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§ 3-09 Quality Assurance.
   (a)   Policy.
      (1)   The Health Authority shall establish and implement written policies and procedures for a Quality Assurance Program which ensures the delivery of quality health care. This program shall be systematic and include objective criteria for evaluating care and shall include procedures for the following:
         (i)   monitoring and evaluation of the quality, appropriateness, and effectiveness of health care services; and
         (ii)   prompt identification and resolution of problems.
      (2)   Hospital Prison Wards shall meet accepted community standards for accreditation. Each hospital that is designated to provide health services for inmates shall have a single physician of attending status responsible for all treatment provided to inmates in that hospital.
   (b)   Quality Assurance Program.
      (1)   The monitoring and evaluation activities of the Quality Assurance Program shall reflect the following:
         (i)   the ongoing collection and/or screening and evaluation of information about health care services to identify opportunities for improving care and to identify problems that have an impact on health care provision and clinical performance;
         (ii)   the use of objective criteria that reflect current knowledge and clinical experience;
         (iii)   the identification of problems and improvement of the quality of health care through appropriate actions by administrative and health personnel; and
         (iv)   documentation and reporting of the findings, conclusions, recommendations, actions taken and the results of such actions.
      (2)   The administration and coordination of the overall Quality Assurance Program will be designed to assure the following:
         (i)   all monitoring and evaluation activities are performed appropriately and effectively;
         (ii)   necessary information is communicated within and between the Health Authority and the Department of Correction when problems or opportunities to improve health care involve more than one department or service. Communication with the Department of Correction must be consistent with State law and 40 RCNY § 3-08(c) of these standards regarding confidentiality.
         (iii)   the status of identified problems shall be tracked to assure prompt improvement or timely resolution;
         (iv)   all documented information and recordings will be statistically analyzed to detect trends, patterns of performance or potential problems;
         (v)   a quarterly statistical report outlining the types of health care rendered and their frequency shall be prepared by the Health Authority; and
         (vi)   the objectives, scope, organization, and effectiveness of the quality assurance program shall be evaluated at least annually and revised as necessary.
      (3)   There shall be monthly meetings attended by the facility correctional administrator, the chief representative of Health Services at the facility and representatives of the medical, dental, and nursing staff.
         (i)   each meeting will include a written agenda as well as the taking and distribution of minutes.
      (4)   All Hospital Prison Wards shall be inspected as part of the accreditation process by the Joint Commission on Accreditation of Hospitals (JCAH), and shall be in compliance with JCAH and State Department of Health standards. In addition, each hospital that is designated to care for inmates will submit as part of their quarterly written reports to the Health Authority, a section that reflects quality assurance activities concerning care provided to inmates.
      (5)   The Health Authority shall annually conduct itself or contract for a formal evaluation of the quality, effectiveness, and appropriateness of health services provided to inmates in each New York City correctional facility. If the review is conducted by the Health Authority, it must be done by personnel other than those who provide care directly to inmates.
         (i)   At a minimum the evaluation will consist of the items outlined in 40 RCNY § 3-09(c).
         (ii)   The findings, conclusions, and recommendations of the Health Authority's evaluation shall be documented and distributed to the appropriate authorities, including the Board of Correction.
   (c)   Monitoring and Evaluation.
      (1)   The quality of care shall be evaluated and monitored to ensure that medical judgments are soundly made and documented and that medical procedures are appropriately performed and evaluated. Monitoring and evaluation shall assess the appropriateness of diagnostic and treatment procedures, the use of adequate and complete diagnostic procedures including laboratory and radiology studies when indicated. Other subjects which should be reviewed include but need not be limited to: inservice training for medical personnel; the provision of chronic care services; adherence to protocols as evidenced by chart review; whether protocols are updated to reflect current medical knowledge; and whether staff education is successfully conducted to ensure compliance with current protocols.
      (2)   The quality, content and completeness of medical and dental records and entries will be evaluated and shall at a minimum include verification of:
         (i)   timely and adequate transfer of appropriate health care documents and information when inmates are transferred to or from other correctional facilities.
         (ii)   confidentiality and security of records.
      (3)   The quality, completeness and efficiency of receiving screening services shall be evaluated, including at least a review of any cases where an inmate with a serious health problem, which went undetected at screening, was placed in the general population and of cases where there are substantial delays in conducting the screening.
      (4)   An evaluation of the quality and appropriateness of surgical and anesthesia services shall be conducted and include at least the following:
         (i)   a regular and systematic evaluation of inmates who require hospitalization following surgery;
         (ii)   a regular review to ensure that procedures are done in appropriate time frames after they are ordered;
         (iii)   review of the inspection and testing of anesthetic apparatus before use; and
         (iv)   review of the documentation of surgical and anesthesia procedures, annual review and revision as necessary.
      (5)   The quality and appropriateness of emergency services will be evaluated and include at least a review of the following:
         (i)   correctional and health personnel response times to emergencies; and
         (ii)   sufficiency of supplies, equipment, materials and emergency health care per- sonnel.
      (6)   An evaluation of quality control in radiology, pathology, and other laboratory services will be performed and include a review of at least the following:
         (i)   the documentation, accuracy, and completeness of procedures; and
         (ii)   all safety aspects of the radiology service.
      (7)   Procedures for medication prescription, administration, and dispensing will be reviewed to ensure compliance with all applicable Federal, State, and local laws.
      (8)   Procedures for inventory control and documentation to account for the use of materials, supplies, equipment and medication shall be evaluated.
      (9)   Staffing needs shall be evaluated regularly to assure the maintenance of an adequate number of qualified health care personnel as consistent with the needs of the correctional facility.
         (i)   Written job descriptions shall be reviewed to maximize the functional responsibility, authority, and utilization of available health care personnel and to make changes or additions where necessary;
         (ii)   All health care personnel will receive periodic job performance appraisals by their supervisors which will include licensure or certification renewal; and
         (iii)   Inservice training shall be reviewed at least annually by the Health Authority to ensure that the quality, scope and effectiveness of training is adequate.
      (10)   All powered emergency, radiology, pathology, surgical, and dental equipment shall be tested at intervals deemed necessary to assure their proper functioning, but in no case shall such intervals exceed six months.
      (11)   Procedures for the management of hazardous materials and wastes in accordance with Federal, State, and local laws and regulations shall be reviewed.
      (12)   Documents and records will be made available to the Board of Correction by the Health Authority, Health and Hospitals Corporation and the Department of Correction in a timely fashion to allow the Board to monitor compliance with all parts of these standards. These records do not include individual medical records for living inmates, which must be obtained using standard procedures of informed consent and release.