Why are these Standards necessary?
The prison environment presents a significant challenge for the delivery of high quality primary healthcare.
The Standard guidelines for corrections in Australia,1 which are endorsed by all state and territory governments, provide a basic framework for the delivery of health services to people incarcerated in Australian prisons.
The RACGP, acting on a recommendation by GPs working in the area of custodial health, has developed the Standards for health services in Australian prisons to provide a more complete framework for the delivery of safe, high quality healthcare to prisoners, and to engage health professionals working in prisons in comprehensive quality improvement initiatives (see Appendix A). It is acknowledged that health services in Australian prisons are run by the relevant state or territory department of health or department of justice (Victoria only), However, the RACGP Standards for health services in Australian prisons are designed to support GPs who are working to achieve better health outcomes for people incarcerated in Australian prisons or detained in custody.
The RACGP Standards for health services in Australian prisons are intended to cover health services provided to prisoners and remand prisoners. Health services provided to offenders (people subject to community corrections orders outside of prisons) lie outside the scope of these Standards as it is assumed this cohort of patients will be able to access primary healthcare from general practices in the wider community, for which the RACGP Standards for general practices will apply.
Any assessment against the RACGP Standards needs to be based on common sense and should not seek to penalise or exclude health services on the basis of technicalities.
The challenges behind the Standards
The Standard guidelines for corrections in Australia2 stipulate that each prisoner is to have access to evidence based health services, provided by a registered and competent health professional, providing a standard of care comparable to that which they would receive in the general community.
This requirement poses special challenges for health professionals on three key fronts.
First, the closed environment of prisons means that prisoners necessarily have restricted access to the broad range of healthcare available in the wider community. In addition, health professionals often need to balance a patient’s right to privacy and confidentiality against a need for safety and security.
Second, the patient population in prisons is generally characterised by complex clinical needs making it more difficult for health professionals to achieve good health outcomes. Studies that investigate the health status of incarcerated people both in Australia and internationally, identify consistent patterns of disease that are significantly higher than the same disease representation in the general community.3 Communicable diseases, such as hepatitis B and C, HIV/AIDS and
tuberculosis are prevalent at higher rates in prisons than found in the general community. The higher incidence of some communicable diseases can be attributed to high risk behaviour such as the sharing of needles for intravenous drug use, prison tattooing and unprotected sexual activity.
Illicit drug use and abuse is a problem. Prison entrants are five times more likely than those in the general population to have used illicit drugs (71% compared to 13%).4 In many jurisdictions some drug treatment programs are restricted to prisoners who were on the treatment program in the community before entering prison.5
The mental health problems of incarcerated people include a high prevalence of anxiety and depression as well as post-traumatic stress disorder, psychosis, suicidal thoughts, suicide attempts and other self harming behaviours. The Australian Institute of Health and Welfare (AIHW) reports a higher incidence of mental health problems in the Australian prison population than in the general population, with similar statistics found internationally. The AIHW reports that in a census week in mid-2009, 37% of prison entrants reported having a mental health disorder at some time, and a history of mental health problems was more common among female prison entrants (57%) than male entrants (35%).6
The Australian Bureau of Statistics (ABS) documents the incarceration rate of Aboriginal and Torres Strait Islander people as 21 times more likely than that of non-Indigenous Australians.7 This significant representation highlights the need to incorporate appropriate cultural practices8 within healthcare delivery, including appropriate training of health service staff.
Why are the Standards important to our health service?
Striving for standards of excellence is important for a number of reasons.
- The Standards provide a framework for safe, high quality healthcare in the prison setting comparable to healthcare available in the general community
- The Standards provide a structured way for your health service to self assess quality and safety systems before considering what changes may need to be
- Achieving the Standards is an indication that your health service is providing safe, high quality care
- Using the Standards to undertake quality improvement initiatives creates opportunities for collaborative teamwork and for assessing whether intended
outcomes have been achieved
- Engaging in quality improvement and meeting the Standards demonstrates to the prison community that your health service is serious about providing safe, high quality healthcare.
How can our health service use the Standards?
Your health service can self assess against the Standards as part of your quality improvement process, or you might collaborate with other health services to assess each other.
The chart below shows the hierarchical relationship between standards, criteria, indicators and explanations.
Each standard describes an element of the health service’s activity that is critical to quality and safety.
Each standard has a number of specific criteria that separate the standard into several components. Each criterion describes a process that your health service can use to meet the standard.
Each criterion has explanation notes to provide assistance to your health service in meeting the criterion. The explanations provide further detail, definitions of terms, and assistance for your health service in considering ways in which you might be able to demonstrate achievement of the criterion. The explanations provide a detailed description of the RACGP’s position on related issues and are the authoritative view on the interpretation of the criterion.
Each criterion is followed by a number of indicators that provide ways for your health service to demonstrate that it has achieved that criterion. There are indicators that require demonstration of the processes used to meet the criterion; indicators that require your staff to be aware of those processes; indicators that require documentation of your processes; and indicators that ask for a feedback mechanism to ensure the process is working properly.
The indicators seek to focus on principles of quality and safety. For example, the indicator on scheduling care does not specifically require an ‘appointment book’ to be used, rather it requires ‘effective scheduling of care’. This approach allows health services to focus on achieving timely access to care based on clinical need, rather than on the particular mechanism used for booking appointments.
The advantages and disadvantages of structure, process and outcome measures have been reviewed.9 Most process measures require less risk adjustment for patient illness than do most outcome measures.10 This is important in a context such as corrections, where the population of people incarcerated may change rapidly and frequently. Where the determinants of the outcome are beyond the control of the health service provider, process indicators are preferable.11,12 As a result, the RACGP decided to focus on process indicators that are in the direct control of health services. Although in many instances, outcome indicators are the ideal measure of quality, consideration needs to be given to causality, and to whether there are intervening variables affecting the outcome that are beyond the control of the health service under assessment, in which case pragmatism is required.
The Standards are written as an integrated whole. For example, you will see that indicators relating to privacy appear in more than one place in the Standards. This indicates that your health service should consider a number of different systems that collectively contribute to the protection of patient privacy, for example:
- the way in which your health service uses recall and reminder systems (Criterion 1.3.1)
- how your health service stores patient health information (Criterion 1.7.1)
- how your information technology provides protection from unauthorised access (Criterion 4.2.2)
- whether your health service provides screens, curtains, gowns or sheets to protect the privacy of patients when they undress (Criterion 5.1.1)
- how the physical structure of your health service protects privacy during consultations (Criterion 5.1.2).
You can assess your health service against each criterion and related indicators to determine whether you have achieved a particular standard. At times your health service may find some indicators are not applicable to you. If this is the case, it is important to consider why they do not apply and whether your peers would agree.
Your health service can use the following ways to demonstrate how you achieve the standards, criteria and indicators:
- interviews with all staff (medical, clinical, allied health and administrative)
- interviews with the medical staff (doctors) in your health service
- interviews with other staff who provide clinical care (eg. nurses or allied health staff)
- interviews with administrative staff in your health service (eg. receptionists)
- direct observation of your health service
- reviewing your patient health records
- reviewing your documentation (eg. your policy and procedures manual, patient information sheet, continuing professional development data or appointment schedule).
The use of different sources of information allows ‘triangulation’ of the information – allowing a more robust assessment of whether your health service is meeting the Standards.
Are some criteria and indicators in the Standards more important than others?
Some indicators are of central importance to quality and safety. These key or mandatory indicators are marked with a flag symbol next to the indicator. Flagged indicators assist your health service to determine whether you have achieved the critical aspects of a criterion. Indicators that do not have flags are still important (though not mandatory) and provide guidance to your health service about other ways you might demonstrate quality and safety.
Providing healthcare to incarcerated people presents unique challenges. Some clinical risks may be magnified in this setting. As such, there is a range of systems/processes in the Standards where extra vigilance is needed to ensure the provision of high quality and safe care to patients within prisons. These criteria include the following.
How do the Standards help reduce risk?
Every system in a health service is vulnerable to errors (eg. equipment, policies and procedures, clinical performance). Not all vulnerabilities in a health service have an adverse impact on patient care but if vulnerabilities ‘line up’ in sequence they can combine to produce an error or an adverse event. Safeguards therefore need to be put in place in each system to reduce the likelihood of an error occurring.13
The Standards provide ways of checking for vulnerabilities in systems that are important to safety and quality. Meeting each of the integrated criteria establishes a form of safeguard for patients and health services by closing the ‘holes’ in the system.
is essential that your health service meet all the standards and criteria to be confident you have minimised the chance of an error occurring and have increased the safety and quality of the care your service provides. When assessing your health service against these Standards, you might wish to identify areas in which you could improve. You may wish to prioritise these improvements if you want to make a number of changes. Some improvements may take a period of time to implement and evaluate. The important issue is that your health service actively works toward those improvements.
What is the value of peer review in our health service?
If your health service is undertaking a self assessment against the Standards, you might consider discussing the assessment informally with a trusted colleague. A ‘fresh set of eyes’ over your systems can assist in identifying areas that your health service does really well and those that require improvements. Peers can make judgments that take into account all factors and provide feedback on innovative ways to improve your health service.
Does meeting the Standards protect our health service legally?
During the review of the Standards for general practices (2nd edition), the RACGP commissioned a legal opinion on a number of areas of the Standards. In addition, all medical defence organisations in Australia were consulted on the priority areas they thought needed to be included. The RACGP considered these views and weighed the medicolegal risk, the benefits to patient safety and the feasibility of health services implementing these systems. In issues of high medicolegal concern, such as the follow up of tests and results in Criterion 1.5.4: System for follow up of tests and results, the RACGP has endeavoured to prepare standards that reflect what would reasonably be expected of a health service in a prison and a general practice within the community. Health services are encouraged to seek further advice from their doctor’s medical defence organisation, relevant professional indemnity insurer and the relevant government departments within each state or territory if they have concerns about a particular issue.
The Standards concentrate on principles of quality and safety in the delivery of healthcare, however health services should be aware of relevant and changing state, territory or federal legislation that may impact on the way they work.
We welcome your feedback
The RACGP NECSGP welcomes feedback regarding possible improvements to these Standards. Any comments or ideas about the RACGP Standards for health services in Australian prisons can be forwarded to:
Chair, National Expert Committee on Standards for General Practices
The Royal Australian College of General Practitioners
100 Wellington pde
East Melbourne Victoria 3002
Telephone 03 8699 0414
Facsimile 03 8699 0400
► This symbol means a particular indicator is ‘flagged’ or mandatory; indicators which are not ‘flagged’ are discretionary.