Performance-Based Standards for Correctional Health Care Explained:
Using performance-based standards allows you to improve your organization by looking at outcome measures to evaluate if the results you wanted to obtain were achieved.
The Bottom Line — What's Different?
What Does This Mean for Accreditation?
The Fundamentals of Performance-Based Standards
Understanding the difference between outcome measures and process indicators
The Bottom Line — What's Different?
The biggest change in terminology is that what we used to call standards has all been reclassified as "expected practices." The reason for this change reveals the fundamental difference between prior standards and ACA's new performance-based standards.
Without exception, the drafters of the new Performance-Based Standards for Correctional Health Care found that all prior health care standards described activities or practices that were prescribed for practitioners, but a performance-based standard should describe a condition to be achieved and maintained.
Return to top
What Does This Mean for Accreditation?
Guided by a summary of significant incidents and a report that examines conditions of confinement, the Commission on Accreditation for Corrections currently examines issues that affect the life, health and safety of staff and offenders. As data is collected for the new outcome measures, the Commission will have more information about actual and ongoing operations. More important, you will have an important new management tool.
Return to top
The Fundamentals of Performance-Based Standards
ACA's performance-based standards have several elements:
- PERFORMANCE STANDARDS
- OUTCOME MEASURES
- EXPECTED PRACTICES
- PROTOCOLS
- PROCESS INDICATORS
These elements are defined and described as follows:
PERFORMANCE STANDARDS
A performance standard is a statement that clearly defines a required or essential condition to be achieved and maintained.
A performance standard describes a "state of being," a condition, and does not describe the activities or practices that might be necessary to achieve compliance. Performance standards reflect the program's overall mission and purpose and contribute to the realization of the goal that has been articulated.
The drafters of the new standards found it difficult to articulate clear and concise standards. The closer a draft standard came to meeting the definition of a performance-based standard, the simpler it seemed to appear. In drafting the new performance-based standards we were constantly fighting the urge to describe an activity rather than identifying the overarching purpose for the activity. During many of the working group meetings, it was common for a proposed standard to be met with the response "Why?" While often frustrating, by continuing to ask the "why" question, the drafters were able to identify basic statements of conditions that must be defined through performance standards.
Because performance standards are so fundamental and basic, it is less likely that they will require frequent revision, but as the field continues to learn from experience, we can predict, and even hope, that the expected practices that are prescribed to achieve compliance with standards will continue to evolve.
OUTCOME MEASURES
Outcome measures are quantifiable (measurable) events, occurrences, behaviors or attitudes that demonstrate the extent to which the condition described in the corresponding performance standard has been achieved. Outcome measures describe the consequences of the organization's activities, rather than describing the activities themselves.
Because outcome measures are quantifiable, they can be compared over time to indicate changes in the conditions that are sought. Measurable outcome data are collected continuously but are usually analyzed periodically. The first time you measure an outcome, you establish a point of reference. By comparing the next measurement (weeks or months later), you can identify progress, or lack of progress, toward the desired outcome.
Outcome measures are distinct from the activities of a program. For example, counting the number of vaccinations given to inmates is not an outcome measure (it is a process indicator), but measuring the incidence of disease in the inmate population is an outcome measure. Giving vaccinations is an activity (practice) that we believe will improve inmate health (performance standard) that can be measured by the incidence of disease (outcome measure).
Similarly, the number of inmates who were provided with substance abuse treatment would be a process indicator, where the number of inmates who pass drug screening tests would be an outcome measure. Treatment activities (practices) are provided to reduce offender substance abuse (a performance standard), which can be measured by the results of drug tests (outcome measures).
Most performance standards have several outcome measures that may be used to determine if the condition described in the standard has been achieved. Conversely, a single outcome measure might be used to ascertain compliance for more than one standard. Outcome measures look at the bigger picture by asking, "What actually happened?"
EXPECTED PRACTICES
Expected practices are actions and activities that, if implemented properly (according to protocols), will produce the desired outcome — achievement of the condition described in the standard.
Expected practices represent what the practitioners believe is necessary to achieve and maintain compliance with the standard —but may not be the only way to achieve compliance. These activities represent the best thinking of the field, supported by experience, but often are not founded on research. As conditions change and as we learn from our experience, we expect practices to evolve.
It is arguable that expected practices should be changed over time to reflect our growing body of knowledge and experience. On the other hand, it is likely that we will see much less change with the overarching performance standards, which are more basic and fundamental.
PROTOCOLS
Protocols are written instructions and formats that guide implementation of expected practices, such as:
Policies and procedures;
Post orders;
Training curriculums;
Formats to be used, such logs and forms;
Diagrams such as fire exit plans; and
Internal inspection forms.
Protocols provide a map to guide the proper implementation of expected practices. Protocols describe, usually in great detail, how to implement activities that are described in expected practices.
PROCESS INDICATORS
Process indicators can be used frequently — even continuously — to monitor activities and practices. But process indicators are not an "end" in and of themselves — they just tell us if the expected practices are being implemented.
Return to top
Understanding the difference between outcome measures and process indicators.
Process indicators relate directly to expected practices. Process indicators tell you if practices are consistently implemented according to protocols. For example, several expected practices address the provision of substance abuse services to offenders. Process indicators can establish if measured activities — such as screening, assessment and therapy — were actually delivered to offenders, but it is the outcome measures, such as the results of drug tests, that determine whether offender substance abuse patterns were positively affected.
Most of the process indicators referenced in this draft refer to written documentation that can be consulted "after the fact." In addition to these "footprints" that are left by an organization, implementation of expected practices may be confirmed during on-site inspection activities such as observation or interviews (staff, volunteers, offenders, others). Good managers combine review of documentation with random observation and interviews to monitor activities.
These additional activities (observations and interviews) are also a central part of ACA's accreditation process, comprising much of the work that is conducted on-site during audits. Accreditation participants also will recognize many of the protocols described in this draft as the "primary documentation" required by ACA as part of the accreditation process. Similarly, many of the process indicators cited in this draft are currently used as "secondary documentation" by the Commission.
Observation and interview activities are usually suggested only when other methods are not possible and to verify the accuracy of documentation. Observation, interview and measurement rely on an on-site "single point in time" activity, while the other methods have the ability to examine practices randomly, over a longer period of time.
Outcome measures look at the "bottom line." Was the desired condition or state of being described in the performance standard achieved?
There are three basic ways to express outcome measures:
As rates (the frequency of an occurrence over time);
As ratios (comparing two numbers as a fraction or decimal such as the number of offenders diagnosed with hepatitis divided by the average daily population); or
As proportions (the relation of a part to the whole such as the number of offender grievances found in favor of the offender divided by the total number of grievances filed). A percentage is a proportion multiplied by 100.
You rarely will find an outcome measure that calls for simply counting an event or occurrence. We believe that outcome measures should include a numerator and a denominator if they are to be useful as management tools.
Whenever possible, we have tried to use denominators that reflect the volume of activity. Therefore, it is preferable to divide by the average daily population rather than simply counting the number of events. We have tried to use the "Average Daily Population for the Past Twelve Months" whenever appropriate. In a few instances, we have used other denominators. A summary of the activities is contained in Attachment I of this manual entitled: " Health Care Outcome Measure Worksheet." For programs pursuing accreditation, the worksheet must be completed prior to an on-site evaluation of compliance.
What do the numbers mean after the math is done? They provide a starting point for analyzing and assessing the organization. The first time you generate outcome measures, they may not mean much to you, but their value grows every time you measure. The second time you measure outcomes, you will be able to compare current outcomes with those that you measured in the past. In this way, outcome measures become a valuable management tool. Over time, the series of outcome measures that you calculate can provide invaluable insight into many aspects of your operation. Sometimes, they will provide you with important "red flags" that identify troubling trends.
Return to top
