§ 3-09 Quality Assurance.
RCNY § 3-09
(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.
(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.
(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.
(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.
(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.
