Background

The District of Columbia Jail and CTF house inmates awaiting trial or who  have been sentenced for misdemeanors. The Jail was opened in 1976, and  from 1985 to July 2002, a court order limited the population to 1,674  inmates. Since July 2002 the population has grown, and during March  2004, the facility had an average daily population of 2,357. In addition to  serving as an overflow facility, the CTF houses pregnant inmates, inmates  with disabilities who need medical services, inmates in witness protection,  and inmates who need to be separated from the general inmate  population. Opened in 1992, the CTF is operated by a private company, the  Corrections Corporation of America (CCA), under a contract with DoC.  During March 2004, the CTF had an average daily population of 1,197.
In 1995, the U.S. District Court for the District of Columbia removed  medical services at the Jail from DoC’s control, placing these services  under the temporary supervision of a court-appointed Receiver. This  removal resulted from the District of Columbia’s failure to address  problems identified in two lawsuits brought against the Jail in 1971 and  1975, which alleged that DoC was failing to provide minimally adequate  medical care for inmates. Before it terminated the receivership in 2000,  the Court hired a national expert in correctional health care to conduct an  independent quality review of medical services provided by CCHPS to  inmates at the Jail. DoC subsequently contracted directly with this expert  to help develop a set of performance assessment instruments for  reviewing CCHPS’s clinical services and monitoring activities and to  conduct quarterly on-site reviews of CCHPS.
DoC has a constitutional obligation to ensure that medical care is provided  to inmates in its custody, and DoC’s contract with CCHPS requires  CCHPS to provide comprehensive medical services to all inmates assigned  to the Jail and the CTF and to establish a quality improvement program to  monitor the quality of medical services it provides. In some areas,  particularly the assessment of inmates’ health when they are admitted to  the facilities, the contract lists specific services that CCHPS must provide,  such as certain diagnostic tests. In other areas, such as services for  inmates with chronic conditions, the requirement to provide care is less  detailed. In addition to describing services that CCHPS is required to  provide, the contract states that DoC can impose monetary damages on  CCHPS if it does not meet 12 specific requirements. (See app. II for a  description of the contract requirements that are linked to monetary  damages.) Compliance with the requirements is to be determined through  monitoring by DoC or its designee.
The contract with DoC also requires that CCHPS acquire and maintain  accreditation for its medical services. The Jail’s medical services are  accredited by the National Commission on Correctional Health Care  (NCCHC), while the CTF is accredited by the American Correctional  Association (ACA). NCCHC and ACA, both national, not-for-profit  organizations, offer voluntary accreditation processes for medical services  provided in correctional facilities; relatively few jails nationwide are  accredited by these organizations. NCCHC accredits only a correctional  facility’s medical services, while ACA accredits all aspects of the  correctional facility, including medical services. Both organizations have  developed detailed accreditation standards that include, for example,  specific elements that are required in an inmate’s initial medical  assessment and in a facility’s quality improvement program. The  accreditation process for both organizations includes on-site inspections  of the facility every 3 years and submission of an annual report certifying  that the facility continues to be in compliance with the accreditation  standards. During on-site inspections, inspectors interview staff, review  documentation provided by the facility, and examine a sample of inmate  medical records. NCCHC and ACA inspectors submit their findings to  expert panels, who make the accreditation decisions.
One component of the quality improvement program required by both  NCCHC and ACA is a grievance system that allows inmates an opportunity  to question or complain about their care. Inmates at the Jail or the CTF  who have concerns about medical services can complete a grievance form  and submit it to the warden’s office in their facility. The warden’s staff  records the grievance in their system and then forwards it to CCHPS.  CCHPS’s medical director and quality improvement coordinator review  the grievance and work with the clinicians involved to determine if the  inmate’s complaint is valid and, if so, how it should be addressed. If it is  determined that an inmate needs to receive care, CCHPS schedules an  appointment. After CCHPS has reviewed the grievance, it sends a report to  the warden, who then provides a response to the inmate.
In June 2000, we testified before the House Committee on Government  Reform, Subcommittee on the District of Columbia, about the provision of  medical services at the Jail. We reported that the per inmate cost at the  Jail was higher than those at the two other jurisdictions reviewed, and that  services and staffing levels also exceeded those of the other jurisdictions.  We also found that there were no specific criteria that determine an  acceptable level of medical service and staffing at a jail. Rather, the range  of services was a function of many local factors, including the specific  demands and constraints placed on the facility’s service delivery system.

	CCHPS Provides a Range of Services to Inmates and Has Established Systems to Monitor Service Quality

As required by the contract, CCHPS provides a broad range of medical  services to Jail and CTF inmates, and the types of services CCHPS  provides at the Jail have not changed significantly over the life of the  contract. In addition, CCHPS assists DoC in helping inmates obtain  services beyond those included in CCHPS’s contract, such as emergency  and specialty care that cannot be provided at the Jail or the CTF. CCHPS  also assists DoC in its efforts to work with other District of Columbia  agencies and community providers to link soon-to-be-released inmates in  need of medical services with services in the community. As part of its  contract with DoC, CCHPS has also developed a system to monitor the  quality of the medical services it provides to inmates. A key component of  this program is quarterly analyses of random samples of inmate medical  records to measure how consistently CCHPS delivers required services to  inmates.

		CCHPS Provides Screening and Treatment Services Required in Its Contract and Assists DoC in Obtaining Additional Services

As required by the contract, CCHPS provides a broad range of medical  services to Jail and CTF inmates, including primary care services such as  sick call and chronic care; mental health care; and specialty care, such as  dental and orthopedic services. (See table 1 for a description of these  services.) At intake, all inmates receive a health assessment—referred to  as an intake screening—that screens for physical and mental health  conditions. The inmates receive a physical examination and are asked  about current and past health problems, substance abuse, and medication  use. In addition, they receive a chest x-ray and skin test to identify  possible tuberculosis. As part of the mental health screening, inmates are  asked a series of questions. If inmates respond positively to any of these  questions, or if they are a juvenile or in jail for the first time, they are  referred for a comprehensive mental health assessment. Based on the  findings of the intake screening, inmates in need of medical care may  receive treatment in a chronic or specialty care clinic, receive therapy for  mental health problems, or be placed in one of two specialized mental  health units. According to CCHPS officials, in 2002 they conducted an  average of 1,654 intake screenings each month. About 20 percent of these  inmates were referred to a chronic care clinic, and about 34 percent were  referred for further mental health assessment.
There have been no significant changes in the types of medical services  provided by CCHPS since the start of its contract with DoC. However,  there have been some minor changes, including modifications to on-site  specialty clinics. For example, in 2001, the requirement for an oral surgery  clinic was deleted from the contract, and more recently CCHPS combined  the ophthalmology and optometry clinics. In addition, CCHPS began  offering endocrinology and infectious disease clinics on-site—even though  they are not required by the contract—to improve inmates’ access to these  services and continuity of care. CCHPS officials had expected the  consolidation of medical services at the Jail and the CTF to result in some  service efficiencies, such as combining the on-site specialty clinics offered  at both facilities; however, CCHPS and DoC officials told us it has not  been feasible to easily move inmates between facilities because of security  issues. CCHPS therefore continues to offer all on-site specialty clinics at  both facilities.
When inmates need medical services that cannot be provided at the Jail or  the CTF, CCHPS refers them to providers in the community. These off-site  services, including emergency care and certain specialty services, are not  part of the CCHPS contract; instead, DoC has an agreement with the  District of Columbia Department of Health (DoH) to provide services to  inmates through Greater Southeast Community Hospital. When Greater  Southeast is not able to provide the needed services, it in turn refers the  inmates to other members of the DC Healthcare Alliance and other  community providers. DoC pays for all off-site services through an  interagency agreement with DoH; in 2003 there were 4,169 appointments  for inmates off-site.
Although DoC’s contract with CCHPS does not specify that CCHPS  provide discharge planning services to inmates, NCCHC accreditation  standards include discharge planning activities. Both CCHPS and DoC  have made efforts to plan for the release of inmates with medical  conditions and to link them to community-based medical services. For  example, CCHPS’s policies require that inmates receive a 2-week supply of  medications at the time of their release. In addition, CCHPS provides  support to DoC’s collaboration with the District of Columbia Department  of Mental Health (DMH) to help Jail inmates obtain access to community  mental health services when they are released.
CCHPS supports DoC’s and DoH’s discharge planning efforts to link  inmates who have certain chronic and communicable diseases, such as  tuberculosis, to community-based medical services. In addition, through a  joint program of DoH’s HIV/AIDS Administration and DoC, Family and  Medical Counseling Services, Inc. (FMCS), a community-based provider,  offers HIV testing and links HIV-positive inmates to services in the  community when they are released. CCHPS refers inmates requesting an  HIV test to FMCS and provides FMCS with office space, computers, and  access to the inmate’s electronic medical record in the CCHPS system.

		CCHPS Developed a System to Monitor Its Medical Services

As part of its contract with DoC, CCHPS is responsible for monitoring the  quality of the medical services it provides to Jail and CTF inmates, and  CCHPS has established a quality improvement program to fulfill this  responsibility. A key component of the program is a quarterly analysis of  random samples of inmate medical records using standardized  performance assessment instruments. These quarterly analyses provide  CCHPS with quantitative data about its performance in certain areas. Each  assessment instrument measures CCHPS’s performance of a specific set of  activities; these activities are generally more detailed than the  requirements described in the contract. (See app. III for a summary  description of the instruments.) Using the samples of medical records and  other documentation to complete the performance assessment  instruments, CCHPS clinicians determine how consistently CCHPS  delivers required services to inmates. Currently, there are 23 performance  assessment instruments, 20 of which measure medical services provided  to inmates in various service areas. For example, the intake services  instrument includes a measurement of the percentage of inmates who  received a chest x-ray for tuberculosis within 24 hours of admission. The  remaining 3 instruments measure the extent to which CCHPS has  conducted other components of its quality improvement program, such as  validating that clinical staff are licensed.
In addition to these quarterly analyses of medical services, CCHPS’s  quality improvement program also includes other reviews, such as annual  reviews of urgent care and radiological safety procedures, monthly  reviews of inmate grievances and of any inmate deaths, and ongoing  reviews of infection control activities. The program also requires CCHPS  to conduct at least two in-depth studies a year, each of which focuses on a  specific issue, such as a medical service problem that has been identified  by the quarterly analyses.

	DoC Established Several Mechanisms to Oversee CCHPS’s Delivery of Medical Services

DoC has developed several mechanisms to oversee CCHPS’s delivery of  medical services to inmates and enforce CCHPS’s compliance with the  contract. For example, DoC’s contract with CCHPS gives DoC the  authority to impose monetary damages if CCHPS fails to meet any of 12  requirements specified in the contract, most of which relate to CCHPS’s  performance in providing key medical services. For most of these  requirements, the contract authorizes DoC to impose the damages if  CCHPS fails to deliver the required service to a minimum percentage of  inmates—for example if CCHPS does not conduct an intake screening  within 24 hours for 95 percent of inmates. (See app. II for additional  information on the contract requirements that are linked to monetary  damages.) Some of the requirements relate to CCHPS’s staff, including  ensuring that staff have required licenses and credentials. In addition, the  contract contains a requirement that CCHPS have an infection control  program approved by DoC. DoC, or its designee, is responsible for  determining CCHPS’s compliance with these 12 contract requirements.
To further assist DoC in overseeing CCHPS’s delivery of services, the  contract also stipulates that CCHPS will submit quarterly and annual  progress reports to DoC. These progress reports are to include a  description of quality problems, such as those identified by CCHPS’s  quality improvement program or the independent reviewer, and actions  taken to correct them. DoC also requires CCHPS to maintain accreditation  of its services. In addition, DoC staff responsible for oversight of the  contract are frequently on-site at the Jail and the CTF observing the  contractor, and, as of May 2004, DoC had plans to begin jointly conducting  the quarterly analyses of inmate medical records with CCHPS.
Furthermore, DoC’s independent reviewer conducts quarterly reviews of  CCHPS’s activities. Each review consists of two principal components.  First, the independent reviewer checks the accuracy of CCHPS’s internal  use of the standardized performance instruments. To do this, he uses the  same performance assessment instruments that CCHPS uses in its quality  improvement program to examine a sample of the analyses CCHPS has  completed, and assesses whether CCHPS accurately characterized the  medical records studied. Second, in addition to validating CCHPS’s  analyses, the independent reviewer uses the performance instruments to  independently assess the quality of CCHPS’s services by analyzing a  separate random sample of inmate medical records in selected service  areas, such as mental health services. While CCHPS uses the  performance assessment instruments as a quality improvement vehicle,  the independent reviewer’s use of these instruments contributes to his  assessment of whether CCHPS is meeting its contractual obligations.  However, the independent reviewer does not specifically evaluate  CCHPS’s compliance with the contract requirements associated with  monetary damages.
As part of his review, the independent reviewer also assesses other  components of CCHPS’s quality improvement program, visits the medical  units at the Jail and the CTF, and interviews CCHPS staff. After conducting  the review, the independent reviewer provides DoC with a written report  describing his general findings, including service areas in which CCHPS  excels or needs to improve. Since August 2000, the independent reviewer  has conducted 14 quarterly on-site reviews of CCHPS.

	CCHPS Generally Meets Contract Requirements, but DoC’s Oversight of CCHPS Is Incomplete

Most available evidence indicates that CCHPS has generally complied with  the contract, but DoC has not exercised sufficient oversight to be assured  that problems are not occurring or are quickly corrected. The independent  reviewer has reported that CCHPS’s services meet the contract’s  requirements for access to care and quality. In addition, CCHPS has  generally met the contract requirement that it implement a quality  improvement program. However, in a few areas, CCHPS has not always  met the contract’s requirements, such as submitting required quarterly and  annual progress reports describing quality problems and actions taken to  correct them. Although the independent reviewer provides important  information about CCHPS’s performance, limitations in DoC’s oversight of  CCHPS may hinder the agency’s ability to be assured of CCHPS’s  compliance with the contract. For example, DoC has not enforced the  contract requirement that CCHPS provide it with quarterly and annual  progress reports. Furthermore, although DoC has authority to impose  monetary damages on CCHPS if it does not meet certain requirements  included in the contract, DoC has not collected data needed to impose  these damages or developed formal procedures for determining whether  CCHPS has met these requirements and for imposing damages if CCHPS  has not met them.

		CCHPS Generally Provides Required Medical Services and Internal Monitoring, but a Few Gaps Remain

On the basis of his review, the independent reviewer has consistently  reported that CCHPS’s medical services meet the contract’s requirements  for access to care and quality. He has also reported that services meet the  “required constitutional standards of care.” In addition, he told us that, in  his opinion, CCHPS is one of the best correctional health care providers in  the country. According to the independent reviewer, some activities, such  as documenting the administering of medication, have been performed  consistently over the life of the contract. Other activities have improved  over time. For example, in one report, the independent reviewer noted  that CCHPS’s chronic disease guidelines were outdated, but later reported  that CCHPS had appropriately revised the guidelines.
In addition, CCHPS generally meets the contract requirement that it  implement a quality improvement program. CCHPS has used the  performance assessment instruments each quarter to monitor its services,  and the independent reviewer has concluded that CCHPS accurately uses  these instruments to assess its medical services. For example, based on  data from its quarterly analyses, CCHPS identified problems in inmates’  access to dental care. As a result, CCHPS conducted a study to identify  ways to improve access to this service and eventually established a system  that gave higher priority to care for inmates with more serious dental  problems. CCHPS’s subsequent review found that access had improved.
While CCHPS’s medical services and monitoring efforts generally meet the  requirements of the contract, in a few areas CCHPS has not always met  requirements. For example, the contract requires that CCHPS provide  timely follow-up services to inmates with abnormal chest x-ray results.  Although CCHPS has recently improved its performance, the independent  reviewer had repeatedly found that CCHPS did not always provide timely  follow-up services to these inmates. The independent reviewer also  recently determined that CCHPS is not performing reviews of inmate  deaths. This is an NCCHC requirement, and CCHPS’s quality improvement  program specifies that CCHPS should conduct such reviews monthly.
In addition, CCHPS has not regularly submitted the required quarterly and  annual progress reports providing information on quality problems and its  actions to correct them. CCHPS has never submitted quarterly reports, and  submitted only one annual report. Furthermore, the annual progress  report CCHPS did submit provided only limited information. For example,  it did not discuss CCHPS’s lack of timely follow-up on abnormal x-ray  results, although the independent reviewer had repeatedly identified this  as a problem.
Inmates have expressed concerns about other medical services required  by the contract. Our analysis of a sample of the 369 inmate grievances  submitted from April 2003 through October 2003 found that many  complaints related to inmates’ ability to gain access to requested sick call  and primary care services and to the timely distribution of medications.  For example, some inmates complained that they had submitted multiple  requests to be seen during sick call and had not yet been seen. CCHPS’s  internal monitoring has also identified problems related to sick call  services, such as inconsistent use of the protocols developed to guide  inmate health assessments. In addition, advocacy groups with whom we  spoke expressed concern about distribution of medications on weekends  and to newly admitted inmates.

		DoC’s Oversight Limitations Reduce Its Assurance That CCHPS Complies with Contract

Although the independent reviewer provides important information about  CCHPS’s services, DoC has other weaknesses in its oversight of CCHPS  that reduce its ability to be assured that CCHPS is complying with the  contract and that problems are not occurring. DoC has never used its  authority to impose monetary damages on CCHPS for failing to meet  certain contract requirements. This is in part because it lacks the  necessary data and a formal procedure for determining whether CCHPS  has met the requirements; it also lacks a procedure for imposing damages  if they are warranted. To evaluate CCHPS’s compliance with many of the  requirements that are linked to monetary damages, DoC needs data that  indicate the percentage of inmates for whom CCHPS provided the  required service. One potential source for such data is the performance  assessment instruments used by CCHPS and the independent reviewer,  which measure many of the activities included in these contract  requirements. However, at present, DoC neither regularly collects data  itself nor requires the independent reviewer or CCHPS to submit data they  collect through their quarterly analyses of services. DoC officials also  were not able to provide any documents that articulated how, and how  often, they would evaluate CCHPS’s compliance with the contract  requirements associated with monetary damages, and DoC has not  provided CCHPS with information on the status of its compliance.  Furthermore, if DoC were able to determine that CCHPS was not meeting  a contract requirement, it has not determined whether it would  immediately impose damages on CCHPS or first give CCHPS an  opportunity to correct the problem.
In addition, DoC has generally not enforced the contract requirement that  CCHPS submit quarterly and annual progress reports describing quality  problems and actions taken to correct them. These reports would allow  DoC to obtain information on how CCHPS is addressing compliance or  other performance problems identified by CCHPS’s own monitoring or the  independent reviewer. For example, the independent reviewer has  repeatedly reported that CCHPS did not consistently screen and treat  female inmates for chlamydia and gonorrhea. In addition, while CCHPS  usually responds to inmate grievances in a timely way, the independent  reviewer has reported on several occasions that CCHPS does not analyze  grievances in a sufficiently thorough way to identify systemic problems in  CCHPS’s services. Enforcing the requirement that CCHPS submit regular  progress reports would better enable DoC to ensure that CCHPS promptly  corrects such problems.
An area where DoC has been slow to carry out its oversight responsibility  relates to the contract requirement for an infection control plan. To  maintain its NCCHC accreditation, CCHPS must have an infection control  plan, and the April 2003 modification of the contract required that  CCHPS’s plan be approved by DoC. Although CCHPS submitted an  infection control plan to DoC for approval in August 2003, DoC did not  complete its review and approve the plan until June 2004.
In addition to having gaps in its oversight of services provided by CCHPS,  DoC is not providing systematic oversight to ensure that, when CCHPS  refers inmates to off-site services, inmates receive those services  promptly. DoC officials believe the closure of District of Columbia General  Hospital in 2001 and the shift of off-site services to Greater Southeast  Community Hospital have resulted in delays in obtaining off-site care for  inmates, particularly in certain specialty areas, such as orthopedics and  dermatology. The independent reviewer and CCHPS have also expressed  concerns about access to off-site services. CCHPS, which is responsible  for arranging and monitoring off-site appointments, documented earlier  delays in obtaining these appointments, but at the time of our review, it no  longer possessed this documentation. Despite its concerns, DoC has not  systematically documented more recent delays in obtaining off-site  appointments for inmates, is not able to provide any data on the nature or  length of delays, and has no plans to study this issue.

	Average Per Inmate Medical Cost at Jail Has Decreased

From 2000 to 2003, DoC’s average daily cost of providing medical services  to an inmate at the Jail decreased by almost one-third. This resulted from a  decrease in the total cost of providing medical services to inmates despite  an increase in the inmate population. DoC and CCHPS officials told us  they controlled costs in various ways, including reducing personnel  expenditures. In 2003, DoC consolidated the services provided to inmates  in the Jail and the CTF under one CCHPS contract and introduced a daily  per inmate pricing structure, known as per diem pricing. The total cost to  provide medical services to inmates at the Jail and the CTF in 2003 was  about $15.8 million, an average of $13.28 per inmate.

		Cost of Medical Services at Jail Decreased, Despite Growth of Inmate Population

From initiation of the CCHPS contract in 2000 to 2003, the average daily  per inmate cost of medical services at the Jail decreased by almost one- third, from about $19 a day to about $13 a day. The average decrease  resulted from a decline in the total cost of services, combined with a rise  in the inmate population. During this period, the total cost of providing  medical services at the Jail decreased from about $11.7 million to about  $11.4 million, about 3 percent. (See fig. 1.) At the same time, the average  daily population in the Jail increased by about 680 inmates, about 41  percent. (See fig. 2.) In fiscal year 1999, the last full year in which the  Receiver directly provided medical services at the Jail, the total cost was  about $12.6 million and the average per inmate cost was about $21 a day.
As a result of the combination of decreased cost and increased inmate  population, DoC’s average daily cost of providing medical services to an  inmate at the Jail since CCHPS began providing services fell by almost  one-third from 2000 to 2003. (See fig. 3.)
DoC and CCHPS officials told us that they were able to reduce the total  cost of providing medical services at the Jail through various means. For  example, in 2003, DoC officials stopped paying CCHPS a management fee.  DoC also negotiated with CCHPS officials to reduce employee salaries and  fringe benefits, and CCHPS made more efficient use of its staff. For  example, CCHPS was able to eliminate unnecessary testing done at intake,  such as conducting repeat chest x-rays for recently returned inmates,  which allowed CCHPS to increase staff time available for providing other  services. In addition, CCHPS officials told us they have selectively  replaced higher salaried staff with lower salaried staff; in one case they  changed a vacated pharmacist position to a pharmacy technician position.
CCHPS also controlled personnel expenditures by reducing the overall  number of staff at the Jail, while still meeting NCCHC standards for  physician staffing levels. When the contract began in March 2000, CCHPS  had about 125 full-time equivalent (FTE) positions at the Jail, and there  were about 18 Jail inmates for each clinical staff member. As of April 2003,  CCHPS’s FTEs at the Jail had decreased to about 114, and the number of  inmates for each clinical staff member had risen to about 27. NCCHC  requires jails to maintain one physician on-site for 3.5 hours a week for  every 100 inmates, and as of April 2003, CCHPS exceeded this standard by  having one physician on-site for about 4.3 hours a week for every 100  inmates. Until April 2003, DoC established required staffing levels for  CCHPS as a part of its contract, but the contract now allows CCHPS, with  DoC’s approval, to adjust staffing levels in response to inmate population  changes.

		Cost in 2003 Reflected Addition of the CTF and Change to a Per Diem Pricing Structure

In 2003, the total cost for medical services in the Jail and the CTF was  about $15.8 million; over the course of that year 17,431 inmates were  admitted to both facilities. In the same year, DoC consolidated medical  services for CTF inmates into the contract for services for Jail inmates. It  also introduced a daily per inmate pricing structure—known as per diem  pricing—to calculate the rates paid to CCHPS. This pricing structure uses  a per diem rate schedule, which is a sliding scale of prices that declines  slightly as the combined inmate population increases. The schedule starts  at $14.75 per inmate when the inmate population is below 2,200, and  incrementally falls to $13.00 per inmate when the population exceeds  3,200. For example, if the combined population on a particular day were  2,000 inmates, the per diem rate would be $14.75 and the total cost to DoC  for that day would be $29,500. According to DoC officials, the per diem  rate declines when the inmate population rises to reflect economies of  scale. Over the course of 2003, the per diem rate charged to DoC for  services at the jail and the CTF averaged $13.28 per inmate.
The per diem pricing structure has simplified DoC’s contract  administration by generally eliminating the need for a reconciliation  process. Prior to April 2003, the contract required that DoC and CCHPS  complete quarterly reconciliations to determine the difference between  CCHPS’s expected staff costs at the beginning of the contract year and  CCHPS’s actual staff costs during the year. These differences resulted  primarily from inmate population changes. However, as DoC and CCHPS  negotiated the final amount of each reconciliation, the process became  increasingly lengthy and several unresolved reconciliations accumulated.  Over the first 3 years of the contract, for example, DoC completed only 4  of the 12 scheduled reconciliations. When the per diem pricing structure  was implemented in 2003, all incomplete reconciliations were resolved in a  final reconciliation settlement.

	Conclusions

DoC has provided a broad range of medical services to inmates at the Jail  and the CTF since the receivership ended in September 2000. CCHPS’s  medical services have generally met the contract’s requirements for access  to care and quality, and CCHPS has demonstrated a commitment to  providing inmates with the services they need by adding on-site specialty  clinics to improve access and continuity of care. CCHPS also regularly and  accurately monitors its services to ensure that it is providing appropriate  care. However, CCHPS has not always met all contract requirements for  service delivery and quality improvement activities.
Although DoC has taken an important step toward ensuring the quality of  services that CCHPS provides to inmates by retaining the independent  reviewer, it has not taken several other actions that would help it better  oversee the care that inmates receive. For example, DoC has limited its  ability to hold CCHPS accountable for meeting the contract requirements  that are linked to monetary damages. For monetary damages to be a viable  oversight and contract enforcement mechanism, DoC would need to  obtain data that demonstrate whether CCHPS is providing required  services to the minimum percentage of the inmate population stipulated by  the contract. However, DoC has not collected these data. DoC would also  need to develop formal procedures for assessing CCHPS’s compliance  with the requirements and for imposing monetary damages if they are  warranted.
Furthermore, DoC has not enforced the requirement that CCHPS regularly  submit progress reports describing how it is correcting problems  identified through performance monitoring, including any problems that  may place CCHPS out of compliance with the contract. If CCHPS provided  this information, DoC could ensure that CCHPS promptly took corrective  action to respond to problems identified by the independent reviewer or  CCHPS’s own monitoring, such as CCHPS’s failure to promptly follow up  on abnormal chest x-ray results. Having the capacity to enforce the  contract requirements linked with monetary damages and requiring  CCHPS to submit regular progress reports would strengthen DoC’s ability  to ensure that CCHPS provides important medical services to inmates.

	Recommendations for Executive Action

To help ensure that CCHPS provides required medical services to inmates  of the District of Columbia Jail and the CTF, we recommend that the  Mayor require the Director of DoC to take the following two actions:    Develop formal procedures—including collection of needed data—to  regularly assess whether CCHPS’s performance meets the contract  requirements that are linked to monetary damages and to impose these  damages.
Ensure that CCHPS submits to DoC the required quarterly and annual  progress reports, which should describe identified problems and the  actions CCHPS has taken to correct them.

	Agency Comments and Our Evaluation

We provided a draft of this report to DoC for comment. In its response  DoC did not comment on our recommendations, but provided additional  information about its contract with CCHPS and medical services for  inmates of the Jail and the CTF. In addition, DoC elaborated on its  oversight of medical services provided by CCHPS. (DoC’s comments are  reprinted in app. IV.)
DoC emphasized in its comments that the independent reviewer acts at the  request and on behalf of the agency. We noted in the draft report that  DoC’s hiring of the independent reviewer was an important step toward  ensuring the quality of CCHPS’s services and described the independent  reviewer’s role in DoC’s oversight of CCHPS. DoC expressed concern that  the issues discussed in the independent reviewer’s reports are intended to  identify opportunities for CCHPS to improve, but that the draft report  portrayed them as problems or deficiencies. While some issues raised by  the independent reviewer could be characterized as opportunities for  service improvement, we found that others indicated performance  shortfalls related to specific contract requirements.
In its comments, DoC discussed our finding that CCHPS has not regularly  submitted the quarterly and annual reports required by the contract; these  reports are to provide DoC with information on problems identified by  CCHPS’s performance monitoring or by the independent reviewer and on  CCHPS’s corrective actions. DoC stated that instead of the quarterly  reports, it relies on certain monthly reports and regular verbal  communication. DoC’s comments describe two types of monthly reports,  one providing various data on off-site services and the other relating to  two performance measures reported to the Office of the Mayor. However,  undocumented verbal communications and these narrowly focused  monthly reports are not a substitute for the quarterly progress reports  called for in the contract and do not enable DoC to ensure that CCHPS is  addressing identified problems. DoC’s comments acknowledge that  CCHPS has not submitted all required annual reports. We do not agree that  the information provided in the December 2002 report on the  reconciliation of CCHPS’s expected and actual costs, which DoC cites in  its comments, provided DoC with the type of information required in the  annual progress reports. For example, this report contains no information  about how CCHPS planned to improve its performance in screening and  treating female inmates for chlamydia and gonorrhea.
DoC highlighted its role in reducing the cost of medical services provided  to inmates by CCHPS. In the final report we provided additional  information on DoC’s role. DoC also noted that the average daily cost of  services decreased from about $19 to about $13, which we stated in our  draft report, and that this will result in savings over the remaining life of  the contract. However, while the average daily cost per inmate in 2003 was  $13.32, under the current rate schedule, daily per inmate costs may range  from $13.00 when the combined Jail and CTF population exceeds 3,200 to  $14.75 when the inmate population is below 2,200. Therefore, costs over  the remaining life of the contract will depend largely on the inmate  population.
In response to DoC’s comments, we replaced the term “financial penalties”  with “monetary damages.” While the comments state that DoC has other  remedies for contract nonperformance, we believe that the authority to  impose monetary damages is also a useful means of ensuring CCHPS’s  compliance with the contract.
In its comments, DoC described changes in the District’s health care  system that have affected the provision of off-site medical services for  inmates. Because the focus of our report was on services provided by  CCHPS through its contract with DoC, a detailed discussion of these  developments was not within the scope of the report. DoC also stated that  there was a past study on delays in obtaining off-site appointments for  inmates and that there is no need to conduct an additional study. The draft  report did not recommend that DoC conduct an additional study, but  reported that DoC and the independent reviewer have identified problems  with access to off-site services and that DoC has not collected data on  delays.
We incorporated other information provided by DoC in its comments on  our draft report where appropriate.
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies to the DoC Director,  interested congressional committees, and other parties. We will also make  copies available to others on request. In addition, the report will be  available at no charge on the GAO Web site at http://www.gao.gov. If you   or your staff have any questions about this report, please call me at (202)  512-7119. Another contact and key contributors are listed in appendix V.

Appendix I: Scope and Methodology

We examined the medical services provided by the Center for Correctional  Health and Policy Studies, Inc. (CCHPS) to inmates at the Jail and the  Correctional Treatment Facility (CTF), including CCHPS’s internal  monitoring; the District of Columbia Department of Corrections’ (DoC)  oversight of those services; CCHPS’s contract compliance; and the cost of  services under the contract. To provide information on CCHPS’s and  DoC’s activities, we reviewed documents and interviewed officials from  those two organizations. DoC documents we reviewed included  contracting documents such as the original request for proposals and  subsequent modifications, reports of inmate population volume, and  specialty clinic utilization statistics. In reviewing DoC’s activities, we  assessed DoC’s internal controls related to the contract with CCHPS.  CCHPS documents we reviewed included policies and procedures, staffing  plans, annual progress reports, and quarterly performance analyses. We  also interviewed the independent reviewer hired by DoC and analyzed the  reviewer’s quarterly reports to examine CCHPS’s medical services and  CCHPS’s quality improvement activities. In addition, we analyzed  documents and interviewed officials from the National Commission on  Correctional Health Care and the American Correctional Association to  obtain information on their correctional health care accreditation  standards, their accreditation review processes, and their findings on DoC  facilities. We also reviewed our previous work on medical services at the  Jail. We reviewed issues related to medical services provided to CTF  inmates only since April 2003, when DoC expanded its contract with  CCHPS to include medical services for inmates at that facility.
To obtain information on inmate complaints about medical services the  contract requires CCHPS to provide and on CCHPS’s responses to these  complaints, we conducted an independent analysis of randomly selected  samples of grievances submitted by inmates at the Jail and the CTF. Of the  201 grievances at the Jail and the 168 grievances at the CTF during the  period April 1, 2003, through October 31, 2003, we randomly selected 75  grievances for each analysis, for a total sample size of 150. DoC was able  to provide us with the detailed information needed for our analysis on 72  of the 75 grievances selected from the Jail and on 72 of the 75 grievances  selected from the CTF. Grievances for which DoC could not provide the  requested information were excluded from each analysis. For both the Jail  and the CTF samples of inmate grievances, we analyzed the timeliness of  CCHPS’s response, the subject of the grievance, and the extent to which  CCHPS’s response addressed the principal areas of concerns cited in the  complaint. The final sample size of 144 grievances produced estimates  about types of grievances and timeliness of responses with a margin of  error of plus or minus 5.0 percent at the 95-percent confidence level.
Although we focused principally on medical services provided by CCHPS  under its contract with DoC, we also obtained information about inmate  services that are not part of the CCHPS contract—such as off-site  services—by reviewing documents and interviewing officials from CCHPS,  DoC, and the District of Columbia Department of Health (DoH).  Documents we reviewed included contracts between DoH and community  providers and utilization data on off-site services provided to inmates. We  also interviewed officials from the District of Columbia Department of  Mental Health, a community health care provider, and groups providing  legal services to inmates.
To calculate the total annual and average per inmate costs of the medical  services that CCHPS provided, we reviewed documents such as DoC’s  budget records, purchase order summaries, contract pricing  modifications, and CCHPS invoices. We interviewed officials from the  District of Columbia Office of Contracting and Procurement; DoC,  including its Office of the Chief Financial Officer; and CCHPS. We also  examined independently audited accounting data from the District of  Columbia Office of Financial Operations and Systems. We determined that  the medical services cost information we reviewed was reliable, based on  documentation provided by the District of Columbia Office of Financial  Operations and Systems stating that the source of the data was the System  of Accounting and Reporting, the District of Columbia’s official accounting  records, which is subject to an independent audit each year. We made  certain assumptions to define four comparable 12-month periods that  approximated the DoC-CCHPS contract year. Although there are slight  differences between the time periods defined for total costs and inmate  population averages, the length of each period was 1 year. Total cost data  for 2000, 2001, and 2002 are from March 12 of each year through March 11  of the following year, coinciding with the DoC-CCHPS contract year, while  inmate population data for 2000, 2001, and 2002 are from April 1 of each  year through March 31 of the following year, approximating the DoC- CCHPS contract year. Total cost and inmate population data for 2003 are  from April 1, 2003, through March 31, 2004, approximating the DoC- CCHPS contract year. We calculated the average daily inmate population  for each annual period by first calculating an average daily population for  each of the 12 months within the period, and then averaging the monthly  averages.
We applied an accrual methodology to calculate the total costs associated  with each annual period. The DoC-CCHPS contract during the years 2000  through 2002 specified a fixed contract price at the beginning of each year,  subject to reconciliations during the year. Reconciliations conducted  during contract years often resulted in adjustments to DoC payments in a  subsequent contract year. By applying an accrual method, we attributed  reconciliation costs to the years from which they originated rather than  the years in which they were paid. We performed our work from August  2003 through June 2004 in accordance with generally accepted  government auditing standards.

Appendix II: Requirements Linked to Monetary Damages Provisions in the CCHPS Contract

The contract between DoC and CCHPS contains certain requirements that  CCHPS must meet. If these requirements are not met, DoC has the  authority to impose specified monetary damages on CCHPS. Table 2  summarizes the requirements linked with monetary damages.

Appendix III: Performance Assessment Instruments Used to Monitor Services Provided by CCHPS

In 2000, DoC, CCHPS, and the independent reviewer hired by DoC to  monitor CCHPS’s medical services developed performance assessment  instruments to allow them to determine how consistently CCHPS  delivered required medical services to inmates and whether it conducted  activities included in its quality improvement program. Table 3 describes  the measures included in the performance assessment instruments, as well  as the samples measured and the sources of the samples. When reviewing  services, the person conducting the assessment determines whether each  bulleted measure has been met.

Appendix IV: Comments from the District of Columbia Department of Corrections

Appendix V: GAO Contact and Staff Acknowledgments

	GAO Contact

	Acknowledgments

In addition to the person named above, key contributors to this report  were Emily Gamble Gardiner, Marc Feuerberg, Krister Friday, and Anne  Montgomery.

Summary:
Why GAO Did This Study

Since the end of a court-ordered receivership overseeing medical services at the District of Columbia Jail in September 2000, the Department of Corrections (DoC) has contracted with the Center for Correctional Health and Policy Studies, Inc. (CCHPS) to provide inmate medical services. GAO was asked to provide information on (1) the medical services DoC contracted with CCHPS to provide, including CCHPS's monitoring of its services; (2) mechanisms DoC established to oversee CCHPS's services; (3) CCHPS's contract compliance and DoC's efforts to ensure compliance; and (4) the cost of medical services. To collect this information, GAO analyzed documents and interviewed officials from District agencies, CCHPS officials, and an independent reviewer hired by DoC to monitor medical services.

What GAO Found

DoC has contracted with CCHPS to provide a broad range of medical services to inmates at the District of Columbia Jail and the Correctional Treatment Facility (CTF)--an adjacent overflow facility. Services include health screenings at intake; primary care services, including care for chronic conditions; mental health care; and specialty care. In addition, CCHPS assists DoC in helping inmates obtain services not included in the contract, such as specialty or emergency services that cannot be offered on-site. As part of the contract, CCHPS also established a quality improvement program to monitor its services. A key component of the program is a quarterly analysis of random samples of inmate medical records to measure how consistently CCHPS delivers required services. DoC established several mechanisms to oversee CCHPS's delivery of medical services to inmates. For example, DoC retained an independent reviewer to monitor the services provided by CCHPS on a quarterly basis. In addition, the contract gives DoC authority to impose monetary damages on CCHPS if it fails to meet any of 12 requirements specified in the contract, most of which relate to providing key services to a minimum percentage of inmates. The contract also requires CCHPS to submit quarterly and annual progress reports describing quality problems identified by the independent reviewer or its own monitoring and actions taken to correct them. Although available evidence indicates that CCHPS has generally complied with the terms of its contract, DoC has not exercised sufficient oversight to provide assurance that problems are not occurring or are quickly corrected. The independent reviewer has consistently found that CCHPS's services meet the contract's overall requirements for access to care and quality, but has also reported that CCHPS has not always met certain requirements. For example, while CCHPS recently improved its performance in providing timely follow-up services to inmates with abnormal chest x-ray results, the independent reviewer had repeatedly found problems in this area. DoC has not taken actions that would allow it to be assured of CCHPS's compliance with contract requirements linked to monetary damages. The agency has not collected data or developed a formal procedure to determine whether CCHPS has met the requirements, and it lacks a procedure to impose damages if warranted. Also, DoC has not regularly enforced the contract requirement that CCHPS submit quarterly and annual progress reports describing quality problems and corrective actions, and CCHPS has often not submitted these reports. From 2000 to 2003, the average daily cost of providing medical services to a Jail inmate decreased by almost one-third, from about $19 a day per inmate to about $13 a day. In 2003, DoC consolidated the services provided to inmates in the Jail and the CTF under one contract with CCHPS. In that year, during which 17,431 inmates were admitted to the Jail and the CTF, the total cost of providing medical services at both facilities was about $15.8 million.