Bureau of Prisons Health Care: Inmates' Access to Health Care Is Limited
by Lack of Clinical Staff (Letter Report, 02/10/94, GAO/HEHS-94-36).

Federal prisoners with special needs, including women, psychiatric
patients, and those with chronic illnesses, have not been receiving all
of the health care they need at medical referral centers run by the
Bureau of Prisons (BOP). A lack of doctors and nurses is a major
problem. Some of BOP's medical referral centers that GAO visited failed
to correct identified quality-of-care problems. Although the doctors at
each of the centers GAO visited were qualified, many physician
assistants did not meet the training and certification requirements of
the medical community outside of BOP. To reduce its reliance on
community hospitals and other outside health care facilities, BOP is
considering building six large hospitals and acquiring several military
facilities. But BOP has yet to develop the data needed to determine the
kind of medical services needed by inmates and the type of services it
can effectively and efficiently deliver. Without such information, BOP
can only guess at the numbers and types of staff it would need to run
these hospitals. BOP should consider drawing on the experience of states
with problems in providing inmates with adequate medical care. These
states have successfully contracted out some or all of their inmate
medical care.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-36
     TITLE:  Bureau of Prisons Health Care: Inmates' Access to Health 
             Care Is Limited by Lack of Clinical Staff
      DATE:  02/10/94
   SUBJECT:  Prisoners
             Health care services
             Physicians
             Quality assurance
             Correctional facilities
             Health care facilities
             Health services administration
             Cost effectiveness analysis
             Health care cost control
             Medical information systems
IDENTIFIER:  Butner (NC)
             Lexington (KY)
             Springfield (MO)
             
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Cover
================================================================ COVER


Report to the Chairman, Subcommittee on Intellectual Property and
Judicial Administration, Committee on 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/HEHS-94-36

BOP:  Inmates' Access to Health Care


Abbreviations
=============================================================== ABBREV

  AIDS - acquired immunodeficiency syndrome
  AMA - American Medical Association
  BOP - Bureau of Prisons
  JCAHO - Joint Commission on Accreditation of Healthcare
     Organizations
  OPM - Office of Personnel Management
  PA - physician assistant
  PHS - U.S.  Public Health Service
  RN - registered nurse
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-249967

February 10, 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. 

As agreed with your office, we reviewed the following four issues: 

  Are inmates with special medical needs--including women,
     psychiatric patients, and inmates with chronic medical
     conditions--receiving the care they need? 

  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 BOP considering the most cost-effective alternatives to meet
     inmates' rising needs for medical services? 

We also agreed to concentrate our review on three of BOP's seven
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.\1 We reviewed selected reports and
correspondence from the other four centers. 


--------------------
\1 The other four medical centers are in Rochester, Minnesota;
Terminal Island, California; Fort Worth, Texas; and Carville,
Louisiana. 


   BACKGROUND
------------------------------------------------------------ Letter :1

BOP's 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 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. 

BOP's 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 has directed six of its seven medical referral centers to seek
accreditation by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).\3 Each was surveyed in March 1993 for
accreditation.  Five were fully accredited and one, the Terminal
Island, California, center, was refused accreditation. 


--------------------
\2 Tertiary care medical centers have the capability to provide all
medical or surgical care, such as surgery that requires an intensive
care unit for recovery. 

\3 Carville 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
Carville. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

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 sufficient time to provide individual and group
counseling to psychiatric patients.  As a result, some patients'
conditions were not improving and others were at risk of serious
deterioration. 

While all three centers had quality assurance programs intended to
identify 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
assistants 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,\5
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. 

BOP 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. 


--------------------
\4 Chronic conditions are permanent or long-term health care needs
that do not require constant and extensive medical monitoring by a
physician. 

\5 The cost to provide inmates with medical care at community
hospitals increased by 27 percent from fiscal year 1991 to 1992, from
$53.5 to $68.0 million. 


   PRINCIPAL FINDINGS
------------------------------------------------------------ Letter :3


      WOMEN INMATES NOT RECEIVING
      TIMELY PELVIC EXAMINATIONS
      AND PAP TESTS
---------------------------------------------------------- Letter :3.1

BOP 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. 

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 Clinical 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 pelvic
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 full-time
gynecologist, a full-time nurse practitioner, and a part-time
physician assistant to perform these functions.  However, the
staffing 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 so.\6 Thus, as of June 14,
1993, only a part-time physician assistant was providing care in the
gynecology service for about 2,000 inmates. 

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. 


--------------------
\6 A 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. 


      PSYCHIATRIC PATIENTS NOT
      RECEIVING NEEDED THERAPY
---------------------------------------------------------- Letter :3.2

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. 

BOP's Chief Psychiatrist told us that an ideal staffing pattern in a
BOP psychiatric unit is one psychiatrist for each 20 to 25 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 insufficient to provide adequate
treatment to the 294 acute and chronic care mental health patients
the center serves. 

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. 

   Figure 1:  Psychiatrist
   Staffing at Three BOP Centers
   (July 1993)

   (See figure in printed
   edition.)


      NUMBER OF AUTHORIZED NURSING
      POSITIONS AT CENTERS IS
      INSUFFICIENT
---------------------------------------------------------- Letter :3.3

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
nurse-to-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
staffing 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 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 leave.  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 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
---------------------------------------------------------- Letter :3.4

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: 

  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 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 until 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
     Clinical 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. 

BOP 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. 

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 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. 


--------------------
\7 Hypoglycemic 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 to nausea and vomiting, or
overexerts without compensating with additional carbohydrates. 


      PHYSICIAN ASSISTANTS LACK
      CREDENTIALS AND ADEQUATE
      SUPERVISION
---------------------------------------------------------- Letter :3.5

Many physician assistants in BOP lack 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 Assistants.\8
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. 

Further, 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 assistants.  As a result, inmate
patients were at risk of not receiving quality medical care. 

BOP's 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. 

In June 1991, a consultant\9 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. 

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

   (See figure in printed
   edition.)

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
supervision.  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, 1993, the position was not
filled.  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 assistants. 
However, a medical records audit conducted by Springfield staff in
April 1992 found that over a 1-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. 


--------------------
\8 Thirty-four of the 66 physician assistants working in BOP at its
seven medical referral centers have 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. 

\9 Dr.  Joseph A.  Leiberman III, M.D.  and M.P.H., Professor and
Chairman, Department of Family and Community Medicine, Medical Center
of Delaware, Wilmington, Delaware. 


      MEDICAL REFERRAL CENTERS ARE
      NOT USING QUALITY ASSURANCE
      DATA TO IMPROVE CARE
---------------------------------------------------------- Letter :3.6

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. 

BOP's 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 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 test\10 of his heart showed abnormalities and
     scar tissue, indicating a previous heart attack.  As a result of
     these findings, 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 1-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 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.\11 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
comfortable\12 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.  Physicians 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 all physicians at each of these
centers and found that BOP personnel had verified all physicians'
credentials. 

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 thoroughly when he first reported his
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. 


--------------------
\10 An electrocardiogram test is performed to diagnose cardiac
disease and abnormal cardiac rhythms. 

\11 Privileging is the process of evaluating physicians' clinical
experience, competence, ability, judgment, and health status when
granting them permission to treat certain illnesses and perform
certain medical procedures. 

\12 The cancer had spread throughout the patient's body, and he was
unable to move his extremities.  His primary pain medication was
Motrin. 


      BOP PLANS MAJOR HOSPITAL
      ACQUISITION PROGRAM WITHOUT
      FULLY ASSESSING ITS NEEDS
---------------------------------------------------------- Letter :3.7

BOP 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. 

In fiscal 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. 

BOP 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. 

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, BOP has 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 alternative 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 maintained and that physicians will provide inmates with
needed treatment and periodic examinations.  Before this decision,
Missouri was encountering staffing 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, BOP 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 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. 


--------------------
\13 Butner's current medical beds will be used for chronic patients
who require minimum care or those who no longer need medical care. 

\14 If Missouri's number of inmates exceeds 14,000, the cost for each
additional inmate is about half of the base cost. 


   CONCLUSIONS
------------------------------------------------------------ Letter :4

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
------------------------------------------------------------ Letter :5

We recommend that the Attorney General require the Director of BOP to
do the following: 

  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. 

  Determine the most cost-effective approaches to providing
     appropriate health care to current and future inmate
     populations. 

  Revise BOP hiring standards for physician assistants to conform to
     current community standards of training and certification. 

  Reemphasize to the wardens of medical referral centers the
     importance of taking corrective action on identified quality
     assurance problems. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :6

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.)

BOP's 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 findings
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. 

In responding to our recommendation that BOP needs to prepare a needs
assessment of medical services that its inmate population requires
and determine 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 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, and 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
contracting 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
reemphasized to the wardens of medical referral centers.  In both
areas, BOP agreed to take corrective action to resolve the problems. 


---------------------------------------------------------- Letter :6.1

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.  Major contributors to
this report are listed in appendix VI. 

Sincerely yours,

David P.  Baine
Director, Federal Health Care
 Delivery Issues


OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

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: 

  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 television 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. 

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. 


BUTNER MEDICAL REFERRAL CENTER
========================================================== Appendix II


   MISSION OF REFERRAL CENTER
-------------------------------------------------------- Appendix II:1

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
-------------------------------------------------------- Appendix II:2

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
-------------------------------------------------------- Appendix II:3

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


   NUMBER AND TYPE OF MEDICAL BEDS
-------------------------------------------------------- Appendix II:4

The Joint Commission on Accreditation of Healthcare Organizations
rates the Butner medical referral center as a 180-bed forensic
inpatient hospital. 


   NUMBER AND TYPE OF STAFF
   POSITIONS AUTHORIZED AND FILLED
-------------------------------------------------------- Appendix II:5

In July 1993, Butner's medical referral center had 91 authorized
health care positions, including 9 psychiatrists, 4 medical
physicians, 1 optometrist, 2 forensic fellows,\15 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. 


--------------------
\15 For several 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. 


   STAFF ORGANIZATION
-------------------------------------------------------- Appendix II:6

The Associate Warden for Health Services at Butner is responsible for
all 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.  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 8:00 a.m.  shift. 


LEXINGTON MEDICAL REFERRAL CENTER
========================================================= Appendix III


   MISSION OF REFERRAL CENTER
------------------------------------------------------- Appendix III:1

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
------------------------------------------------------- Appendix III:2

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
------------------------------------------------------- Appendix III:3

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 60-bed transitional unit for
mental health patients.  The transitional unit does not have nursing
coverage.  In addition, the center has 34 obstetric beds. 

BOP 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. 


   NUMBER AND TYPE OF MEDICAL BEDS
------------------------------------------------------- Appendix III:4

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
------------------------------------------------------- Appendix III:5

In July 1993, Lexington was authorized 126 health care staff,
including 8 physicians (one of which is a clinical 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 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 a.m.  to 4:00 p.m., although 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
------------------------------------------------------- Appendix III:6

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


SPRINGFIELD MEDICAL REFERRAL
CENTER
========================================================== Appendix IV


   MISSION OF REFERRAL CENTER
-------------------------------------------------------- Appendix IV:1

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
-------------------------------------------------------- Appendix IV:2

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
-------------------------------------------------------- Appendix IV:3

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 TYPE OF MEDICAL BEDS
-------------------------------------------------------- Appendix IV:4

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


   NUMBER AND TYPE OF STAFF
   POSITIONS AUTHORIZED AND FILLED
-------------------------------------------------------- Appendix IV:5

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,
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
-------------------------------------------------------- Appendix IV:6

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 patients. 




(See figure in printed edition.)Appendix V
COMMENTS FROM THE DIRECTOR,
FEDERAL BUREAU OF PRISONS
========================================================== Appendix IV



(See figure in printed edition.)

See p.  21. 

See p.  4. 



(See figure in printed edition.)

See p.  5. 

See p.  9. 



(See figure in printed edition.)

See p.  7. 

See p.  10. 

See p.  14. 



(See figure in printed edition.)

See p.  16. 

See p.  11. 



(See figure in printed edition.)



(See figure in printed edition.)

See p.  18. 

See pp.  21 and 22. 

See pp.  18-19. 

See pp.  21 and 22. 



(See figure in printed edition.)

See p.  22. 

See pp.  20 and 22. 



(See figure in printed edition.)

See pp.  20-23. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix VI

HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION,
WASHINGTON, D.C. 

James A.  Carlan, Assistant Director (202) 512-7120
Mary Ann Curran, Evaluator-in-Charge
Lawrence L.  Moore, Evaluator
