Tracey Titus, RN, CCHP-RN, is Vice President, Accreditation, for the National Commission on Correctional Health Care. This post is based on her session “Let’s Get Organized Using the New NCCHC Standards” taking place at the 2018 Spring Conference on Correctional Health Care in Minneapolis, MN April 21-24, 2018. Learn more about the conference and register HERE.

Accreditation through the National Commission on Correctional Health Care (NCCHC) establishes the quality level of health care provided to a facility’s inmates. It indicates a constitutionally acceptable level of care, which translates into improved health status, fewer grievances and lawsuits, and reduced health risk to the community when inmates are released. Obtaining accreditation is a challenging task and health care settings obtaining and maintaining accreditation are to be commended.

As health care evolves, so must the standards. New standards are set to release in April and accredited facilities have approximately six months to transition to the new requirements. Accreditation surveyors will use the new standards for all surveys conducted on or after November 1.

Using valuable feedback from correctional health practitioners, the 2018 standards are reorganized, streamlined, and simplified to make information easier to find. There are now seven sections, rather than nine, with most content remaining but more logically organized.

Organizing for a Survey

In her session at the NCCHC Spring Conference, Tracy Titus will examine the standards in a new way, showing how to bring much of the required documentation together in one place and organized by responsibilities of key staff, training requirements, and time requirements. She will also share the simple chart she used as a health services administrator (HSA) to keep on track for a survey.

Every HSA or accreditation manager needs to find their best method for organization. As an HSA for many years, Tracy made a chart of recurring tasks that needed to be completed daily, weekly, monthly, quarterly, and annually. It was kept on a clipboard on her desk where she could check it on a regular basis.  She also kept file folders for each standard and stored ongoing documentation in the appropriate folder. This worked because it matched her organizational style. No one method, however, is required by NCCHC. Others may choose to keep hard-copy binders or store documentation electronically.

Common Challenges

NCCHC accredits facilities of every size. Each faces its own challenges when it comes to organizing the system, not only for a survey, but also for an efficiently run daily operation. Whether there is one person in charge or teams of people in charge, her best tip is to be accreditation ready every single day.  That involves keeping up with patient care, documentation requirements, meeting requirements, and training requirements. It pays off in the end because you ultimately will be providing quality care to your patients in a well-organized system.

One area that is sometimes difficult to verify during a survey is the required training, both for health staff and correctional officers. Many standards require training and some components are included in training programs and some are not. For example, Standard C-04 Health Training for Correctional Officers requires that officers are trained in numerous health-related topics. While all of the components must be included to meet the standard, surveyors often find only CPR, first aid, and suicide prevention training documentation. Another challenge is verifying that at least 75% of officers on each shift have current health-related training.

Another area of concern is the standard on medication administration training.  The standard requires at least four components to be present in the training: security, accountability, common side effects, and documentation. However, the course content is often missing one or more of these components.

Do We Need Folders? 

A frequent question asked is whether NCCHC requires a file folder for every standard. In fact, NCCHC does not have a set requirement on how documents should be organized.  What works for one facility may not work for another, so survey teams are adept at reviewing documentation in a variety of formats.  What is important is that the HSA, accreditation manager, or their designees are prepared to show the team the requested documentation. During a survey, the goal is to verify as much as possible while on-site. If the required documentation is not readily available, missing, incomplete, or otherwise cannot be verified, it can lead to compliance concerns.

Another frequent concern is when administrators set up a file folder for each standard but the surveyors do not look in all folders during the visit. For some standards, verification cannot be done simply by looking at a file folder. A large part of verifying compliance is through health record review. NCCHC teams always include a physician surveyor who spends most of the time on-site reviewing documentation of care provided during the previous years.

Help is Available!

NCCHC’s mission is to improve health care in jails, prisons, and juvenile facilities across the United States. Getting organized is the first step, and NCCHC’s accreditation staff are prepared to help administrators achieve the goal of having a well-organized system. They offer free webinars on how to prepare and organize for a survey, not only for new facilities but also for facilities going through the reaccreditation process. Administrators should feel free to contact NCCHC at any time with questions. Tracy can be reached at accreditation@ncchc.org.

How do you prepare for an accreditation survey? Share your experience in the comments section of this post.

This post is part of a series discussing topics addressed during sessions of the 2018 Spring Conference on Correctional Health Care. All posts in this series can be found HERE.