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Mi Doc Medical Care Assessment Ncchc Doc Response 2008

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The Michigan Department of Corrections
Response to the Report
By
The National Commission on Correctional Health Care:

A Comprehensive Assessment
of the
Michigan Department of Corrections
Health Care System

“We commend the MDOC and the BHCS administration for the positive way they have
embraced our recommendations and those of other consultants. If this strategic plan and the
recommendation of our report are implemented, the MDOC’s health delivery system can, once
again, become a leader in the correctional health care field.” NCCHC Report, page 58

January 2008

MICHIGAN DEPARTMENT OF CORRECTIONS
Response to the NCCHC Assessment of the Prisoner Health Care System
INTRODUCTION
As a result of concerns over the quality of health care being provided to prisoners by the
Michigan Department of Corrections (MDOC), Governor Granholm ordered an independent
comprehensive review of prisoner health care to assure that the current health care delivery
system meets its commitments of providing quality, medically-necessary health care to prisoners
that meets program goals, in an efficient, cost-effective manner. In January 2007, a contract was
awarded to the National Commission on Correctional Health Care (NCCHC) through the
competitive bid process. In late January 2007, NCCHC began their review. The independent
review consisted of two phases:
Phase One, now complete, consisted of a comprehensive review of the prisoner health care
system, an assessment of “best practices” research that could be applied for system
improvement, the provision of a set of recommendations for system improvement, and the
publication of a report of their work. The objectives for Phase One included:
•
•
•
•
•

Examine the effectiveness of the current programs and measure the extent to which
current programs are achieving intended goals
Determine if the MDOC is using its resources in the most effective manner
Assess internal business processes to determine proper alignment with strategic plans
Provide basic structure and process for MDOC leadership to use for ongoing evaluation
and planning
Identify any organizational, attitudinal or cultural barriers in the relationships among
custody, health care and mental health care that has potential for impeding or impairing
the efficient and effective delivery of adequate care to prisoners.

Phase Two consists of presenting the findings and recommendations to various audiences as
determined by the department and additional clarifications and/or follow up including technical
assistance with implementation of select finding and recommendations, and assistance in
conducting MDOC staff training sessions. Phase Two is currently underway.

FINDINGS AND RECOMMENDATONS
The National Commission on Correctional Health Care’s (NCCHC) report, “A Comprehensive
Assessment of the Michigan Department of Corrections Health Care System” (January 2008)
identified 56 recommendations of systemic changes to improve the effectiveness and efficiencies
of the Michigan Department of Corrections (MDOC) health care system.
As part of their report, NCCHC compares their recommendations to the components of the
MDOC Prisoner Health Care Improvement Project Strategic Plan to determine how our current
plan aligns with their recommendations.

Response to NCCHC’s Comprehensive Assessment of MDOC Health Care System

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The department is in near total agreement with the recommendations from NCCHC and almost
all of their recommendations are aligned with the Strategic Plan and are already being
implemented through the department’s new Health Care Quality Improvement Team.
There are two recommendations that cannot be readily implemented as they are subject to
administrative and cultural barriers that will require additional review and consideration by the
department. These two recommendations focus on the bifurcated staffing model that uses
MDOC civil servants for clinical staff and contractual Medical Practitioners and a
recommendation to cease using the electronic medical record for documenting chronic care
clinics. The department is in agreement with the need for change in these two areas although our
solutions may differ from those proposed in this report.

NCCHC RECOMMENDATIONS BEING IMPLEMENTED
The following narrative categorizes the NCCHC recommendations and our responses according
to Public Act 124, Section 302, which requires the department to report on five distinct areas of
organizational structure, administration and management, and the timeliness, appropriateness and
quality of services of the prisoner health care system. A summary of the NCCHC
recommendations categorized by the requirements of the appropriations law is provided to assist
in the review (see Attachment No. 1):

Area One: Organizational Structure, Administration and Management
The NCCHC report contained 22 recommendations related to the organizational structure,
administration and management of the health care delivery system. Through the work of the
Health Care Improvement Team (HCIT), the MDOC conducted a critical assessment of the
administration and management of health care operations. The HCIT reviewed the health care
operations and developed a comprehensive strategic plan to guide the Bureau of Health Care
Service (BHCS) in the redesign of the health care delivery system.
In the context of the systemic redesign of the health care delivery system, HCIT identified the
following areas for improvement: BHCS management infrastructure, health services contracts,
quality assurance, communications and independent reviews. In addition, the HCIT developed a
pilot program for community placement of medically fragile prisoners. Contracts targeted for
improvement by the HCIT include: the Health Services Managed Care Contract, the Pharmacy
Contract, the Electronic Medical Record system and the Mental Health Services Agreement with
the Michigan Department of Community Health.
As noted in the NCCHC report, the MDOC Strategic Plan for Improvement is substantially
aligned with the recommendations of the NCCHC. In their conclusion, NCCHC states: “We
commend the MDOC and the BHCS administration for the positive way they have embraced our
recommendations and those of other consultants. If this strategic plan and the recommendation
of our report are implemented, the MDOC’s health delivery system can, once again, become a
leader in the correctional health care field.” (page 58)

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Progress to date on those HCIT activities that are aligned with the NCCHC recommendations for
management, structure, organization and administration include:
•

The HCIT has developed, and is promulgating, a new management structure for prisoner
health care to enhance the strategic planning, quality assurance and contract performance
monitoring of the health care delivery system.

•

A Request For Proposals (RFP) for an updated and robust electronic medical record has been
posted and is currently in the evaluation process in collaboration with the Department of
Management and Budget and the Department of Information Technology. This initiative
surpasses the more limited recommendations of the NCCHC for improvements to the
electronic health record.

•

An RFP for managed care health services was posted in July 2007 that was subsequently
withdrawn to strengthen the process and improve competitive bidding. A Request For
Information (RFI) in advance of the second RFP was posted in November 2007.

•

MDOC hosted a successful RFI conference attended by over 50 participants from the
community of potential vendors. MDOC has informed potential bidders of its plans to
incorporate the recommendations of the NCCHC report into the final RFP for health care
services. In fact, most of the potential bidders have requested a copy of the NCCHC report
to assist with the development of their proposals for the second RFP that will be posted in
March 2008.

•

An RFI for the re-entry and community placement of medically fragile prisoners will be
posted in February 2008. A limited, but very successful, pilot program in Muskegon County
that started in 2007 offers tremendous lessons that are assisting in the development of
information for this RFI. The planned statewide demonstration project that will result from
this RFP will greatly surpass the more limited recommendations of the NCCHC in its report.

•

An RFP for Pharmacy is being developed and is scheduled for posting in March 2008. The
recommendations of the NCCHC report will be incorporated into this RFP.

•

An RFI related to psychological services for assaultive offenders and for sex offenders is
scheduled for March 2008. The recommendations of the NCCHC in these areas will be
incorporated into the RFI for these services.

Area Two: Timeliness, Appropriateness, and Quality of Clinical Services Provided Through
the Department Including Nursing, Dental, and Clinical Support Services
The NCCHC report included 11 recommendations related to the clinical services provided
through the civil service system. Given the nationwide shortage of nurses, the recommendation
of the NCCHC that we convert some of the vacant Registered Nurse positions to Licensed
Practical Nurses and Certified Nursing Assistants has resulted in the department reviewing our
current staffing levels to determine what mix of civil service and contract staffing is essential to
deliver the most efficient health services to the prisoner population.
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We will also ensure that staff has the necessary tools to perform their jobs as this is essential in
the timely delivery of health care services.
Progress to date on the HCIT activities related to clinical services that are aligned with the
NCCHC recommendations include the following:
•

The MDOC, in collaboration with the Department of Management and Budget and the
Department of Information Technology, is currently in the RFP evaluation process for a new
electronic medical record.

•

The upgrade to a fully integrated electronic medical record system will greatly enhance the
efficiency of staff and provide additional reporting capabilities.

•

The new electronic medical record system will also incorporate dental and mental health
records along with a requirement for a web-based application.

•

HCIT has developed, and is seeking approval for, a new management structure that includes
two leadership positions dedicated to enhancing contract monitoring and performance
improvement.
o A Quality Assurance Administrator position with support staff is currently in process
to monitor clinical performance by both contract providers and civil service health
staff.
o An Assistant Chief Medical Officer to strengthen the clinical oversight by the BHCS
for performance monitoring of the health service contract providers.

•

The development of an Independent Review contract to assist in the utilization practices of
the health care delivery system has been incorporated into the strategic plan for development
in FY 2009.

Area Three: Timeliness, Appropriateness, and Quality of Clinical Psychological Services
Provided Through the Department, Including Intake Processing, Assaultive Offender
Program and Sex Offender Treatment Program
The NCCHC report included four recommendations related to clinical psychological services.
Progress to date on HCIT activities related to the NCCHC recommendations to improve clinical
psychological services includes:
•

The HCIT is reviewing the current delivery of Assaultive and Sex Offender programming
and will develop evidence-based treatment programs with established outcome measures that
can be effectively implemented based on best practices within the correctional industry. The
department will be issuing an RFI for information on industry wide assessment tools and
evidence-based delivery programs. The RFI will be issued in March 2008.

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Area Four: Timeliness, Appropriateness and Quality of Mental Health Services to Treat the
Seriously Mentally Ill Provided Through the Department Of Community Health, including
Inpatient Care, Rehabilitative Treatment, Residential Treatment, Crisis Stabilization and
Outpatient Mental Health Treatment
The NCCHC report included two recommendations related to mental health services. The
NCCHC report generally characterized the quality of the mental health care services as good, but
noted systemic problems impeding the delivery of these services due to communications issues
and structural deficits stemming from the bifurcated delivery system of the MDOC and the
Michigan Department of Community Health.
Progress to date on the HCIT activities related to the NCCHC recommendations to improve the
delivery of mental health care services includes:
•

The MDOC and the Michigan Department of Community Health are conducting a broadbased, comprehensive review of the MDOC’s prisoner mental health programs. A multidisciplinary work group including representatives from the private sector and general public
is reviewing the overall processes within the mental health systems including mental health
and substance abuse. The recommendations of the Mental Health Work Group are expected
in April 2008. The NCCHC recommendations will be incorporated into the recommendations
of their report.

•

Pursuant to the 2007 legislative mandate for an independent review of mental health care, the
MDOC has taken the preliminary steps to award a contract for this review as another set of
critical inputs to this process. (See PA 124 of 2007, Section 302.)

Area Five: Timeliness, Appropriateness, and Quality of Primary On-Site Medical Services,
On-Site Inpatient Medical Services, Specialty Services, and Utilization Review Procedures
Provided by the State’s Health Care Contractors
The NCCHC report contained 14 recommendations related to on-site medical services, specialty
services and utilization review procedures provided by the state’s health care contractors.
Progress to date on the HCIT activities related to the NCCHC recommendations to improve onsite medical services, specialty services and utilization review includes:
•

To address the challenges and issues with the current contract approach, the HCIT redesigned
the managed care contract from a “cost plus administrative fee” contract to a “fixed cost”
contract with risk sharing. Under the guidance of the Department of Management and
Budget, an RFP was issued with a requirement that the vendors be Michigan licensed
managed care companies. Additionally, the RFP had service level agreements that contained
outcome expectations with penalties for failure to achieve required performance objectives.

•

The RFP generated over 400 questions and resulted in four proposals, with one qualified bid
that was later withdrawn by the vendor. The MDOC and the Department of Management
and Budget realized through this process that this approach, while sound, needed further
development on the scope of services and an allowance for greater flexibility in how these
services will be delivered.

Response to NCCHC’s Comprehensive Assessment of MDOC Health Care System

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•

The MDOC subsequently issued an RFI to seek input from vendors in the health care field to
help address the areas that needed further clarification. This process afforded the department
the opportunity to engage with prospective vendors to look at best practices and
recommendations for areas in need of improvement.

•

Based on the recommendations of the NCCHC and information gathered from the RFI
process, the MDOC will be able to develop an RFP that will establish performance objectives
and an avenue to ensure greater contract compliance. It is anticipated that the new RFP will
be issued in late March 2008.

•

Additionally, the MDOC will be working on a contract for an independent third party review
of health care operations ensuring timely, medically-necessary care is being provided.

NCCHC RECOMMENDATIONS TO BE IMPLEMENTED
Only three NCCHC recommendations are not currently addressed in the Prisoner Health Care
Improvement Project Strategic Plan. These three recommendations are identified below
including the progress being made to meet those recommendations by the HCIT.
1. Determine whether the prisoners’ view that the Parole Board will not release someone with
chronic medications; and, if false, educate the inmate population.
This issue has been investigated by the HCIT and they have determined that this view is false.
In fact prisoners are being released with a 30-day supply of medications, which NCCCH
points out in the report is more generous than they find in most other states (page 16).
Additionally, the medication supply process has been reviewed and incorporated into the
Michigan Prisoner ReEntry Initiative program to ensure prisoners are not released without
necessary medications until they are able to be linked to a provider in the community.
2. Research the issue of incinerating pharmaceutical waste with appropriate environmental
authorities to see if these regulations apply in Michigan, and change practice if necessary.
This issue is being investigated by the HCIT. If it is determined that the MDOC is in
violation of any environmental laws, policy and procedure will be changed in order to
comply with the applicable laws.
3. Clarify the guidelines for issuing non-medical items and appoint a single ombudsman to
address these requests.
This issue will be a task for the Continuous Quality Improvement Committee and monitored
by the Quality Assurance Administrator to ensure the non-medical needs of the prisoner are
met using uniform guidelines for issuing such items. In addition, a Disabilities Coordinator
was recently hired who coordinates the approval of necessary non-medical equipment.
ATTACHMENTS:
¾ Summary of NCCHC Recommendations by Legislative Required Categories
¾ Addendum 1 to NCCHC Report regarding Alignment of Recommendations to MDOC Strategic Plan
¾ The MDOC Strategic Plan to Improve Prisoner Health Care

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