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design its own QIP with at least 3 – 5 projects per year that address trends, outliers, or other problems to identify root causes and develop and test interventions. CT DOC’s ability to make data‐driven decisions is hampered by a lack of actionable data and performance improvement feedback. Staff report inconsistent and infrequent QI processes at the system or facility level. According to staff reports and data and information HMA received, there are major drivers impacting the lack of QA/QI at this time including a limited ability (or instructions how) to mine data/information from the EHR and, of particular importance, no regular dashboards to flag concerns and inform administrators or providers. Reporting from contracted providers is limited as well. An exception to this is the pharmacy contract, which requires reporting from the vendor and should be a Recommendation 31 model for reporting for other vendors. There are some other notable exceptions in facility‐specific QI documents and ISBARs (Identify, Situation, Background, Assessment and Recommendation). It is very good that some of the facilities are identifying areas for performance improvement. A well‐planned and consistent process for data collection, analysis, and performance processes is needed. The health care system needs a formalized approach that can provide real‐time data to identify service challenges, gaps, and issues that will automatically generate process improvement activities. Policy and Procedures The importance of having well‐defined policies in place cannot be overstated. Having formal policies can make an organization run more smoothly and efficiently. Policies and procedures bring order to operations and provide employees with a clear understanding of what is expected of them by establishing boundaries, guidelines, and best practices as they deliver care. Policies also protect the organization when relevant regulations and nationally accepted correctional health care standards are incorporated into their content. At HMA’s request, NCCHC Resources Inc. (NRI) additionally (and separately) completed a review of CT DOC’s health care policies and procedures. The review was guided by current correctional health care standards as defined by NCCHC and the American Correctional Association (ACA), and general knowledge of correctional health care. A crosswalk of these standards and the CT DOC Administrative Directive, Chapter 8: Health Care Service, Hygiene and Sanitation, is attached to this report as Appendix 6. High‐level findings from both HMA’s and NRI’s review include the following: · The documents listed in the CT DOC procedure column are treatment protocols and were not considered to be policy statements. Treatment protocols require a separate review by medical and nursing leadership to ensure they are current in their clinical content and that they meet the scope and standards of practice for those who use them. · Topics addressed in the national standards are mentioned in some of the policies, but the policies do not provide the information needed for uniformity of approach across the facilities.

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