United States, Generd Accounti~

Office

GAO

Report to the Chakman, Subcommittee
on Intellectual Property and Judicial
Administration, Committee an the
Judiciary, House of Representatives

February 1994

BUREAU OF’PRISONS
HEALTH CARE
Inmates’ Access to
Health Care Is Limited
by Lack of Clinical
Staff

GAO

United States
General Accounting Office
Washington, D.C. 20548
Health, Education, and
Human Services Division

B-249967
February lo,1994
The Honorable William J. Hughes
Chairman, Subcommittee on Intellectual Property
and Judicial Administration
Committee on the Judiciary
House of Representatives
Dear Mr. Chairman:
In March 1992, you requested that we evaluate the adequacy of the Federal
Bureau of Prison’s (BOP) medical services and the effectiveness of its
medical service’s quality assurance program. At that time, allegations of
patient neglect, unacceptable medical practices, and incompetent
physicians in BOP were receiving attention in the national media.
/4
v/

As agreed with your office, we reviewed the folIowing four issues:
Are inmates with special medical needs-including women, psychiatric
patients, and inmates with chronic medical conditions-receiving
the care
they need?
9 Does BOP have quality assurance systems in place that detect problems
with health care, and is corrective action taken to prevent similar
problems?
Are BOP physicians and other health care providers qualified to perform
the services they are assigned?
Is BOPconsidering the most cost-effective alternatives to meet inmates’
rising needs for medical services?

l

l

l

We also agreed to concentrate our review on three of BOP’Sseven medical
referral centers-Butner, North Carolina, which serves only male
psychiatric patients; Lexington, Kentucky, which provides medical
services only to female inmates; and Springfield, Missouri, which serves
only male inmates.’ We reviewed selected reports and correspondence
from the other four centers.

Background

Health Services Division is responsible for providing health care
services to approximately 78,000 inmates housed in 71 correctional
facilities throughout the United States. This includes emergency and

BOP’S

I

‘The other four medical centers are HI Rochester, Minnesota; Terminal
Texas: and Carville, Louisiana.

Island, California:

Fort Worth,

I
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B-349967

urgent care and care needed to prevent further deterioration of an
inmate’s condition. At most correctional facilities, only basic care, such as
a physical examination, is provided. Inmates who require more intensive
care or suffer from chronic conditions are either treated at one of seven
BOP medical referral centers or are referred to community hospitals with
which BOP contracts to provide the needed care.
medical referral centers are staffed by physicians, dentists, physician
assistants, nurses, and other health care staff. They provide care to
inmates of various security levels, from minimum to high. Five of the
centers treat male patients only, one treats female patients only, and one
provides care to patients of both sexes. The centers provide various types
of services to patients, including medicine, surgery, radiology, psychiatry,
and laboratory services. Inpatient services are available only at the
centers. None of the centers provides tertiary care.2 In addition, each of
the centers houses nonpatient inmates who help maintain the centers. .The
services provided by each of the three centers we visited are described in
appendices II, III, and IV.

BOP’S

has directed six of its seven medical referral centers to seek
accreditation by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).~Each was surveyed in March I993 for
accreditation. Five were fully accredited and one, the Terminal Island,
California, center, was refused accreditation.

BOP

Results in Brief

Inmates with special needs, including women, psychiatric patients, and
patients with chronic illnesses,4 were not receiving all of the health care
they needed at the three medical referral centers we visited. This situation
was occurring because there were insufficient numbers of physician and
nursing staff to perform required clinical and other related tasks. For
example, physicians did not always have enough time to supervise
physician assistants who provided the bulk of the primary care given to
inmates, and nurses did not have sulXcient time to provide individual and
group counseling to psychiatric patients. As a result, some patients’

Tertiary care medical centers have the capability to provide all medical or surgical care, such ss
surgery that requires an intensive care unit for recovery.
%rviIIe is managed and operated by the Public Health Service (PHS), which provides medical care to
BOP inmates under an interagency agreement. PHS has not sought JCAHO accreditation for CarviIIe.
4Chronic conditions are permanent or long-term health care needs that do not require constant and
extensive medical monitoring by a physician.

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conditions were not improving and others were at risk of serious
deterioration.
While all three centers had quality assurance programs intended to
identity problems with health care, two of the centers failed to correct
identified quality assurance problems. At Springfield, key staff, such as
physicians, did not use adverse outcome data to help improve inmates’
care, while Lexington was so understaffed its personnel could not act on
any but the most severe problems identified. As a result, quality-of-care
problems recurred.
Physicians at each of the centers we visited were qualified to perform the
work they were assigned. However, many physician assistanti did not
meet the training and certification requirements of the medical community
outside of BOP.
To reduce its reliance on community hospitals and the associated costs of
providing health care to patients in a non-BoP setting,’ BOP is considering
constructing six large acute tertiary care hospitals; acquiring several
military facilities; or both. But BOP has not yet developed the data with
which to determine what kind of medical services are needed by its
inmates or the type of services it can efficiently and effectively provide,
Absent such data, BOP has little basis for deciding the numbers and types
of staff it would need to operate these hospitals.
needs to determine its basic requirements and consider the costs and
benefits of other alternatives for meeting its needs before proceeding with
the construction or acquisition of facilities. For example, BOP can draw on
the experience of several states that have had problems similar to BOP'S in
providing inmates access to adequate medical care. These states have
contracted out some or all of their inmate medical care and found that the
medical care received under this process is better than it was when the
prison system was providing the care directly, according to state officials.
BOP

?he cost to provide inmates with medical care at community hospitals increased by 27 percent from
fiscal year 1991to 1992,from $63.6to $68.0 million.

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Principal Findings
Women Inmates Not
Receiving Tirnely Pelvic
Examinations and Pap
Tests

policy requires that female inmates receive a physical examination,
which includes a pelvic examination and Pap test, when entering the
prison system and, thereafter, on an annual basis. The physical
examinations are done to detect any health problems that might exist, and
the pelvic examinations and Pap tests are designed to detect cancer at its
early stages. The examinations and Pap tests are especially important in
identifying and treating sexually transmitted diseases, which many of
these women contracted before entering the federal prison system. If
these diseases are left untreated, irreversible complications can occur.
BOP

But at the Lexington Medical Referral Center, which specializes in
providing medical care to women, pelvic examinations and Pap tests were
not done in a timely manner and in some cases may not have been done at
all. In fact, these tests were often only performed when the patient had a
problem that brought her to sick call, according to the center’s former
Cliniczd Director. As a result, patients were at risk of having an
undetected, untreated cancer progress to a serious condition before it
received attention. This situation was occurring because medical staff at
Lexington could not perform the pehic examinations and Pap tests and
also perform their required daily duties.
In August 1992, the gynecology nurse at Lexington estimated that the
center was 6 months behind in performing pelvic examinations and Pap
tests. At that time, the gynecology service had a fU-time gynecologist, a
full-time nurse practitioner, and a part-tune physician assistant to perform
these functions. However, the &aEmg situation worsened in the ensuing
months. In January 1993, the only gynecologist at Lexington transferred to
another facility for personal reasons. In June 1993, the nurse practitioner
for the gynecology clinic retired, leaving only a part-time physician
assistant and a clinical nurse to provide gynecological examinations, tests,
and treatment in the gynecology service. The clinical nurse, a registered
nurse, could not do pelvic examinations and Pap tests because she was
not credentialed to do ~0.~Thus, as of June 14,1993, only a part-time
physician assistant was providing care in the gynecology service for about
2,000 inmates.

sA registered nurse’s (RN) scope of practice does not usually include performing pelvic examinations
or pap tests unless the RN is a specialist with advanced training in gynecology.

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Staffing shortages were not the only reason pelvic examinations and Pap
tests were delayed or not performed. Lexington had no system to assure
that all new entrants to the center were referred to a physician, nurse
practitioner, or physician assistant who could perform the examination
and test. Upon entry to the center, inmates are seen by a physician
assistant, who determines from their health care record whether they need
a pelvic examination and Pap test. Those requiring such services are
referred to the gynecology service. But Lexington’s former gynecologist
told us that if a physician assistant fails to make this referral to a
physician, the patient will not be seen unless she requests the examination
or develops a problem that requires the examination and test. Because no
one reviews the physician assistants’ work to assure that inmates’ needs
for specialized tests are accurately recorded, a patient with a
gynecological problem could enter the prison system and have the
problem go undetected until it had advanced to a serious state.

Psychiatric Patients Not
Receiving Needed Therapy

Many psychiatric patients in the Springfield and Lexington Medical
Referral Centers were not receiving regularly scheduled individual and
group therapy that could improve their mental condition. This situation
was occurring because neither facility had a sufficient number of
psychiatrists to perform this work. In fact, the Chief of Psychiatry at
Lexington told us that he could not provide the type of psychiatric care
each patient needed and was lucky if he could “eyeball” each patient daily.
The staffing shortages in these centers were placing inmate patients at risk
of receiving poor or untimely psychiatric assessments and inadequate
monitoring of their mental conditions.
Chief Psychiatrist told us that an ideal stafsng pattern in a BOP
psychiatic unit is one psychiatrist for each 20 to 26 patients. Using the
staffing pattern cited by the Chief Psychiatrist, Springfield would need a
minimum of 12 psychiatrists to provide quality mental health care. But
Springfield has not met this standard. In September 1989, Springfield was
authorized seven psychiatric positions to serve approximately 300 acute
and chronic care mental health patients But between January 1991 and
August 1992, it never had more than four psychiatrists. In April 1991, it had
only one psychiatrist working in the center. In 1992, Springfield decreased
the number of authorized psychiatrist positions to five, and by June 1993,
four of these positions were filled. But, this number of psychiatrists is
insticient
to provide adequate treatment to the 294 acute and chronic
care mental he&h patients the center serves.
BOP'S

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The Lexington Medical Referral Center was also below its authorized
number of psychiatrists. At the time of our visit in July 1992, Lexington
was authorized three psychiatrists but had only two for 237 acute and
chronic care mental health patients. In March 1993, BOP authorized
Lexington to hire a fourth psychiatrist. However, in July 1993, the center
had only three psychiatrists on its staff. To meet the Chief Psychiatrist’s
optimal staffing level, the center would need nine psychiatrists.
Of the centers we visited, Butner was the only facility whose authorized
strength met optimal staffing requirements. It was authorized nine
psychiatrist positions to treat its 230 acute and chronic care mental health
patients. However, as of July 31,1993, only seven of these positions had
been filled.
Figure 1 shows the number of psychiatrists needed for ideal staffing, the
number of authorized positions, and the number of positions filled at the
three centers as of July 1993.

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B6P Centers (July 1993)

15

Number of psychiatrists

Lexington
BOP Medical Referral Center

El

Ideal Number
Authorized
Actual

Number of Authorized
Nursing Positions at
Centers Is Insufficient

Nursing shortages were prevalent in the psychiatric units at each of the
three centers we visited. As a result, nurses at each location told us that
their efforts were limited to addressing patients’ immediate symptoms,
such as disruptive behavior, and they had no time to seek long-term
solutions to patients’ psychiatric conditions. For example, in Lexington,
one nurse was usually assigned to 34 acute mental health patients on each
shift. In Springfield and Butner, the nurseto-patient ratios were roughly
the same-Springfield assigns four to seven nurses per shift for 177 acute
mental health patients, and Butner assigns one to three nurses per shift for
75 acute mental health patients.
Although BOP has no staffing policies governing nurse-to-patient ratios,
psychiatric nurses at all three centers told us that they could not
adequately treat all their patients under the current sQ@mg arrangements.
For example, Butner’s Director of Nursing in a May 1993 memo to the
Associate Warden for Health Services said that the nurses provide about
13 minutes of nursing care a day for each patient. She added that no other

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health care institution measures patients’ nursing care time in minutes
rather than hours. Further, the Director of Nursing believes that the
authorized staffing level of 15 nurses is dangerously low. During its
March 1993 accreditation survey, a JCAHO surveyor also stated that Butner
needed more nurses. However, even if the central office approves an
increase in nursing staff at Butner, the Director of Nursing is not sure she
can fill positions with nurses from the community because its salaries are
at least $7,000 below nursing salaries in the community. Butner asked for
an increase in nursing salaries in 1992, but central office refused the
request, stating that the center did not have enough vacancies to justify the
salary increase.
The situation was the same at the Lexington Medical Referral Center. In
March 1993, BOP’S central office approved 20 additional medical positions
(10 nurse positions and 10 other positions such as physician assistant and
occupational therapist) for Lexington. At that time, BOP’S Medical Director
told us that the center was in a crisis situation and needed the additional
staff to provide adequate care to the patients. However, as of June 1993,
the center had not received funding for the positions and had not hired any
nurses. Further, it was still unclear whether the center would be able to
recruit the additional nurses because its salaries were about $3,000 per
year below those found in the community.
The Director of Nursing at the Springfield Medical Referral Center told us
that nurses were available in the Springfield area and that recruiting and
retaining nurses were not problems. But nurses at the center told us that
the number of authorized nursing positions was too low to provide
adequate care to both the mental health patients and the medical and
surgical patients. For example, from March to May 1993, some nurses on
the mental health unit were asked to fill in on the medical and surgical
units while nurses were on Ieave. The Warden stopped this practice in May
because it jeopardized the medical condition of the mental health patients
in units from which the nurses were drawn. In July 1993, despite receiving
overtime from its nurses to staff the medical and surgical units, the center
could not meet all its patients’ needs. For example, from July 11 to July 17,
1993, the center had 2,141 hours of nursing staff absences in surgical,
medical, and mental health units, according to the Director of Nursing. But
only 40 of these hours were covered through overtime; the remaining
hours were not covered.
The Springfield Medical Referral Center has not requested additional
nursing positions from the central office because the nursing department

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has not accurately determined patients’ nursing needs. Rather than
determining the amount of nursing time needed to fully address patients’
needs, the nursing department schedules only the staff time it has
available to provide care. This action justifies the existing nurse staffing
levels. But according to the nursing staff, the medical and surgical patients
admitted to the center during 1993 are more acutely ill than patients
admitted in past years. As a result, they stated that the patients need more
hours of care than they can provide within existing staff levels. For
example, between December 1991 and June 1993 the number of end-stage
acquired immunodeficiency syndrome (AIDS) patients being treated at the
Springfield center increased from 10 to 31. Therefore, more hours of
nursing time were needed to care for these patients than other, less ill
patients would need.
Some nurses at Lexington also told us that if BOP hired psychiatric
technicians, more of the psychiatrists’ and nurses’ time could be spent in
providing therapy to psychiatric patients. BOP’S Medical Director told us
that he was considering the use of psychiatric technicians at the medical
centers but, as of March 1993, he had not acted on this issue.

Some Inmates With
Chronic Conditions Not
Receiving Follow-Up Care

Patients with chronic conditions that cannot be stabilized often require
frequent observation and monitoring by a nurse in a chronic care unit.
However, the Lexington Medical Referral Center closed its chronic care
unit in August 1990 because it did not have a sufficient number of nurses
to staff the unit. As a result, most inmates with chronic care conditions,
such as high blood pressure, diabetes, and cardiac conditions, were
housed in units that did not have frequent monitoring by nurses. The
center relied on inmates with chronic conditions to appear at sick call or
schedule a clinic appointment themselves when they needed medical care.
The Clinical Director told us that physicians try to periodically check
when their chronic care patients were last seen. But with little time to see
scheduled patients, this check is not a priority and is not always made.
Relying on inmates with chronic health problems to appear at sick call or
schedule a clinic appointment for themselves is ineffective because some
chronically ill inmates may not recognize that their conditions warrant
medical treatment until the condition becomes serious. For example:
l

An inmate housed in a unit that did not, have frequent nurse monitoring at
the Lexington Medical Referral Center had serious chronic problems,
including hypertension, diabetes, and renal difficulties. From January 1992

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until her death in July 1992, the patient was periodically admitted to the
acute inpatient care unit at the Lexington Medical Referral Center and to
two community hospitals for treatment of her existing conditions. But her
condition required closer monitoring. After each admission/treatment, she
was returned to a unit that did not have frequent monitoring by nurses and
was told to present herself to the clinic if further problems occurred. The
inmate did not assure that her treatment for diabetes was closely
regulated, and she developed hypoglycemia.7 The situation went
undetected unti another inmate brought the patient to the medical staff in
a confused state. The patient was transferred to a community hospital for
treatment but eventually died. The ClinicaI Director told us that if the
center had sufficient nursing staff to operate a chronic care unit for this
type of patient, the hypoglycemia might not have gone undetected and
treatment could have been started sooner, possibly preventing the
patient’s death.
policy requires that patients with AIDS be seen monthly. But this was
not occurring at the Lexington Medical Referral Center because the center
did not have sufficient medical staff to perform required work. Rather than
monthly visits, the 17 AIDS patients in Lexington were scheduled to be seen
by a physician every 6 months, unless they had symptoms that required
immediate treatment. Springfield and Butner had sufficient staff to
perform monthly assessments of their 40 and 14 AIDS patients, respectively.
BOP

Medical centers are also required to have infection-control programs in
place to identify and control the spread of infectious diseases. All three
centers we visited had an infection-control program and a person assigned
to conduct the program. However, the centers varied in their effectiveness
in treating tuberculosis. Tuberculosis is a major problem in correctional
facilities because it occurs three times more often than it occurs in the
community. To illustrate, outbreaks of tuberculosis have recently
occurred in some state prison facilities, and some cases have surfaced in
BOP correctional facilities. Inmates who have a positive tuberculosis test
and fail to complete the medication treatment risk developing active
tuberculosis disease, which can be transmitted to other inmates and staff
Lexington was the first medical referral center in the BOP system to
perform annual tuberculosis testing of all inmates and track inmate
patients’ compliance with treatment. Specifically, in the summer of 1992,
the center hired two Public Health Service (PHS) pharmacy students to
review all patient medical records to assure that every inmate who had
%lypoglycemic reactions result when a patient omits a meal or eats less food than prescribed, receives
an overdose of insulin, has a nutritional and fluid imbalance due UBnausea and vomiting, or overexerts
without compensating with additional carbohydrates.

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tested positive for tuberculosis was complying with treatment. They found
that about 27 percent of the 135 inmates who had tested positive for
tuberculosis were not following their prescribed medical regimen The
center staff immediately initiated a counseling program for these inmates
to assure compliance, The compliance rate at the time of our visit 3
months later was close to 100 percent.
The Butner Medical Referral Center began annual tuberculosis testing in
March 1993 after an inmate with active tuberculosis went undiagnosed for
about 1 month while housed at the center. At Butner, the nurses
administer preventive medication to inmates with a positive skin test,
observe the inmate taking the medication, and document that the patient
took the medicine. In contrast, Springfield tests every 2 years unless an
inmate has symptoms of tuberculosis, such as coughing and fever. Further,
the Springfield center relies on the patients to take their prescribed
preventive medications and does not rely on direct observation by the
staff. Staff become aware of noncompliant inmates when their
prescriptions are not refilled at appropriate times or during staff
inspections of inmates’ cells.

Physician Assistants Lack
Credentials and Adequate
Supervision

Many physician assistants in BOPlack generally required education and
certification and are not receiving adequate supervision from physicians.
At the three centers we visited, 11 of 27 physician assistants had neither
graduated from a program approved by the American Medical Association
(AMA)nor obtained certification from the National Commission on
Certification of Physician Assistants8 However, BOP’S policy does not
require physician assistants to be certified by the National Commission on
Certification of Physician Assistants or to have graduated from a program
approved by the AMA.This policy is in contrast to the community’s,
Department of Veterans Affairs’, and military services’ requirements that
physician assistants have approved education or certification before they
can be hired.
F’urther, physicians at these centers told us that they lack the time to
adequately supervise physician assistants. This situation occurred because
centers either did not have sufficient medical physicians or did not assign
a sufficient number of these physicians to supervise their physician

Thirty-four of the 66 physician assistants working in BOP at its seven medical referral centers h&e
not met either of these requirements. Of these individuals, 28 were foreign medical school graduates.
These providers are not licensed to practice medicine in the United States, but current Office of
Personnel Management regulations permit them to work as physician assistants in federal facilities.

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assistants. As a result, inmate patients were at risk of not receiving quality
medical care.
Medical Director agreed that physician assistants should have
approved education or certification. But he believes that adopting more
stringent hiring criteria for BOP’S physician assistants would limit BOP’S
ability to hire such personnel because its current salary structure is
significantly lower than what certified personnel can obtain in the private
sector.
BOP’S

credentialing policy on its physician assistants was formulated using
a 1970 Office of Personnel Management (OPM) qualification standard. This
standard requires only that a physician assistant receive training from a
nationally recognized professional medical group, such as the AMA,or by a
panel of physicians established by a federal agency for this purpose. But
the Chief of OPM’S Standards and Qualifications Branch told us that the
qualification standards are minimal federal hiring standards. The standard
was issued on an interim basis and was to be examined further as the
physician assistant occupation evolved. On August 2, 1993, the Chief of the
Standards and Qualifications Branch at OPM told us that he hoped a revised
standard would be issued in 1993. He explained that OPM has been
conducting an overall study of medical occupations and that no changes
will be made to the 1970 standard until BOP and the military services
submit comments.
BOP’S

In June 1991, a consultant9 expressed concern to BOP that its physician
assistants lacked proper qualifications for the position and that BOP
physicians were not providing them with adequate supervision.
Specifically, he noted that uncertified physician assistants were providing
the bulk of health care to inmates and that the ratio of attending
physicians to physician assistants was suboptimal. The consultant was
also concerned that the training physician assistants received was
inconsistent and might even have been inappropriate for the type of care
and treatment they provided to inmates. He recommended that more
physician positions be authorized to improve overall quality of care. But as
of July 1993, BOP had not been able to fill all the physician positions that
were authorized in any of the centers we visited.

ODr.Joseph A. Leiberrnan III, M.D. and M.P.H., Professor and Chairman, Department of Family and
Community Medicine, Medical Center of Delaware, Wilmington, Delaware.

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We corroborated the consultant’s findings concerning both credentials and
supervision, Figure 2 shows the number of physician assistants at six
centers and the number who lacked credentials.

Figure 2: Physician Assistants (PA)
With and Without Credentials at Six
BOP Medical Centers

Number of
15

Mdical

PA’s

Refetral Contere
PA’s wlthout Credentials
PA’s with Credentials

Physicians at Lexington told us that they lacked sufficient time to review
charts for patients seen by physician assistants and as a result, they had
not reviewed any. At Butner, physicians reviewed some charts, but told us
that physician assistants needed more supetiion.
As a result of our visit,
Butner’s Warden authorized an additional physician to be hired to provide
better supervision for physician assistants. But as of July 29,J993, the
position was not fiied. BOP’S Health Services Manual states that
supervision of physician assistants can be achieved through a daily
physician review of at least 10 charts of patients seen by physician

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assistants. However, a medical records audit conducted by Springfield
staff in April 1992 found that over a l-month period the physician
responsible for the outpatient department reviewed only 14 of 90 charts
for patients seen by physician assistants.
In addition to providing inadequate supervision to physician assistants,
physicians at the Springfield facility did not always provide appropriate
clinical support to these personnel. According to hospital policy,
physicians are required to respond to physician assistants’ requests for
consultations on patients’ conditions within 10 days of receipt of the
request. In an August 1992 memorandum to the center’s Clinical Director,
the Assistant Clinical Director stated that physician assistants did not
believe that they were receiving timely responses to their requests for
physician consultations.

Medical Referral Centers
Are Not Using Quality
Assurance Data to Improve
Care

Each of the three centers we visited had quality assurance programs that
were identifying actual and potential quality-of-care problems. But only
the Butner Medical Referral Center has a program in place that was
addressing these problems. At the Springfield Medical Referral Center,
neither the physicians nor the other health care providers were accepting
responsibility for the problems identified by the quality assurance
personnel. And at Lexington, insufficient numbers of clinical staff
prevented the quality assurance coordinator from taking corrective action
on identified problems. As a result, quality-of-care problems continued to
occur in both centers,
In May 1992, a consulting team visited Springfield and reported that the
center’s quality management process had resulted in little evaluation,
action, or followup for the data collected or problems identified. The team
also found little interdisciplinary cooperation or collaboration among
nurses, the quality assurance staff, and the physicians. The consulting
team concluded that until quality improvement was considered everyone’s
responsibility, the system would not function properly.
quality management process includes internal and external reviews
of mortality cases. The effectiveness of these reviews is limited because
(1) medical center reviewers make few recommendations and (2) the
external reviewer’s findings are seldom communicated in writing to the
centers for corrective action. Our review of 44 mortality cases over the
period October 1990 to September 1992 at Springfield showed that the
clinical staff who reviewed the mortality cases limited their review to
BOP'S

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determining whether the death was preventable or not. They did not
address whether the adverse outcomes that occurred were associated with
quality-of-care problems and what corrective action could be taken to
prevent recurrence of the problems. We identified quality-of-care problems
in 12 of these cases. We believe that in these cases, corrective actions
should have been implemented to improve future patient care. The
following example is a case in point:
. A 47-year-old patient was uncooperative upon admission to the psychiatric
unit at Springfield Medical Referral Center in May 1991, making it
impossible for clinical staff to take his medical history or perform a
detailed physical examination. Nursing notes indicated that the patient
was cooperative as of December 1991. The patient saw a physician
assistant on April 14, 1992, with shortness of breath and a high pulse rate.
An electrocardiogram testlo of his heart showed abnormalities and scar
tissue, indicating a previous heart attack. As a result of these fmdings, the
physician assistant referred the patient to a physician for further follow-up
care. On April 16, 1992, a general practice physician saw the patient but
did not perform a complete history and physical or cardiac workup, nor
did he order medications for the patient.
During the next few weeks, the patient’s condition worsened, and he was
seen by a physician assistant on May 21, 1992. The physician assistant
ordered a repeat electrocardiogram, a chest X-ray, and other cardiac tests.
The chest X-ray showed that the patient’s heart had increased significantly
in size and he had an increased amount of fluid in his lungs. The physician
assistant performed a detailed history and physical on the patient on May
22,1992. He believed the patient could be in cardiac failure and notified
the general practice physician. The physician saw the patient that day. But
despite his worsened condition, the patient was not transferred from the
psychiatric unit to the medical acute care unit until May 28,1992. The
patient died of cardiac complications on May 29,1992.
The mortality review committee found that the patient had not received a
cardiac evaluation, but it had no recommendations on this case.
Additionally, it did not comment on the l-year delay in taking a detailed
patient history and conducting a physical examination. These situations
are in violation of BOP policy, which requires that both be performed
within 14 days of admission into a center. Instead, the history and physical
examination were performed on May 22, 1992,7 days before the patient
died. Further, the committee made no recommendations about when a
‘*An electrocardiogram test is perfonned to diagnose cardiac disease and abnormal cardiac rhythms.

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patient should be transferred to a medical acute care unit. The center
should have (1) taken action to assure staff adherence to BOP policy
concerning examining newly admitted patients, (2) developed a standard
operating procedure for when to transfer patients to the medical acute
care unit, and (3) established protocols for closely monitoring patients
with both physical and mental health problems.
The failure of medical center staff to deal with identified quality-of-care
problems was also occurring in the area of clinical privileging.” Our
review of the files of physicians currently employed at the three centers
we visited showed that the physicians were qualified to perform the work
they were assigned. But at Springfield, often no action was taken against
physicians once performance problems were identified. For example, the
patient care practices of two physicians had been repeatedly challenged
by nurses, physician assistants, and the medical services quality assurance
committee from 1990 to 1992. In one case, the medical staff quality
assurance committee recommended that (1) an entry be made in a
physician’s file indicating that he had failed to consult with a specialist to
make a cancer patient’s remaining days more comfortable12 and (2) the
case be referred to the medical executive committee for review. The
medical executive committee concluded that the care provided by this
individual was not “standard of care normally practiced.” The Joint
Commission also had identified a lack of effective pain management of
patients as a problem during its February 1993 accreditation survey of
Springfield.
We found that one of the aforementioned physicians was involved in three
other incidents involving quality-of-care issues. However, no action was
taken to prevent these problems from recurring or to restrict the
physician’s privileges. The physician was still employed and in good
standing at the center.
Butner and Lexington had not identified any performance problems with
their physicians. Fhysicians employed at the three centers we visited all
had appropriate credentials and were educationally qualified to perform
the work they were assigned. Further, we examined the credential files of

Wrivileging is the process of evaluating physicians’ clinical experience, competence, abiity, judgment,
and health status when granting them permission to treat certain illnesses and perform certain medical
procedures.
lZThe cancer had spread throughout the patient’s body, and he was unable to move his extremities. His
primary pain medication was Motrin.

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all physicians at each of these centers and found that
verified all physicians’ credentials.

BOP

personnel had

Lack of sufficient staff to perform quality assurance activities can inhibit
the effectiveness of a quality assurance program. The Lexington Medical
Referral Center had one quality assurance coordinator who was also
responsible for infection control and risk management. In addition, she
was the center’s only anesthetist. These and other duties limited the time
she could give to quality assurance issues. As a result, the quality
assurance programs at this center suffered. For example, our review of
patients’ charts indicated that of 54 inmates who had abnormal
mammograms, 26 left the medical referral center without being informed
that they had an abnormal test result that required follow-up care and
monitoring. We discussed this situation with the quality assurance
coordinator and although staffing was still a problem she immediately
made this a priority and began sending letters to inmates with known
addresses telling them of their abnormal test results. However, when she
performed this duty, work in other quality assurance areas had to be
deferred.
In contrast to the Springfield and Lexington Medical Referral Centers, the
Butner quality assurance program was identifying quality assurance
problems and taking action to resolve them. Quality assurance activities at
this center were used to help center management evaluate the quality of
care provided and identify areas needing improvement. These activities
included studying the effects of specific psychiatric medications, setting
limits on lengths of stay and requiring justification when these limits were
exceeded, and performing random peer reviews of individual cases and
taking corrective action to prevent recurring problems.
Clinical and other staff such as counselors and case managers, work
together to serve as the quality assurance committee, evaluate clinical
indicators, and determine acceptable thresholds for adverse patient
outcomes. Outcomes that exceed established thresholds are reviewed to
identify preventable problems, and corrective action is taken to lessen the
chance that they will recur. In addition, adverse events that appear to be
unpreventable are analyzed, and areas for improvement are identified and
reported to staff in order to minimize future occurrence. For example,
when an inmate died in December 1991 from a cardiac condition, the
Associate Warden for Health Services established a mortality review
committee to investigate his case. The committee found that the patient
could have been evaluated more thoroughJy when he first reported his

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symptoms. The committee indicated that the staff should have continued
close monitoring of the patient even after his condition responded to
treatment. The committee made several recommendations, including
future staff training in identifying and treating impending heart attacks to
prevent similar occurrences.

BOP Plans Major Hospital
Acquisition Program
Without Fully Assessing Its
Needs

recognizes that its health care costs are escalating. Additionally, its
capacity to provide necessary in-house care with existing staff levels is at
risk. Because of recruitment and retention problems, several of BOP’S
medical referral centers have been unable to consistently provide care for
patients’ health needs. Routine care is sporadic, emergency cases must be
transported to outside hospitals and providers, and each of the centers we
visited must contract out all work needed for most specialties. To help
cope with this situation, BOP is planning a major hospital acquisition
program for each of its six regions. Under this program, BOP plans to either
construct new hospitals or acquire closed military hospitals. But BOP has
not fully assessed whether inmates’ medical needs justify this acquisition
program nor has it planned how to recruit and retain the clinical staff
necessary to operate these facilities. Further, BOP has not fully explored
cost-effective alternatives to providing necessary medical care to inmate
patients.
BOP

In fBcal year 1992, BOP spent $68 million on care provided in community
facilities, including $12.7 million for correctional officers to escort patients
to and from outside medical appointments. This represents an increase of
$14.5 million over the amount paid in fiscal year 1991 for outside care. But
BOP did not maintain sufficiently detailed accounting records to inform
management about the extent and the types of care they were acquiring
under contract. In 1992, BOP’S Medical Division proposed awarding a
contract to a private consultant to determine the extent of its outside
medical needs and costs. This proposal was not approved because BOP’S
Executive Committee determined that funds were not available. As a
result, BoP cannot accurately plan for the future medical needs of its
inmate population.
has not fully determined its medical needs. In fact, in 1989, a
consultant hired by BOP concluded that BOP did not have a well-defined
medical mission and had not measured inmates’ needs for clinical
services.
BOP

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i

B-249967

Despite this lack of data, BOP is considering acquiring several new
hospitals to care for its patients. One option being considered is to build
an acute tertiary care hospital in each of BOP’S six regions. Each hospital
would have 500 beds and cost about $100 million to construct and equip.
Currently, ESOPhas received funding for one new hospital in Butner, North
Carolina, to replace the current hospital there.13 As an alternative to
building the remaining five acute tertiary care hospitals, BOP is trying to
acquire selected closed military hospitals and use them for its own health
care needs. BOP officials told us that they have acquired the hospital at Fort
Devens in Massachusetts and hope to obtain hospitals at Carswell Air
Force Base in Texas and at March Air Force Base in California. However,
it is unclear what services BOP will provide at these hospitals and how it
will staff them.
In our view, an aiternative to hospital construction or acquisition that BOP
could consider is to acquire medical services that it cannot provide from a
source outside the prison system. At least 15 states provide all or part of
their health care to inmates through private contractors. For example, in
October 1992, the Missouri Department of Corrections entered a contract
with a private contractor to provide health care for its 14,000 or more
inmates. This approach was taken because the state could not recruit
sufficient numbers of medical staff to provide necessary care within the
prison system. Missouri’s Health Services Assistant Director told us that
contract care assures the department that certain staffing levels will be
consistently ma.Wained and that physicians will provide inmates with
needed treatment and periodic examinations. Before this decision,
Missouri was encountering stafZing problems similar to that of BOP’S
hospital in Springfield, Missouri. In 1992, the contractor began providing
all health care for about $1,336 a year per patient (about 14,000 inmates)
or $18.7 million.14 In comparison, EIOP spent about $2,500 a year for each
inmate in 1992 or $198 million. Another option that BOP could consider is
telemedicine. This consists of using electronic voice, video, and data
transmission technology to allow consultant physicians to advise on-site
clinicians on patient treatment. For example, a cardiologist could review
electrocardiogram results to determine whether a patient’s cardiac
condition warrants emergency treatment. Using this technology, BOP could
reduce consultant costs, increase available professional resources, and
eliminate the need for escorting an inmate to an outside provider or health
‘3Butner’s current medical beds will be used for chronic patients who require minimum care or those
who no longer need medical care.
“If Missouri’s number of inmates exceeds 14,000,the cost for each additional inmate is about half of
the base cost

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care facility. BOP could also use this technology to link medical staff in its
medical referral centers with clinical providers in its other correctional
facilities. This would provide timely assessments and treatment plans and
reduce unnecessary transfers of inmates whose conditions are not serious
to the medical referral centers or to outside hospitals.
I

Conclusions

To assure that it operates an efficient, effective medical program for its
inmate population, BOP needs to determine (1) what the health care needs
of its inmate population will be over the next 5-10 years, (2) what in-house
services it should provide to its inmate patients, and (3) how it will obtain
the employed or contracted staff needed to provide medical services. But
BOP has not planned for the future medical needs of its patient population
or fully evaluated all cost-effective alternatives for providing necessary
medical care. Thus, in our view, BoP’s current concentration on acquiring
or constructing new hospitals needs to be reevaluated.
Currently, BOP does not have the capacity to provide appropriate medical
and psychiatric care to inmates at the three centers we visited because it
has been unable to recruit and retain qualified health care staff. Further,
staffing shortages at these medical referral centers are chronic and show
no signs of improving. This, in turn, adversely affects quality assurance
programs, which rely on staff support for effective implementation. In
addition, physician assistants, who are relied upon to provide a significant
amount of primary care to patients, are not as well trained or supervised
as they should be. As a result of these problems, patients are and will
continue to be at risk of receiving poor care.

Recommendations

We recommend that the Attorney General require the Director of
the following:

BOP

to do

. Prepare a needs assessment of the medical services its inmate population
requires and determine what medical services it can efficiently and
effectively provide in-house.
9 Determine the most cost-effective approaches to providing appropriate
health caSe to current and future inmate populations.
l
Revise BOP hiring standards for physician assistants to conform to current
community standards of training and certification.
l
Reemphasize to the wardens of medical referral centers the importance of
taking corrective action on identified quality assurance problems.

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Agency Comments
and Our Evaluation

In a letter dated December 10, 1993, the Assistant Attorney General for
Administration, Department of Justice, stated that BOP found our report to
be informative and comprehensive. However, he also stated that BOP
strongly disagrees with our conclusion that BOP does not have the capacity
to provide appropriate medical and psychiatric care to the inmate
population at the three centers we visited. BOP believes that while more
staff and more resources to provide health care are desirable, it is
providing quality care consistent with community standards with the staff
it has at its disposal.
Despite its objection to our conclusion about the care it is able to provide
to inmates in the facilities we visited, BOP agreed with our specific findings.
Further, the Assistant Attorney General stated that action will be taken on
two of our four recommendations. BOP believes that the intent of our
remaining two recommendations is being dealt with through existing
systems and plans. (See app. V.)
disagreement with our conclusion is not justified by the facts. BOP
acknowledges that it has not been able to recruit and retain sufficient
medical staff to adequately staff the three medical referral centers we
visited. Further, it agrees with our tindings that there are (1) insufficient
nursing staff at each of the centers visited; (2) insufficient numbers of
psychiatrists at the Springfield and Lexington centers; and (3) female
inmates in Lexington who were not receiving timely pelvic examinations
and Pap tests upon incarceration because of staff vacancies in positions
for a gynecologist, physician assistants, and nurses. In his response to this
report, the Assistant Attorney General further stated that BOP has difficulty
in recruiting all ranges of professional staff in the Lexington area because
of its inability to compete with salary ranges offered by community-based
organizations. Each of these conditions form the basis for our conclusion
that BOP does not have the capacity to provide appropriate medical and
psychiatric care to the inmate population at the three centers we visited,
BOP’S

In responding to our recommendation that BOP needs to prepare a needs
assessment of medical services that its inmate population requires and
determme what it can effectively provide in-house, the Assistant Attorney
General stated that BOP has developed a comprehensive data collection
and utilization management system to plan for future medical referral
center needs. In his opinion, this system is growing in sophistication and
will give BOP the capability to determine its health care needs. Thus, in his
opinion, our recommendation has been satisfied. We disagree. BOP’S
system does not provide the type of information needed to make decisions

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B-249967

on what services can be efficiently and effectively provided in-house. Such
data would include information such as an inmate’s condition and the type
and amount of medical care the patient needs. Without this information
BOP cannot accurately determine appropriate staffing needs, and such
information is necessary to determine the extent to which care can be
provided in-house.
The Assistant Attorney General also stated that the intent of our
recommendation that BOP determine the most cost-effective approaches to
providing appropriate health care to current and future inmate populations
is being met through BOP’S Long Range Medical Facilities Plan. This is
partially true. According to the facilities plan, the medical referral centers
will contract with outside services for as many technologically advanced
procedures as possible, consistent with custody and cost considerations.
However, we also believe that BOP should be considering contracting out
when it cannot provide basic services effectively. In its long-range plan,
BOP states that its medical referral centers will, at a minimum, provide
such basic services as obstetrics, gynecology, a.nd cardiology. But we
found that BOP does not have sufficient staff to provide in-house the basic
services required by the facilities plan. In its planning, BOP must recognize
that this problem exists and develop appropriate alternatives. Thus, we
believe that our recommendation needs to be given further consideration.
The Assistant Attorney General did address one aspect of the contractmg
out issue. Specifically, he cited a May 1990 study by Abt Associates that
concluded that privatization of medical referral centers was not feasible
from either a management or cost-effectiveness perspective. But
privatization of medical referral centers is only one aspect of the
contracting option we are recommending that BOP consider. We believe
that BOP should explore the pros and cons of contracting out any element
of medical care that cannot be effectively provided within its medical
referral centers. In this respect, the Abt findings are similar to our findings.
Abt concluded that contracting out of certain elements of medical care
may in fact help relieve a center’s inability to achieve full staffing levels.
Abt also concluded that fully staffing the Lexington and Springfield
centers, by means of either contracted or government employees, will
probably enhance the treatment of medical/surgical patients at these
facilities.
The Assistant Attorney General agreed with our recommendations that
(1) BOP’S hiring standards for physician assistants be revised and
(2) corrective actions on identified quality assurance problems be

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reemphasized to the wardens of medical referral centers. In both areas,
BOP agreed to take corrective action to resolve the problems.
Unless you publicly announce its contents earlier, we plan no further
distribution of this report for 30 days. At that time, we will send copies to
the Attorney General and the Director of BOP and interested congressional
committees, We also will make copies available to others upon request. If
you have any questions regarding this report, please contact me at
(202) 512-7101, Mdor contributors to this report are listed in appendix VI.
Sincerely yours,

David P. Baine
Director, Federal Health Care
Delivery Issues

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Contents

1

Letter
Appendix I
Objectives, Scope,
and Methodology

26

Appendix II
Butner Medical
Referral Center

Mission of Referral Center
Location and Condition of Facility
Number of Inmates and Patients Served
Number and Type of Medical Beds
Number and Type of Staff Positions Authorized and Filled
Staff Organization

28
28
28
28
29
29
29

Mission of Referral Center
Location and Condition of Facility
Number of Inmates and Patients Served
Number and Type of Medical Beds
Number and Type of Staff Positions Authorized and Filled
Staff Organization

31
31
31
31
31
31
32

Mission of Referral Center
Location and Condition of Facility
Number of Inmates and Patients Served
Number and Type of Medical Beds
Number and ‘Qpe of Staff Positions Authorized and Filled
Staff Organization

33
33
33
33
33
33
34

Appendix III
Lexington Medical
Referral Center

Appendix IV
Springfield Medical
Referral Center

Appendix V
Comments From the
Director, Federal
Bureau of Prisons

35

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Contents

Appendix VI
Major Contributors to
This Report
Figures

Figure 1: Psychiatrist Staffing at Three BOP Centers
Figure 2: Physician Assistants With and Without Credentials at
Six BOP Medical Centers

7
13

Abbreviations
AIDS
AMA
BOP
JCAHO
OPM

PA
PHS
RN

VA

Page 26

acquired immunodeficiency syndrome
American Medical Association
Bureau of Prisons
Joint Commission on Accreditation of Healthcare
Organizations
Office of Personnel Management
physician assistant
US. Public Health Service
registered nurse
Department of Veterans Affairs
GAOIEEHS-94-96 BOP: Inmates’

Accessto Health Care

Appendix I

Objectives, Scope, and Methodology

In a letter dated March 23, 1992, the Chairman of the Subcommittee on
Intellectual Property and Judicial Administration, House Committee on the
Judiciary, requested that we investigate the medical care provided to
federal inmates to determine whether (1) quality of care problems were
widespread and (2) the Bureau of Prison’s medical delivery system,
including its quality assurance program, was functioning well. After
consulting with Subcommittee staff, we agreed to focus our review on the
following four issues:
l

l

l

l

Are inmates with special medical needs-including women, psychiatric
patients, and inmates with chronic medical conditions-receiving
the care
they need?
Are BOP physicians and other health care providers qualified to perform
the services they are assigned?
Does BOP have quality assurance systems in place that detect problems
with health care, and is corrective action taken to prevent similar
problems?
Are alternative approaches available to meeting inmates’ medical needs?
To follow up on allegations of problems with BOP health care, we reviewed
files of correspondence sent to the Subcommittee from inmates and their
friends and relatives, reports and other documentation prepared by the
Joint Commission on the Accreditation of Healthcare Organizations and
the American Correctional Institute, a transcript of a 60 Minutes televikion
program on BOP’S medical care for inmates, and inspection reports
prepared by the Offices of Inspector General for the Departments of
Justice and Health and Human Services who reviewed BOP facilities. We
also interviewed a reporter from the Dallas Morning News who wrote a
series of articles on the quality of medical care provided by BOP.
To identify and evaluate BOP policies and procedures governing the
medical care provided to inmates, we visited BOP’S central office and its
regional offices in Annapolis Junction, Maryland, and Kansas City,
Missouri, At BOP’S central office, we interviewed officials from the Medical
Division, the Administrative Division, the Program Review Division, and
the Office of General Counsel. We also reviewed documents related to
health care budget and costs, consultant reports concerning current and
future health care operations, and plans for constructing new BOP
hospitals. At the regional offices, we interviewed regional health services
administrators and reviewed reports submitted by medical referral centers
as well as those prepared by regional staff on the results of their
evaluations of medical referral centers.

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Appendix I
Objectives, Scope, and Methodology

To assess the quality of the health care delivered to patients with special
needs, actions taken on identified problems, and the effectiveness of
quality assurance programs, we met with the wardens; medical, surgical
and psychiatric physicians; nurses; technicians; and other health care staff.
We also met with correctional and administrative employees at medical
referral centers in Butner, North Carolina; Lexington, Kentucky; and
Springfield, Missouri. We reviewed documents related to budget and costs,
staffing, quality assurance plans, pharmacy operations, laboratory
operations, and inmate complaints. In addition, we reviewed minutes of
meetings of the following center committees: medical executive, medical
staff, quality assurance, infection control, nursing, utilization management,
and pharmacy. We also reviewed selected documents from the other four
medical referral centers.
To determine if the qualifications of medical staff to perform assigned
work were being properly evaluated, we interviewed cognizant staff and
reviewed the credentialing and privileging files of physicians and physician
assistants. We determined whether the centers had verified physicians’
and physician assistants’ educational and professional credentials and
whether quality assurance data were present in the providers’ files at the
time privileging decisions were made. We also reviewed any actions taken
when problems were identified.
To evaluate care provided to inmates with special needs, such as chronic
or psychiatric conditions, we reviewed selected patient files of inmates
who died between October 1,1990, and September 30,1992. We also
reviewed files of selected female inmates who had abnormal results on
either their Pap tests or mammograms. We then discussed these cases
with cognizant staff.
We performed our work between April 1992 and August 1993 in
accordance with generally accepted government auditing standards.

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Appendix II

Butner Medical Referral Center

Mission of Referral
Center

The primary mission of the Bureau of Prison’s medical referral center at
Butner, North Carolina, is to provide psychiatric diagnostic and treatment
services to male inmates with minimum to medium security
classifications. The patients being treated have either been convicted of a
crime or are categorized as forensic. Forensic patients have been accused
of crimes and were referred to Butner to determine if they are mentally
competent to be tried in a federal court.
In addition to psychiatric care, the Butner staff and consultants also
provide inmates with outpatient medical care. Inmates who develop acute
medical conditions that require inpatient care are transferred to other BOP
medical referral centers or to a community hospital.

Location and
Condition of Facility

The Butner federal correctional institution opened in 1976 as a psychiatric
referral center. The eight housing buildings are small, open units, which
are mostly unlocked during the day, allowing considerable intermingling
of patients, other inmates, and staff.
One of the buildings housing mental health patients contains a seclusion
admission area with an officers’ station, 10 standard individual cells, 6
double cells, and 4 observation cells. These latter cells have large windows
that allow observers to continually observe the occupant and are used
mainly for patients considered to have the potential to commit suicide.
Because these patients must be watched 24 hours a day (with observation
notes written and initialed every 15 minutes), Butner uses inmate
“companions” to observe the potential suicide patients. These companions
are inmates who have been screened and trained for this work, and a
psychologist supervises them. The remaining three buildings contain open
housing for psychiatric patients, the outpatient clinic, and health care
offices.

Number of Inmates
and Patients Served

In July 1993, the Butner correctional facility housed approximately 800
male inmates. Of these inmates, 180 were mental health inpatients, about
100 were in a substance abuse program, 24 were in the sex offender
treatment program, 20 were in outpatient therapy for sex offenses, and 50
were in outpatient psychiatric treatment. At that time, about 300 inmates,
including some of the mental health patients, required medical care for
chronic medical conditions, such as diabetes, hypertension, cardiac
conditions, or outpatient psychiatry. They were seen in monthly clinics on

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Appendix II
Bntner Medical Referral Center

an outpatient basis by physicians and physician assistants. The medical
staff also served an adjacent BOP camp housing 250 inmates.

Number and ?sTpeof
Medical Beds
Number and Qpe of
Staff Positions
Authorized and Filled

tiStaff Organization

the Butner medical referral center as a MO-bed forensic inpatient hospital.

positions, including 9 psychiatrists, 4 medical physicians, 1 optometrist, 2
forensic fellows,i6 8 physician assistants, 15 nurses, 2 dentists, 2
pharmacists, 5 psychologists, 1 quality assurance coordinator, 5 medical
records staff, 17 clerical staff, and 20 other health care staff. Nine
positions were vacant, including a medical physician, 2 psychiatrists, a
psychologist, 2 nurses, a dental assistant, a physician assistant, and a
vocational rehabilitator.

health care staff plus other staff who work in units housing psychiatric
patients. This arrangement differs from other BOP organizational
structures, where psychologists, unit and caSe managers, and counselors
report through chains of command other than health services. The
Associate Warden believes that this integration of psychiatric medicine,
physical medicine, and unit management helps ensure commonality of
purpose, reduces communication problems, and improves patient
progress.
Butner uses a team approach to patient care. Each patient is assigned to a
psychiatrist and a psychologist who write progress notes daily for
seclusion patients, weekly for assessment and short-term patients and
monthly for long-term and management cases. In addition, each seclusion
patient meets weekly with the treatment services teams, consisting of
psychiatrists, psychologists, a nurse, the recreation therapist, a social
worker, and case managers.
Generally, the doctors and psychologists work the 7:30 a.m. to 4:00 p.m.
shift, although at least one doctor usually works to about 9:00 p.m. In
addition, at least one physician works Saturday and Sunday day shifts.
16Forseveral years, Butner has employed psychiatrists and psychologists in their last year of residency
as ‘fellows” in their specialty. This program helps augment its staff, advertise the center in a positive
manner, and recruit permanent staff, As of July 1993,Butner had 2 forensic fellows working in the
center and counted as part of their authorized positions.

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I

Appendix II
Butner Medical Referral Center

,

.Further, one psychiatrist is always on call. At a minimum, one physician
assistant and one nurse cover the four mental health buildings on the
midnight to 8:OOa.m. shift.

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/,
/
!

/
!
z

Appendix III

Lexington Medical Referral Center

Mission of Referral
Center

The medical referral center at Lexington, Kentucky, provides primary
medical and surgical care; chronic and hospice medical care; and acute,
diagnostic, and chronic psychiatric care exclusively to female inmates.
Care is provided for seriously ill patients, and most surgeries and all births
take place in community hospitals.

Location and
Condition of Facility

The federal correctional institution at Lexington, Kentucky, consisting of
several two- and three-story buildings surrounded by a wire fence, was
designated as a medical referral center in 1990. The buildings were built
around 1934 and are currently in need of repair and renovation. One
building contains most of the medical facilities, including the inpatient
medical and psychiatric units, outpatient clinics, laboratory, pharmacy,
dental clinic, and operating suite.

Number of Inmates
and Patients Served

The Lexington correctional institution houses 1,954 female inmates. The
center has a 22-bed acute care unit with an average census of 15. This unit
also has a recovery and stabilization room, and 24-hour nursing and
physician assistant coverage. A physician is on call after hours. Patients
requiring chronic care are housed in two extended care units, one with 176
beds and the other with 316 beds. Neither unit has nursing coverage. The
mental health unit consists of 34 acute care inpatient beds and a go-bed
transitional unit for mental health patients. The transitional unit does not
have nursing coverage. In addition, the center has 34 obstetric beds.
assigns all inmates with complicated pregnancies to Lexington for
prenatal care. These patients are transferred to the University of Kentucky
hospital once labor begins to ensure that babies are not born within a
prison. Lexington also transfers other patients to community hospitals for
medical and surgical care that Lexington is not staffed to provide.
BOP

Number and Qpe of
Medical Beds

The Joint Commission on Accreditation of Healthcare Organizations rates
Lexington as a 56-bed medical, surgical, and psychiatric hospital.

Number and Type of
Staff Positions
Authorized and Filled

In July 1993, Lexington was authorized 126 health care staff, including 8
physicians (one of which is a cIinicaI director), 4 psychiatrists, a surgeon,
43 nurses, 12 physician assistants, 4 dentists, 4 pharmacists, 3
psychologists, 10 medical records staff, and 37 other clinical staff. At that
time, 32 positions were vacant, including 3 medical physicians (one is the

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Appendix III
Lexington Medical Referral Center

clinical director and the other two are the obstetrics and gynecology
physicians), 1 psychiatrist, 14 nurses, 1 physician assistant, and 13 other
health care staff. The following specialists were working at Lexington
during this time: 1 family practitioner, 2 general practitioners, 2 internists,
1 surgeon, and 3 psychiatrists.
Physicians generally work from 7:30 am. to 4:00 p.m., ahhough a physician
is on call 24 hours a day. A physician assistant acts as the duty officer each
day, responding to calls 24 hours a day throughout the facility.
The facility uses psychology interns from the University of Kentucky and
Public Health Service nursing students who are in their last year of nursing
school. The latter are used as nurses’ aides.

Staff Organization

All health care staff report to the Associate Warden for &nical Programs;
Lexington does not have an Associate Warden for Mental Health Services.
Staff who provide nonmedical inmate services, such as tit managers,
case managers, and counselors, report to the Associate Warden for
Programs, although they meet regularly with health staff to discuss
inmates’ progress.

Page 32

GtOlHEHS-94-36

BOP: Inmates’ Accew to Health Care

Appendix IV

Springfield Medical Referral Center

Mission of Referral
Center

The U.S. Medical Center for Federal Prisoners in Springfield, Missouri, is
one of the Bureau of Prisons’ six referral centers that treat male medical,
surgical, and mental health patients.

Location and
Condition of Facility

The Springfield Medical Referral Center is an administrative facility,
meaning it is equipped to house inmates of all security levels. It was built
about 1933. Inmates live in six connected buildings, each of two or three
stories. The medical facilities are concentrated in four of the six buildings.
The acute and chronic care medical and surgical patients are housed in
units that resemble typical hospital rooms, except that several rooms in
each unit have locked doors. These locked cells are used for patients who
are (1) dangerous to staff or other inmates, (2) participating in the federal
witness protection program, or (3) waiting for their custody status to be
determined. The mental health patients are housed in units that resemble
typical prison cell blocks with one-man cells. Springfield also has a unit
that can contain up to 37 inmates in individual locked cells for disciplinary
or protective reasons.

Number of Inmates
and Patients Served

Springfield serves approximately 1,120 inmates, including 439 patients
who require medical or surgical care and 294 who need psychiatric care.
The medical and surgical care is provided to about 46 acute care patients,
54 patients receiving renal dialysis, and 393 other chronic or recovering
patients. The mental health population includes 177 treatment patients and
117 forensic inmates who are being evaluated for their mental ability to
stand trial.

Number and 137peof
Medical Beds

The Joint Commission on Accreditation of Healthcare Organizations rates
Springfield as a 46bed acute care and 177-bed mental health hospital.

Number and l)pe of
Staff Positions
Authorized and Filled

In July 1993, Springfield had 279 authorized health care positions,
including 5 psychiatrists, 15 medical/surgical physicians, an optometrist,
12 physician assistants, 127 nurses, 9 pharmacists, 12 psychologists, 6
quality assurance staff, 10 medical records staff, and 82 other health care
staff. At that time, 18 positions were vacant, including 3 medical
physicians, a surgeon, a psychiatrist, a physician assistant, 10 nurses, 1
medical reCords staff, and 1 other health care staff. The following
specialists were working at Springfield: 3 general practitioners,

Page 33

GAO/HEHS-94-36 BOP: Inmates’ Access to Health Care

Appendix IV
Springfield Medical Referral Center

4 psychiatrists, 2 internists, 2 neurologists, 1 physiatrist, 1 anesthesiologist,
1 orthopedic surgeon, and 1 chief of health programs.
Physicians and physician assistants are available 24 hours a day. However,
physicians generally work from 7:30 a.m. to 4:00 p.m. During the evening
and night shifts and on weekends, one physician, one psychiatrist, and one
psychologist are on call. Physician assistants are available in the facility 16
hours a day. Nurses are responsible for medical care between 10:00 p.m.
and 6:00 a.m. Nursing service is provided 24 hours a day.

Staff Organization

The Associate Warden for Medical Services supervises most of
Springfield’s health care staff, including nurses and technicians. The
Clinical Director is responsible for the internal medicine physicians,
psychiatrists, surgeons, dentists, physician assistants, the quality
assurance coordinator, utilization manager, and infection-control
practitioners, The Associate Warden for Mental Health Services is
responsible for the psychologists and social workers who work with the
mental health patienti.

Page 34

GAOIHEHS-94-36 BOP: Inmates’ Access to Health Care

Appendix V

Comments From the Director, Federal
Bureau of Prisons

U.S. Department of Justice

Federal Bureau of Prisons

W&in~ron.

DC 20¶34

December 10, 1993
David P. Baine
Director,
Federal Health Care
Delivery
Issues
Human Resources Division
U.S. General Accounting Office
Washington, D.C. 20548
Dear Mr. Baine:
The following
information
is being provided in response to your
requeet to the Attorney General, dated November 9, 1993, for
comments on the General Accounting Office
(GAO) draft
report
"Bureau of Prisons Health Care: Irnnates~ ACCCBS to
entitled,
Health Care Is Limited by Lack of Clinical
Staff."
The GAG
(BOP)
evaluated the adequacy of the Federal Bureau of Prisons'
medical servicee and the effectiveness
of it8 quality
aB8urance
This review afforded the BDP the opportunity
of having
program.
another external
evaluation
of its delivery
of healthcare
services to a incarcerated
inmate population.
Many of these
inmate patients
frequently
begin their incarceration
in the BOP
with significant
physical
and psychiatric
diseases, many timee aa
a result of unhealthy behaviore such as drug abuse, alcoholism,
high-risk
sexual behavior and violence.
Specifically,
GAO
reviewed the following
four iasues:
l

0
l

a

whether

inmates with special medical needs are receiving
the
need;
whether BOP has quality
assurance programs to detect
problems with healthcare
and take corrective
action to
prevent similar
robleme;
whether BOP phys P cians and other healthcare
providers
are
qualified
to perform the services they are aesi ned;
whether BOP ia considering
the moat cost-effect
4ve
alternativea
to meet the rising needs of inmates for medical
eervfces .
care

they

The GAO toured and reviewed three of seven Medical Referral
Centers (MRC) of the Bureau.
The Bureau MRCs provide inpatient,
outpatient,
psychiatric,
chronic,
and tertiary
care to
approximately
78,000 inmates housed in 71 correctional
facilities
throughout
the United States.
All Beven of the Bureau MRCs are
of
fully
accredited
by the Joint Commission on Accreditation
Healthcare Organizations
(JCAHO). The GAO vieited
the Federal
Medical Center (FMC) at Lexington,
Kentucky; the Federal
Correctional
Inetitution
(PC11 at Butner, North Carolina;
and the
Medical Center for Federal Prisoners
(MCFP) at Springfield,
Missouri.

Page Et6

GAMIEAS-9436 BOP: Inmates’ Access to Health Care

AppendixY
CommentaFromtheDirector,
3ureauofPrisons

Federal

2

Mr. David P. Baine
Seep. 21

BOP found the draft report to he informative
and comprehensive.
disagreea with the eneral finding
of GAO
However, BOP strongly
that it currently
doee not have the capac 9 ty to provide
appropriate
medical and peychiatric
care to the inmate
GAO bases its determination
on ite belief
that the
population.
alified
healthcare
BOP hae been unable to recruit
and retain
lim 9"rations,
the POP
Within the context of resource
staff.
continuouely
and carefully
balances the resources it allocates
to
each of ite programs to achieve it6 overall,
coordinated
mi89iOn
While in an ideal setting more etaff and
of care and custody.
more retaources to provide healthcare
ia deairable,
BOP believes
that it is rwiding
quality
care coneistent
with conrnunity
It recpaste that GAO
etandarde wPth the resources available.
modify ita draft report conaietent
with the faatr providad below.
a Re Meet-

Mt?dlGal Needs of IMIzrtes

The GAO draft report identified
that inmatee with special needs,
including
women, peychiatric
patienta,
and patients
with chronic
illneesee
are not receiving
all of the healthcare
they need at
the three MRCe visited.
See p, 4.

GAO stated that famala patientm at FMC Lexington axe not
receiving
timely palvic examinatiam
and PAP teeta upon
incarceration.

By policy,
BOP requires pelvic examinations
and PAP tests on
atiieeion.
However, as noted in the GAO Report, during the
period of the DA0 review, these teete were not being done in a
timely manner due to a lack of etaff.
The staff vacancfee were
of physician
gynecologiets
and physician
in the professions
aseiatante,
as well aa nuf0ea.
BOP agrees with this finding
for
the period of the GAO review.
The BOP has had staff shortages at FMC Lexington,
and during
these periode of shortages the number of procedures bein
performed fell behind.
However, the Bureau recently
ass 9 gned an
additional
20 poeitione
to R-K Lexington,
and ae of September 31,
1993, only 18 of 120 healthcare
positions
at FMC Lexington were
vacant.
In spite of Federal salary limits,
BOP is still
able to
maintain a quality
staff
who care about the inmatea and their
problem.
It ie difficult
to find potential
applicants
who are
willing
to work for lese compeneation, and reepect the human and
medical rights of the inmate population.
Additionally,
the BOP
hae difficulty
recruiting
all ranges of professional
medical
staff due to it8 inability
to compete with salary rangee offered
by community baeed organizations.
For example, the average
starting
salary offered in the conrmunity to phyeician
assistants
ie 40 to 60 percent higher than in the BOP.

Page36

GAO/HEHS-94-36BOP: 1nmates'AccesstaHeak.h Care

Appendii V
CommentsFrom the Director,Federal
BureauofPrisons

3

Mr. David P. Paine
See p. 5.

GhO stated
that many psychiatric
patient8
at the MCPP
8pringUrld
and FHC Luington
#RC8 are not receivfng
rqu~arly
Lack of admquata
l chmduled individual
mnd group tharapimm.
paychirtrint
and pmychiatrie
nut8ing pomitionn warn identified
aa the cause of thim dmffciancy.

The GAO used an "ideal"
GAO's atatement ie not entirely
correct.
inmate psychiatric
practitioner
ratio of 25 to 1 proposed by the
Chief Peychiatriet,
BOP. However, they applied thie ratio based
only on the psychiatrist
poeitione
without regard for the acuity
level or the type of illness
involved.
The BOP employs an extensive
team approach to treating
mental
health patients,
involving
not only psychiatrfets,
but
psychiatric
nursee, social workers, medical nurses,
correctional
couneelore,
case managera,
peychologiete,
While this team approach is
correctional
etaff,
and chaplaine.
consistent
with the conununity mental health model, the GAO
correctly
noted an insufficient
number of peychiatriets
at the
MCFP Springfield
and PZ4CLexin ton MRCs. The BOP continue0 to
actively
recruit
for
these pos 9tions.
See p. 9.

WO ateted

that 'em.
lrmutmm with chronia
condition8
The QAQ intwptatm
follow-up
follow-up
aare.
by a aura* in a chroda arm unit.
a8 monitoring
receiving

are not

care

The BOP policy on chronic care monitoring
is specific
and
appropriate.
All chronic care patienta
are identified
upon
incarceration
or upon development of a chronic disease.
Once
identified,
inmates are regularly
scheduled in chronic care
clinics
which are held at least four time6 per year.
Additional1
inmatee have access to healthcare
professionals
on
and as needed on an
a daily baa X'a through eick call. visits
emergency basis 24 hours a day.
BOP believes
it exceeds the community standard.
Chronic care
patients
in the community are treated at their physicians'
office6
or through hospital-baaed
outpatient
facilities
while
continuing
to live in their homes. Patient0 in the coramunity
report to their physician
provider
as needed for treatment of
chronic lllneeeee.
Twenty-four
hour nureing staff coverage to
monitor chronic care patients
ia neither a conmunity standard nor
cost effective.
As noted above, BOP policy requires those inmates identified
as
having chronic care condition6
to be evaluated by a ph sician at
least four time6 a year.
BOP agrees with the GAO find 1 ng that
at FMC Lexington and WFP
not all chronic care patients
Springfield
were monitored according
to policy.
BOP continually
tracks inetitution
data and ataff
to ensure chronic care patients
are monitored at least four times a year.
Due to etaffin
COnStraintE,
BOP is not alwaye able fully
to comply with f ta
policy.
However, theee patiente
have the capability
and
reaponaibility
to request follow-up
care ae needed, consistent

Page37

GAO/HEHS-94-36BOP:Inmates'AccesstiHeaIthCare

Appendix V
Commennts From the

Director, Federal

Bureau of Prisons

-

4

Mr. David P. Baine
with
Seep. 7.

the community standard.
Tha ON2 #tat*8

that

thmra i8 inaufffcieat

nurring

staff

at

the

#RCm.
Each MBC utilizes
a different
BOP concurs with this finding.
classification
system in evaluatin
its nursing requiremente.
A0
a result,
the MBCs are utilizing
d9 ffering
parameters in
In addition
to the recruitment
determining
their needs.
difficulties
already noted, the Bureau needa to reevaluate
its
nurse staffing
practices
throughout BOP. ey doing 80, nurse
managed.
The
utilizatian
can be coordinated
and more effectively
firet
step of the Bureau in addreesing this ieeue will be to
develop or acquire a standard patient
care classification
aystem
for all MRCe. This will result in a staffing
aystem based upon
inmate healthcare
needs and not Fnmtitution
qtaffing patterna.

Seep. 10.

MO Hxted
infaation

clarification

that

the three YRCa varied
ia their
QAO providu
no explanation
of that aaurtioa.

aontrol.

approach
QL

to

Th; B&has

always had an infection
control policy
in place for
Thie olicy is compreheneive and continually
updated
in conjunction
w9 th the ret-ndatlone
made by the Center6 far
Disease Control and Prevention
(CDC). As each inetitution
has
different
miseions and inmate populatione,
the implementation
of
the CDC guidelinea
and recomnendatione
will also differ
from
Institution
to institution
according to local
needs. GAO did not
identify
any deficienciee
in the overall
infection
control
program of the Bureau or in the implementation
of these policies
by the MRCe.
See p. 14.

[uo mtated that of thm thraa ICRCmwXy BCI Butner ha# a
quality
l 8muranco program
in plaera that im addrauinq
quality
l uuranca
problem8.
At NCIP Springfield,
GAO mtatu
neithw
the phyrlaimm
nor other healthcrre
pro-Adore are accepting
re@pon~ibility
for the problw
identifiad
by thair quality
l sruraskc~
perrfxuml.
Q&o rtetu
the rm800
for thi8
lack
of
involvement
on the part of hulthcara
staff is uudrrrtaffing.
QAO dtu
two inmate deatha,
OM at NCBP Springfield,
thm
other et FHC Lexiogton,
that allegedly
resulted
from
underr trf fing.
MCPP Sprin field and FMC Lexington,
ae well as PC1 Butner, have
comprehene ve qualit
aeaurance programs in place.
The JCAHO
evaluated 9the effect x veneas of these programs in February and
March 1993 and found them to be in eubstantial
compliance with
JCABO standards.
However, YCAHOdid identif
aoma deficienciee
at WFP Springfield
anb F'MCLexington in med 1 Cal etaff monitoring
of certain patient
care c
nente such au radiology
and mr ezy.
Both inntitutione
have eubm
plane of action 9n
T tted corrective
response to these deflcienciee.
Lastly,
both institutions

Page38

GAO/HEHS-94-36BOP: IInmates AcceeatoHealth Care

Appendix V
Commentu From the Director, Federal
Bureauof Prisons

5

Mr. David P. Baine
received

full

JCAHO accreditation.

Additionally,
in May 1992, prior to the QAO review, a coneultins
team visited
MCPP Springfield.
at the invitation
of the Warden,
to provide
direction
for rertructuring
the quality
aaaurance
WFP Springfield
redeeigned ite
program at that institution.
quality
assurance program and utilized
the expertiee
of the
consulting
team to refine the program.
review
findinga
iB to
Bureau procedure for disseminating
external
tranmit
to the Regional Director
a written
notice of any
At the @ametime, a tranenittal
is eent to the
deficienciee.
Warden at the MRC for appropriate
consultation
with the Region.
The Regional Directors
are responsible
for eneurin
apYopriate
GAO hae appropr 1 ate
y noted
corrective
action baa been taken.
Therefore,
BOP is
the occarrional deficiencies
of thi6 system.
reutnacturing
its quality
assurance notification
and review
(follow-up)
process.

The K!cpP S ringfield
case involving
the death of a psychiatric
inmate wit R medical probleme ~au evaluated by an external
medical
The QAO concurred with the
consultant,
prior to the GAO review.
finding0
of the conrultant
of BOP, that this cane wa6 incorrectly
recognized the quality
medically
managed. WFP S ringfield
with th Pa case and instituted
corrective
assurance problems
Specifically,
MCFP
actione to prevent further
occurrencee.
Springfield
counseled and monitored the phyeician
in queetion,
and implemented a eyetem of
increased
the level
of staffing,
medical and peychiatric
duty officers.
The F'PICLexin ton case involved an inmate with chronic medical
by the BOP and waa reviewed
problemm. Th 9 8 case was identified
by the Bureau'm external
reviewer
prior to the GAO etudy.
The
external
reviewer Indicated
an inappropriate
level of care wan
provided.
However, there wae no method to verify
whether the
unavailability
of reaourcea affected
the longevity
of thie
patient.
Aa reeult of this case and other case8, staffing
reevaluatione
took place which ultimately
led to the addition
of 20
medical poeitione
at the PMC.

Seep. 16.

Qno recognized that all phyaician#
wloyed
at the three URC8
have appropriate
oredmtiale
and are eduaationally
qualitiod
to pufoa
the work thy
urn ammigned.
Q&O rho
found
that
BDP parronnal
h8d vuifird
all phy#iaiuu*
aredentialm.

See 0. 11.

GAO 8tatod that my phymiaian rr8iatentm
in the BOP lack
generally
raquirad l duaatiou
md aattifiaation,
and are not
rmcdving
l doqu8te ~perviaioa
from phynici~s.
The OffiCe
of Personnel Management (OPM) has eet minimum hiring
standards for physician
aeaistante.
mile
the BOP can exceed the
minimum hiring
rtandarda,
the BOP aunt consider all applicante

Page39

GAO/EEHS-94-36BOP:Inmates'AccesetoHeakh

Care

Appendix V
Comments From the Directcar, Federal
BureauofPrisons

6

Mr. David P. Baine
who meet the minimum training
and experience
the BOP would rick
by OPM. To do otherwise,
non-selected
applicants.

standards Bet forth
legal action from

BOP recognlzee and supports the need to meet the camrmnity
Ccqetltlon
for
etaudud with regard to phyaicfan a~aietantis.
graduates of accredited
ph eician anslrtant
programs is very
hi h, with a roxlrrately
er x potential
openings nationally&
$a
yrevak;aaa
9
we
Y 1 se the public oector for every graduate.
differential@
noted prwiouely,
the BOP ha0 had to
axplore a=I ternative
recruiting
and retention
strategier
to meet
the physician
alraistant
c ormnuuity etaudud.
Pirst BOP petitioned
for and ac ired, a delegation
of
to pen% it in the future to hire
authority
under Titlsf
certified
phyeicfan
amaiatanta bared upon a more competitive
Second, for the past two yeare the BOP haa been
ealary rate.
exploring
academic relationmhipa
with accredited
Physicfan
Amsiataut Training
Programa and the American Academy of Phyeician
Aasietante
throughout
the United Statee to provide additional
training
and upward mobility
for qualified
candidatea.
for
Recojnizinq
the need to meet the comnuuity q taudard
cert ficat on of physician
aoaistanta,
BOP would provide the
opportunity
(ba8ed on available
fuudin 1 for a limited
number of
q taff,
including
foreign meds cal q chool graduates
qualified
currently
practicing
ae physician
aeeiatante
in the BOP, to
attend one of the exietin
accredited
national
training
programe
mith the end goal of cert 4 fication.
Pinally,
the BOP offers an
extensive
and comprehensive continuing
profeesional
medical
education program for all of ite medical staff.
The GAO etatement regardin
the lack of adequate supervision
from
~:;~l~P
for xany physic 9an aruistanto
requires
further
review
The Program Review Diviaiion,
BOP, ha8 reviewed these
URCe wuy'two
yeara.
Program rwiew guidelinea
are In place
that monitor phyrician
mupenrimion of phyeiclan
asmiatante.
BOP
policy require8 a physician
to randomly or epecifically
review 10
Eta1
recorde completed by phyufcian amrrilrtante on a daily
. The Prograx Rwiew DFvielon re orta have confirnr%d that
thin is being done at the three MRCa wPth the exception of leee
than 100 percent coetpliance at mFP Springfield.
This
inconsietency
hae been corrected.
Baaed upon the GAO interview0
with phymiciane and hyoician
atirimtante,
ROP ir gain to rwiew and reevaluate
Pto program
review guidelinea
and d! mcuae the phyrician
monitoring
of
phyelcian
aesietante
with both the physicians
and the phyeician
ac#ellrtants at the MRCS.
t

The Veterans Mnistration
authority
to hire medical
30 U.S.C. S7401, et seq., allows for higher
and lesr competitive
hirlng proceduree.

profeasioaals,

ralariea

Page 40

GAWEEHS-94-36BOP:Inmates'AccesetoHealthCare

Appendix V
Comments From the Director, Federal
Bureau of Prisons

7

Mr. David P. Baine

See p. 18.

GAO mtmtod tht
the BOP $8 planning a major hospital
raquimltion
program without
fully
ammemming it8 no*&.
Additionally,
SAO o&mm tha BOP im wamidecing
the
aonmtruation
of mix larga l oute, tutiay
care hospitala
mad/or l aqulring
several military
frailitiam.
Under current population
projections,
the BOP im planning four
They include the PMC at Butner, BC;
uew mCe at this time.
in the Weetern
Ft. Deveno, MA; Carawall AFB, TX; and a facility
Region.
Two of these facilities
(Ft. Devene and Carewell APB)
are ac imitionm of fonnu
military
hospitals.
Theme propoeed
in the BOP Long Range Medical
acquim 9"tions are detailed
hompitalm
The acquimition
of murplum milita
Facilities
Plan.
is seen am an extremely
coat effective
means of obta r ning
facilities
and am a way to lessen the impact on the c olmmlnity of
closing
the military
facility.

See pp, 21 and 22.

See pp. 18-19.

The BOP has a comprehermive and evolving on-line medical data
collection
mymtem on its nationwide
SBBTRY information
symtem.
mymtem to
The Sensitive
Medical Data system umem the ICD-9-e
encode all medical
encounters of inmater,
including
mgecific
identification
of any tertiary
care
obtained.
One data mymtem
module of SRRTRY, DON, monitorm patients
at the MRCm in
IXN umem JCARO bed
accordance with JCARO definitiona
of bode.
categories
to dctennine the type of patient
bed utilimation
at
each of the MRCm.
The Medical Duty Statue demcrlbem the medical
duty statue of each inmute and identifiem
inmates covered under
In the near future,
the Americana with Disabilities
Act.
additional
ICB-J-CM procedure codeu will be added. This
Information
symtem,
which im now lams than two years old, allowe
BOP to follow morbidity
trendm.
T'he mymtcm is growing in
mophimtication
and will give the Bureau the capability
to
determine its health care needs.
The

rwcmandm,

aaquuimition,
aontreatorm,

See pp. 21 and 22.

thra
im a laak of my data v&Lola would
mediaal plan.
Am l rmmult of thim, GAO
am au l lt-tive
to hospital
aonmtruatioa
aaquiring
madhal marriaem
through private

QAO mtatom

a l trategia

Am noted above, the Bureau ham a canprehensive
and utilization
management mymtem to plan for
facility
needs.
In addition,
the BOP ham for
Long Range Medical Facilitiem
Plan,
Thim plan

muppart

or

data collection
medical and
ears had a
eeveral
identif 1 ee current
future

'
Clinical

International
Clasalffcation
of Dleease, 9th Revision,
Eodificatfon
IICD-9-W.
The fC!D-9-Q& a clammification
system
uoed in health care facilities,
;tm primarily
a universal
classification
eymtem for grouping illnemmem.
It8 mecondmry
purpose is for use in hospital
diseame indexing.

Page41

GAWHEHS-W-%6BOP: hnat.e.s’Acceseti HealthCare

V
Comments Prom the Director, Federal
Bureau of Prisons
Appendix

Mr.

David

resources,
growth.

0

P. Baine
future

growth,

and remourcem needed to meet that

In Nay 1990, an
,PrivatFze
of
requemted by the Office
7 AF
Management and
ted by Abt Associatee
of
concluded that
Cambridge, MA. The Abt etudy generally
of the MRCmwas not feasible
from both management
privatization
The BOP has tried
and cost-effectiveness
permpectivee.
contractin
out its health care programs at two facilities,
the
Federal Pr 9man Camp, Duluth, Minnesota; and the Metropolitan
Noth programa were
Correctional
Center, Chicago, Illinois.
terminated because of contract management problems and excessive
COBto.

See p. 22.

Am part of its
The BOP is again temtin
contract
services.
effort
to deliver
effic 4 ent and effective
health care servicea,
eervicem
contract
BOP recently
awarded a comprehenmive physician
The contract
at PC1 Fort Worth, a MRC for chronic care patients.
rovidem for a complete arra
of specialty
physician
servicea to
g e provided on site by healt rl care providera
from the University
the
of North Texme, Health Science Center at Fort Worth within
context of a Bureau directed
healthcare
delivery
myetern at that
institution.
AB art of the cormnitment of BOP to proactive
strategic
planning,
it Kae regularly
reevaluated
itm healthcare
needs for the inmate
population
for the future and the resource8 that will be required
Ae the medical needs of BOP irmatee
to meet this challenge.
than e, BOP detennlnee what inpatient
and outpatient
medical
requ 9 remente will
be necemeary to provide the inmate population
Conmietent with this
with a community standard of medical care.
standard,
the BOP recruitm,
trains,
and contracts
for the needed
medical staff.
ROP ie taking the following
contained in thim report:

See pp.

20

and 22.

action0

on the recommendations

Reamemendation:
Revise BOP hiring
standards for phymician
ameietants to conform to current community mtandardm of
training
and certification.
m With the implementation
of we
38 BOP will be able to
revise
its hiring
mtandardm for physician
aesistantm to
conform with current c-nity
standards of training
and
certification.

Page 42

GACRHHHS-94-XBBOP:
Inmates' AccesstoHeaithCase

Appendix V
Commenti From the Director, Federal
Bureau of Prisons

David

Mr.

See pp.20-23.

9

P. Baine

umc-daticn

referral
identified

I

centers

quality

Resize
the

to the wardens
of medical
rtance of taking
corrective
action

assurance

on

problems.

s The reetructured
quality
assurance programs of BQP are
addressing the need to reemphasize to MRC staff the
ality
importance
of taking
corrective
action
on identified
BOP will
continue to clOeely man9"tOr
aeeurance probleme.
its quality
assurance programe.
Raamdationr
Prepare a needs assessment of the medical
eervlcea its inmate population
requires
and determine what
yndi;k;eservices
it can efficiently
and effectively
provide
a compreheneive data collection
management system to plan for future
needs.

m BOP has developed

utilization
facility

and

medical

and

Raaommendatloa~ Determine the meet cost effective
approaches
to providing
apprapriate
health care to current and future
inmate populations.
n

The

Bureau

Facilities

has had for.asveral
Plan.

yeare a Long Range Medical

Thank you for the opportunity
to review the draft report.
These
corunents are Intended to share additional
information
with you on
our health care programs and to provide
you with an alternative
perspective
and response to the findings
contained therein.
Should you have any questiona,
please do not hesitate
to contact
me.
Sincerely,
Kathleen

Director

M. Hawk

Page 43

GAO/BEHS-94-36 BOP: Inmates’ Access to HeaN.h Care

Appendix VI

Major Contributors to This Report

cHealth, Education,
and Human Services
Division,
Washington, DC.

(101414)

Mary Ann Curran, Evaluator-in-Charge
Lawrence L. Moore, Evaluator

Page 44

GAORIEHS-94-36 BOP: Inmates’ Access to Health Care