Like many professions, doctors and nurses need peer feedback to improve how they handle patient illnesses or to receive confirmation that they have done a good job. But in correctional health care, conducting peer reviews can be complicated, especially around inmate deaths.

Inmates tend to be a particularly ill population requiring frequent attention and monitoring and, in the case of a death, commonly the result is litigation. This presents correctional agencies with a quandary: How to provide much needed case review without giving away potentially damaging information?

“It is considered the standard of care and is practiced almost everywhere,” said Joseph Paris, Medical Director for the Georgia Department of Correction. “[But] an issue that is of great importance is [if] these reviews are protected and confidential [or whether] they can ever be subpoenaed by plaintiffs who find there are errors and use them against the system.”

Paris recently spoke about conducting these types of mortality reviews at the Society of Correctional Physicians conference in October.

Paris believes that these reviews should be in-depth and include the timeline from when an inmate was booked into a facility to the date of death. But the specifics of how and who conducts them can vary from state to state.

“Most reviews are pretty good at saying when the patient got very sick – we tried CPR or we injected them with this – but there is much more learning or educational value in analyzing the care and event previous to the final episode,” Paris said.

One example of the importance of this analysis, he said, would be in a cardiac arrest death with a patient who has a history of diabetes.

“The patient dies of cardiac arrest, but in-depth review shows his diabetes was never well cared for. It would be no surprise they died. The question is, Why was the diabetes care so haphazard?” Paris said.

Looking into the history of a sick patient's stay and finding a way to improve medical care are the ultimate goals of mortality reviews.

Structure and Goals

According to Paris, reviews of inmate deaths are an important part of continuous quality improvement and are essential to detecting whether there are variances in medical treatment, if there are patterns of variances and to taking corrective action when there are problems discovered -- either systemic or individual.

“When one detects system problems it could include an example of an inmate in need of insulin who could not get to the pill call lines frequently enough and had to miss insulin shots. Individual performance problems would be a physician who sees high blood sugars and fails to adjust insulin levels,” Paris said. “Both need to be found and corrected.”

In Colorado, Chief Medical Officer Cary Shames, has instituted a year-old quality management system that includes a specific process for improving the quality of health care through case and mortality reviews.

The new process requires a peer review for all inmate deaths. Previously those reviews were done on a case-by-case basis, depending on whether the deaths were considered “questionable.”

“It's interesting when you follow a standardized process throughout the various reviews, you sometimes come up with what on the surface would look like there are no quality issues and you are able to determine that there are some systems that were not performing to the level you would like them to,” said Shames.

Shames said the standardization process is important so that quality is improved at all levels, not just for a certain subset of patients

Colorado's new quality management system was already in process when the state issued recommendations and findings in October following a state audit of prison health care performance. The Colorado state auditors' report covered 20 prison-based clinics and two infirmaries and found deficiencies on several levels, but according to Shames, the report confirmed for corrections health care officials the areas they knew needed improvement.

“That is the reason we have been continuing to create and update our quality management system. There are many studies that show if you improve quality, you'll reduce costs but you can't do it the other way around and reduce costs first. We are continuing to grow quality management,” he said.

Shames said he wants the Colorado corrections system's health care to be ahead of the curve and a model for the country. He believes that quality management and review will bring the department to this level.

“I look at quality as a continuous improvement of the system, therefore, if you are not able to identify, review and then close the loop, you'll never get any better. It's about identifying problems and coming up with new ways to improve those systems,” he said.

The Colorado DOC's Peer Review Mortality/Morbidity Committee reviews all inmate deaths to determine whether clinical issues were a factor in the death. Results of the review are then reported to a Quality Management Committee. The committee also collects statistics to improve policies, procedures and practices within the department and between the DOC and outside providers.

The multi-disciplinary Quality Management Committee guides the quality management program. It consists of the chief Medical Officer, chief of Clinical Services, quality manager, chief of Mental Health, chief of Dental Services, regional health services administrators, two physicians, two mid-level providers, utilization manager and one RN.

Shames said the committees were designed to bring in discussion from multiple levels and areas to increase involvement in the process and improve the recommendations that come from it.

“It would be easy for me to make a decision by myself, but I make sure we do it in a committee process so there is ownership so we can implement strategies and solutions. We are able to document continued improvement and improved quality and reduced costs,” he said.

So far, success for Colorado has meant a $1.6 million reduction in health care costs over the last year, which Shames said is in direct correlation to the quality management program.

But beyond the benefits of conducting this type of review are the concerns that many administrators have about the ability of litigators to get a hold on the documents associated with this process and use them against the department and physicians.

Protecting the Review Process

Since litigation is a constant worry for correctional administrators, mortality reviews also need to be guided by state laws around confidentiality, Paris said. Both Paris and Shames agree that confidentiality is needed to have an open discussion about problems than need to be addressed and how to improve the system.

“All of this privilege is crucial to mortality reviews. If there wasn't any, then it would give the plaintiff everything. The issue of how to protect those files is paramount,” Paris said.

Paris said he believes that in general, peer reviews are protected from discovery in a court proceeding if the meeting is a physician-only meeting, the proceedings are typed and one original is kept in relation to the peer review.

He admitted that, in the past, those types of documents have been subpoenaed and obtained by plaintiffs if they could convince the judge that a peer review was done in bad faith. He added that some state rules do allow for participation in by those other than physicians and in those cases, the proceedings of their meetings are protected as well.

Shames said that physicians are naturally concerned that information about the care they provide will be used against them.

“What needs to be addressed is how the information is going to be used and create a feeling of security so that this process isn't to ‘go after' anybody, but rather to improve the care that is being provided,” said Shames.

Implementing this type of peer review process and convincing participants of the benefits is a paradigm shift, he said because no provider wants to offer up information that will get them or someone else into trouble.

“It's not any easy task. That's why you have some systems that are behind others,” Shames said

In the Colorado DOC's provider meetings, participants talk about how quality issues are being addressed to protect both the providers and the patients. Shames also tries to impart that doctors are not expected to be “computers.”

“You are a person and you will make mistakes and won't be right 100 percent of the time, but if someone makes a mistake, we should have a process in place to make sure that mistake does not become an adverse outcome,” he said.

That said, Shames realizes that if the state Attorney General's office or State Auditor's office wanted to review the proceedings of the DOC's peer review processes, they have that ability. Nevertheless, if the process works as it should, and problems are identified and addressed, the department will not look negligent to a court.

“That's why we make sure we do the right things and we document what we are doing and it is used for the protection of all involved,” Shames said.

Local sheriff's departments have also created mechanisms for monitoring quality of care, even as budgets have tightened and the business of monitoring inmates and caring for them has become more difficult.

Multnomah County Monitors Care

Multnomah County, Ore., Corrections Health, which is managed by the county health department, has been conducting mortality reviews of inmate deaths for years – ever since it became accredited by the National Commission on Correctional Health Care. But according to Gayle Burrow, Director of Multnomah County Corrections Health, the process is always a work in progress.

According to Burrow, in the early days, a review was done within a month of an inmate's death and those whose deaths were expected did not require review.

Over the years, the department has updated its practices for mortality reviews and they now include several levels and involve various stakeholders – including custody staff.

“We have our cars serviced every once in a while and [in correctional health care] we need to change things and revise them [too]. We are an ongoing living organization,” said Burrow.

Most recently, following a meeting with a suicide debriefing consultant, the department chose to revisit the role that corrections custody staff played in reviewing that type of inmate death.

“The goal is to make improvements if you need to and give credit for doing a good job,” Burrow said.

Currently, the process involves a facility manager, medical director and/or director of correctional health being called to the facility once a death has occurred.  A debriefing will be conducted with the officer in charge and a manager will speak with staff to ascertain the details of the death.

A physician will review the medical record of the case and a summary will be written for the county attorneys' office. Then a formal debriefing will be conducted with corrections and medical staff to discuss the event and procedure.

“We set it up and everyone who is involved can talk about it and having corrections and medical together is important. We talk about the equipment available, who did CPR, etc,” Burrow said.

A week to a month later a case conference is held with the health staff and nurses on shift at the time to discuss the incident. The meeting includes an attorney, medical director, corrections health director and any other staff that wish to be present.

A formal mortality review is conducted by the multi-disciplinary Quality Improvement Committee that looks into the medical records, the case and into any areas that may need to be strengthened or improved and then follows up with recommendations.

“Sometimes we have no [recommendations] and things went well, they got good care. [But] sometimes we need to review the chest pain protocol and make sure all the nurses are up to speed or improve the communication between corrections and medical,” Burrow said.

Burrow said that the multi-disciplinary nature of the steps involved in the review is important for the county corrections department as it faces tough budget times.

“It heightens our awareness of who does what. We have different roles but the goals are the same. That's really important. We've had to cut staff and [as a result] we have to communicate more clearly and we have to take care of each other,” she said.

Going one step further, Burrows said that the department also reviews deaths of those who were previously incarcerated. Recently, she said, there has been a trend of heroin-related deaths of former inmates who overdosed after release.

“Last year we looked at it and put signs up. Now we are trying to do a survey of the inmates to see how we can communicate with them how dangerous it is to go from clean and sober to their old habits,” she said.

Colorado is also looking at new ways of improving the heath of those in the DOC's care. According to Shames, the DOC is investigating predictive modeling so that officials will not only be able to see which inmate illnesses cost the most money today, but how to target chronic care and disease management to prevent the inmates from becoming sick in the first place.

But to get to this level of health care review, a corrections agency has to be running a sound medical care system – if not, then peer review seems a daunting task.

“When a system is running passably well or very well, there is no disagreement that mortality and peer reviews are important. The problem arises when a system is on the skids. If a system is putting out fires, then the dead patients tend to take less priority than the living ones and a manager confronting this situation would be concentrating on putting out the fires,” said Paris.

Resources:

Georgia DOC - http://www.dcor.state.ga.us/

Colorado DOC - http://www.doc.state.co.us/

Multnomah County Corrections Health -  http://www.mchealth.org/