Cycle 4 Medical Inspection Summary Report April 2017

Robert A. Barton Office of the Inspector General Inspector General CYCLE 4 MEDICAL INSPECTION SUMMARY REPORT April 2017 Off ice of the Inspector General CY CLE 4 ME DICAL INSPECTION SUMMARY REPORT Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer April 2017 Table of Contents INTRODUCTION 1 OVERVIEW 1 CYCLE 4 SUMMARY 1 CONCLUSION 4 TABLE 1: CYCLE 4 INSTITUTION RATINGS 5 TABLE 2: CYCLE 4 RESULTS BY INDICATOR 6 TABLE 3: CYCLE 4 SUMMARY 6 TABLE 4: CYCLE 4 HEDIS SUMMARY 7 INTRODUCTION This summary report is not meant to be a comprehensive review of the Office of the Inspector General (OIG) monitoring of California Department of Corrections and Rehabilitation (CDCR) health care delivery performance from Cycle 4. Readers desiring a more detailed review are referred to the individual published reports found on the OIG website (www.oig.ca.gov) for Cycle 4. This brief summary is provided as merely a guide to be used by stakeholders so they might obtain an overview in a condensed format. OVERVIEW Pursuant to California Penal Code Section 6126(f), the Office of the Inspector General (OIG) conducts an objective, clinically appropriate, and metric-oriented medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster. CYCLE 4 SUMMARY In Cycle 4, the OIG added a case review component to complement the compliance testing inspection process that was in place during the prior three inspection cycles. The OIG measured the quality of care using 16 indicators, depending on whether the indicator was applicable at any one of the institutions. Each inspection included a compliance and case review portion, and an overall score for each indicator was determined based on consensus of expert OIG clinicians and inspectors. The OIG inspected all 35 adult institutions within CDCR. The OIG found that 22 of the 35 institutions inspected (63 percent) performed at an adequate or proficient level. The overall performance of the institutions in each indicator is shown in these three tables, Table 1: Cycle 4 Institution Ratings, Table 2: Cycle 4 Results By Indicator, and Table 3: Cycle 4 Summary at the end of this report. In addition, an average Healthcare Effectiveness Data and Information Set (HEDIS) score for selected areas for all prisons combined, as compared to state and national health systems is included in Table 4: Cycle 4 HEDIS Summary. The following are some strengths identified during the Cycle 4 inspections, as well as some areas that needed improvement. Access to Care Access to care was a particular strength, with 77 percent of institutions scoring in the adequate or proficient range in this indicator. Access to care is a critical component of a health care system. Compliance inspectors found that nursing staff reviewed patient sick call requests and performed face-to-face assessments within required time frames, and the housing units at nearly all institutions had health care service request forms available to patients. However, nursing staff Medical Inspection Summary Report, April 2017 Page 1 Office of the Inspector General State of California showed room for improvement in their medical assessment and documentation of patients’ symptoms and complaints and in referral of patients to a provider when necessary. Diagnostic Services Compliance inspectors found that generally institutions provided diagnostic services to patients within required time frames, but providers did not always timely review diagnostic results. Case review revealed that institutions provided adequate diagnostic services, but observed that some ordered services were not always performed. Emergency Services Generally, emergency services were adequate at the institutions, with nursing staff and providers making good decisions regarding patient care. However, case review exposed some important shortcomings. In some cases, nursing assessment and documentation was poor and interventions were untimely, including delays in emergency cardiopulmonary resuscitation. The OIG clinicians found on-call physician services were sometimes inadequate. This was especially true for institutions that recently changed from having a physician on site 24 hours a day to having one available by phone only. Physicians previously accustomed to onsite direct patient care generally made poor assessments and kept weak documentation when only available by phone. Health Information Management The OIG compliance inspectors and case review clinicians identified several areas for improvement in health information management. Though most document scanning times were generally adequate, scanning accuracy was poor. Hospital discharge reports were typically scanned late, and providers did not review reports timely. Clinician legibility was also poor. CCHCS is in the process of rolling out a new Electronic Health Record System (EHRS). However, the OIG inspected only one institution that had migrated to the new system, and does not have enough information to report on the impact. Health Care Environment The health care environment at almost half the institutions was poor, where clinic common areas and exam rooms did not have sufficient supplies and equipment available for clinicians to complete comprehensive exams or to ensure patients’ privacy. Emergency response bags in many of the institutions’ clinics also lacked required supplies, and institution staff did not always inventory the bags in accordance with policy. However, most institutions followed procedures for adequately sterilizing equipment. Throughout cycle 4 medical inspections, several institutions were undergoing facility improvements to medical clinics and medication rooms. Many of these infrastructure projects were in progress at the time of inspections. In Cycle 5 the OIG may have the ability to report on the impact. Inter- and Intra-System Transfers The majority of institutions performed adequately for patient transfers, and nursing staff, in particular, did well with new arrivals to the institutions by appropriately completing intake screening forms. However, areas for improvement included continuity of care for patients transferred from one institution to another, reception center patients, and patients returned from Medical Inspection Summary Report, April 2017 Page 2 Office of the Inspector General State of California outside hospitals. Specifically, the continuity of medication was a problem, with new medications ordered by community hospitals not being ordered or continued timely by patients’ primary care providers at the institutions. The OIG recommends CCHCS develop a consistent process to ensure that for complex patients, providers at the sending and receiving institutions exchange important patient care information during the transfer period. Pharmacy and Medication Management Pharmacy and medication management exhibited problems with medication continuity and new medication orders for patients returning from outside hospitals. Proper management and storage of medication, including narcotics, was also problematic. Medication preparation at medication lines was generally adequate, but medication administration to patients showed room for improvement. Preventive Services The overall results for preventive services were mixed at the institutions inspected. While most institutions performed well offering vaccinations and cancer screenings, some struggled with tuberculosis medication administration and monitoring. Quality of Provider and Nursing Performance Overall, the quality of provider and nursing care was good. Providers at the institutions were competent and capable of providing adequate care. Several areas of improvement have been noted throughout this summary report, but long-vacant positions and short-staffing were areas of concern at many institutions. Inadequate provider staffing can lead to poor care and low morale within the provider ranks. This concern was especially prevalent at institutions with high-risk patients and patients with severe mental health issues, where patient noncompliance challenged providers’ ability to provide adequate care. Quality of nursing in general was adequate, with areas of needed improvement noted in other sections of this summary. Specialized Medical Housing Most institutions performed adequately in their specialized medical housing units. Nursing staff properly completed admission paper work, and providers typically held timely encounters with patients. However, inadequate nursing assessments for some patients and the use of “cloned” progress notes (those with pre-filled, general, or repetitious statements that may not be applicable for a subsequent encounter) were common. At times, nursing progress notes lacked basic information such as vital signs and discharge instructions. Specialty Services The majority of institutions provided adequate specialty services for patients, and typically met required time frames for providing routine and high-priority services. However, along with overall patient transfer issues discussed above, institutions showed need for improvement in ensuring patients transferring from one institution to another received their previously approved specialty services. Medical Inspection Summary Report, April 2017 Page 3 Office of the Inspector General State of California Secondary Indicators The OIG also used two secondary indicators to test administrative processes at the institutions, which weighed less heavily than the other indicators, and were not a factor to the overall score for the quality of care at the institutions. In general, institutions could improve documentation for committee meeting agendas, such as the Local Governing Body Committee and Emergency Medical Response Review Committee, and completion of nursing and provider reviews. However, most institutions reviewed medical appeals timely, and providers and pharmacists had current licenses. Healthcare Effectiveness Data and Information Set (HEDIS) The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information needed to accurately compare the performance of health care plans. Our inspections were limited to the three measurable areas of diabetes care, immunizations, and cancer screenings. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Each prison report contains a HEDIS comparison specific to that prison. The tables included in this report identify overall scores for all 35 institutions and the overall results of the 16 indicators, as well as the HEDIS comparison with CCHCS averages for all prisons. CONCLUSION The OIG made recommendations to each prison regarding areas for improvement following each inspection. It was evident throughout the inspection cycle that medical staff and administration were open to OIG recommendations for improvement, and in some cases, institutions had already begun implementing corrective measures before the publication of the OIG report. There are three areas that, when remedied, should have a beneficial impact. Adequate staffing should help avoid caseload fatigue and burnout. Completion of building projects may improve facility compliance. CCHCS is in the process of rolling out a new Electronic Health Record System (EHRS) with the goal of improving health information management. This may cause more challenges in the short-term due to training and lack of familiarity with the system. However, it should improve efficiency and performance once staff are trained and familiarized with the system. Finally, the one recommendation made in this summary report is in the area of Inter- and Intra-System Transfers. The OIG recommends CCHCS develop a consistent process to ensure that for complex patients, providers at the sending and receiving institutions exchange important patient care information during the transfer period. For more detailed information, please refer to the individual Cycle 4 Medical Inspection reports. Medical Inspection Summary Report, April 2017 Page 4 Office of the Inspector General State of California TABLE 1: CYCLE 4 INSTITUTION RATINGS Date Institution Inspected Rating Delegated to CDCR Folsom State Prison (FSP) Adequate 7/13/15 Correctional Training Facility (CTF) Adequate 3/09/16 California Rehabilitation Center (CRC) Adequate California Correctional Center (CCC) Inadequate North Kern State Prison (NKSP) Inadequate Chuckawalla Valley State Prison (CVSP) Adequate 5/18/16 California State Prison, Solano (SOL) Inadequate Kern Valley State Prison (KVSP) Adequate California Correctional Institution (CCI) Adequate 6/07/16 Pelican Bay State Prison (PBSP) Adequate 6/22/16 Valley State Prison (VSP) Inadequate California State Prison, Centinela (CEN) Adequate 6/22/16 Sierra Conservation Center (SCC) Adequate 8/25/16 Wasco State Prison-Reception Center (WSP) Inadequate California Institution for Men (CIM) Adequate 10/07/16 Mule Creek State Prison (MCSP) Inadequate Ironwood State Prison (ISP) Inadequate Avenal State Prison (ASP) Adequate 10/19/16 San Quentin State Prison (SQ) Adequate 1/25/17 California Institution for Women (CIW) Adequate 3/10/17 Substance Abuse Treatment Facility (SATF) Adequate California Medical Facility (CMF) Inadequate Calipatria State Prison (CAL) Adequate California State Prison, Corcoran (COR) Inadequate Salinas Valley State Prison (SVSP) Inadequate California State Prison, Los Angeles County (LAC) Inadequate Pleasant Valley State Prison (PVSP) Proficient High Desert State Prison (HDSP) Adequate California Men's Colony (CMC) Adequate California City Correctional Facility (CAC) Proficient Deuel Vocational Institution (DVI) Adequate Richard J. Donovan Correctional Facility (RJD) Adequate Central California Women's Facility (CCWF) Inadequate California State Prison, Sacramento (SAC) Inadequate California Health Care Facility, Stockton (CHCF) Adequate Medical Inspection Summary Report, April 2017 Page 5 Office of the Inspector General State of California TABLE 2: CYCLE 4 RESULTS BY INDICATOR Number Number Number Indicator Name Proficient Adequate Inadequate Institutions Institutions Institutions Access to Care 12 15 8 Diagnostic Services 9 15 11 Emergency Services 2 24 9 Health Information Management (Medical Records) 1 11 23 Health Care Environment 5 13 17 Inter- and Intra-System Transfers 4 24 7 Pharmacy and Medication Management 4 12 19 Prenatal and Post-Delivery 0 2 0 Preventive Services 9 11 15 Quality of Nursing Performance 0 28 7 Quality of Provider Performance 1 26 8 Reception Center Arrivals 0 4 2 Specialized Medical Housing(OHU, CTC, SNF, Hospice) 4 21 7 Specialty Services 5 20 10 Internal Monitoring, Quality Improvement & Administrative 4 5 26 O i Job Performance, Training, Licensing, & Certifications 12 7 16 TABLE 3: CYCLE 4 SUMMARY Case Review Rating Compliance Rating Number Number Number Indicator Name Applicable Proficient Number Proficient Number Institutions & Inadequate & Inadequate Adequate Adequate Access to Care 35 29 6 29 6 Diagnostic Services 35 25 10 22 13 Emergency Services 35 26 9 Not Applicable Health Information Management (Medical 35 18 17 8 27 Records) Health Care Environment 35 Not Applicable 18 17 Inter- and Intra-System Transfers 35 28 7 28 7 Pharmacy and Medication Management 35 26 9 17 18 Prenatal and Post-Delivery 2 2 0 1 1 Preventive Services 35 Not Applicable 20 15 Quality of Nursing Performance 35 28 7 Not Applicable Quality of Provider Performance 35 27 8 Not Applicable Reception Center Arrivals 6 4 2 2 4 Specialized Medical Housing (OHU, CTC, 32 24 8 29 3 SNF, Hospice) Specialty Services 35 26 9 23 12 Internal Monitoring, Quality Improvement, 35 Not Applicable 9 26 and Administrative Operations Job Performance, Training, Licensing, and 35 Not Applicable 19 16 Certifications Medical Inspection Summary Report, April 2017 Page 6 Office of the Inspector General State of California TABLE 4: CYCLE 4 HEDIS SUMMARY California National CDCR/ HEDIS HEDIS HEDIS HEDIS Clinical CCHCS Kaiser HEDIS HEDIS VA Medi- Kaiser Com- Measures Cycle 4 (No. Medicaid Medicare Average Cal (So.CA) mercial Average CA) 20154 20154 20145 20152 20153 20154 Results8 20153 Comprehensive Diabetes Care HbA1c Testing 99% 86% 95% 94% 86% 91% 93% 99% (Monitoring) Poor HbA1c Control 11% 39% 18% 24% 44% 31% 25% 19% (>9.0%)6, 7 HbA1c Control 78% 49% 70% 62% 47% 58% 65% - (<8.0%)6 Blood Pressure Control 82% 63% 84% 85% 62% 65% 65% 78% (<140/90) Eye Exams 78% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots 56% - 54% 55% - 50% - 58% - Adults (18–64) Influenza Shots 74% - - - - - 72% 76% - Adults (65+) Immunizations: 83% - - - - - 70% 93% Pneumococcal Cancer Screening Colorectal Cancer 70% - 80% 82% - 64% 67% 82% Screening Cervical Cancer 84% 59% 92% 87% 60% 76% - 93% Screening Breast Cancer 90% - 87% 88% 59% 74% 72% 87% Screening Prenatal Care 96% 82% 96% 97% 82% 88% - - Postpartum 91% 59% 93% 93% 62% 77% - - Care The table represents the average8 HEDIS scores of all 35 adult institutions compared to the California and national health plan scores in applicable performance measures. Again, for individual prison results, the individual prison report should be referenced. 1. Data was collected throughout Cycle 4 by reviewing medical records from samples of each institution’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. Medical Inspection Summary Report, April 2017 Page 7 Office of the Inspector General State of California 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this measure, an institution’s entire applicable population was tested whenever possible. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The CDCR/CCHCS Cycle 4 Average was determined by adding up the institution scores in each HEDIS measure for all 35 adult institutions and dividing that total number by 35. Medical Inspection Summary Report, April 2017 Page 8 Office of the Inspector General State of California CYCLE 4 MEDICAL INSPECTION SUMMARY REPORT OFFICE OF THE INSPECTOR GENERAL Robert A. Barton INSPECTOR GENERAL Roy W. Wesley CHIEF DEPUTY INSPECTOR GENERAL STATE OF CALIFORNIA April 2017