., deaths) and formal grievances, and aggregation of performance indicator data. A quality improvement committee, comprised of a range of senior and frontline staff, uses information gleaned from these actions to develop or update an annual plan and assess progress on a monthly basis.

Well-run, forward-thinking prison health care systems are vital to state aims of providing care to incarcerated individuals, protecting communities, strengthening public health, and spending money wisely. These steps, among others, can be useful in meeting those objectives.

Matt McKillop leads The Pew Charitable Trusts’ research on state and local correctional health care.