CorrectCare

Guest Editorial

Correctional Health Care Accreditation: From Vision to Imperative

by Lambert N. King, MD, PhD

It was truly an honor to receive the Bernard P. Harrison Award of Merit from NCCHC. I appreciate the warm and generous introduction from my longtime friend and colleague, Dr. Robert Cohen. His comments proved that if you live to be old enough, you can actually be embalmed in schmaltz.

This award is a vivid reminder of my good fortune of being in the right place and time to work with Bernard Harrison and B. Jaye Anno in the 1970s, when we published monographs on the management of tuberculosis and epilepsy in correctional institutions. Together, we were privileged to contribute to an historic movement to support decent medical care for men and women in our jails and prisons.

Bernard and Jaye set an objective considered by many to be improbable, if not unwarranted. Their concept was that the level of health care services in jails and prisons should be examined and elevated through scrutiny and accreditation by outside professional bodies such as the American Medical Association. Were it not for their farsightedness, determination and capable advocacy, this was not necessarily an idea whose time had come.

In the years that followed, I worked at Rikers Island, served as a special master for health care at the Menard Correctional Center, testified in legal cases involving prisoner health and cared for patients at St. Vincent’s Hospital and Queens Hospital Center. In all of these endeavors, the significance of accreditation became ever more apparent.

By accreditation, I mean a periodic process of self- and external evaluation of how we care for patients, based on constantly evolving professional knowledge and evidence-based standards. Doctors and nurses caring for patients in correctional facilities need and deserve to do so in accredited programs that incorporate national standards for patient safety and professional conduct. Today, the National Commission on Correctional Health Care is the most prominent and respected health care accrediting organization in this field.

Why Jail Health Care Matters
I recently testified as a physician expert in two judicial cases that are disturbing but instructive. Both occurred in jails of substantial size. They involved middle-aged men with records of honorable military service who later developed serious chronic medical conditions and were being treated in VA health facilities. Both have families who care deeply about them.

When sent to jail, each was assessed and their chronic conditions were identified. But the subsequent care of Mr. S for hypertension was minimal and fragmented, despite blood pressure elevations that were dangerous. Medication administration records were not credible. After several months, he suffered syncope and a seizure. He was sent to a hospital and admitted to the ICU with severe hypertension. A cerebral hemorrhage was diagnosed on CT scan. After 18 days, he was discharged to rehabilitation for hemiparesis but he remains wheelchair dependent. In a subsequent trial, a jury found that the poor care at the jail was the result of systemic failures and that Mr. S should be compensated $900,000.

As for Mr. C, upon intake he informed the jail health care staff of his history of venous thrombosis and pulmonary embolism and his continuing use of coumadin to prevent a recurrence. But the jail had a policy that prior medications would not be given unless their use was confirmed through an outside provider. After several phone calls, Mr. C’s stated use of coumadin was neither confirmed nor contradicted. Despite pleas from Mr. C and his family, he was not restarted on coumadin.

After six weeks in jail, he was released. Two days later, he was bought to a local emergency department in shock and respiratory failure. He died shortly thereafter. An autopsy found the cause of death to be extensive deep vein thrombosis and massive pulmonary embolism, attributable to lack of chronic anticoagulant therapy while in jail. Inexplicably, however, internal retrospective death review by the jail health care provider organization found no problems in quality of care, including their refusal to believe Mr. C had been taking coumadin.

Accreditation, Quality and Patient Safety
The jails where Mr. S and Mr. C were housed were similar in important ways. Both are being monitored for deficiencies in quality of care by the U.S. Department of Justice, and neither health care program is accredited. When we think about the lapses in quality of care rendered to these two patients, they fall squarely in the domains of medication safety, communication and transitions in care. These are precisely the aspects of care necessary to build a culture of patient safety at the core of contemporary accreditation programs in health care systems throughout our nation.

It is not sufficient for correctional health care professionals and their patients to rely mainly on the Eighth Amendment prohibition against cruel and unusual punishment to assure that quality of care and patient safety are protected in accordance with evolving community standards. We also know that, unfortunately, many correctional institutions are exempt from federal, state and local health care standards and supervision. But correctional health care is very complex and important to the health of our nation. Therefore, it should not continue to be separate and unequal, which is precisely the situation that exists when correctional systems are not accredited by independent and trustworthy professional bodies.

This is not to say that contemporary models and methods of accreditation are infallible or a panacea. They will not prevent all of the “never should happen” events that result from defects in systems or medical negligence. But there is compelling evidence from the Agency for Healthcare Research and Quality that the merging of national patient safety goals with the processes of accreditation is saving lives and decreasing morbidity. There remain no good reasons why doctors and nurses in this country should have to care for patients in systems that elect to remain unaccredited and thereby exempt from regular external examination and review.

Those who care for people in jail or prison know that the integrity of your fiduciary relationship with patients can be strained and tested by the setting in which you work. Despite such pressures, I believe most would say that they remain a doctor or nurse, “first, last and always.” If you work in an accredited program, you know how important and helpful this has been.

Therefore, I am truly grateful for the esteemed Award of Merit in honor of Bernard P. Harrison, knowing that his great insight and dedication to the principles of accreditation have helped so many people in need, while also elevating standards of professionalism in correctional health care. I believe he would strongly agree that we need to move forward with all deliberate speed to achieve accreditation in correctional health care as a rule rather than an exception.

— About the author: Lambert N. King, MD, PhD, is the director of the department of medicine at Queens Hospital Center, Mount Sinai School of Medicine, New York, NY. Read about his receipt of the Award of Merit here.

[This article first appeared in the Fall 2008 issue of CorrectCare.]