BOP Program Statement 6013.01 § 11

reporting and reviewing every inmate death (by natural cause,

suicide, homicide, or accidental). Mortality reviews constitute

a means of:

P6013.01

1/15/2005

Page 11

! Evaluating the health care delivery system;

! Identifying its significant strengths and weaknesses; and

! Taking corrective action where necessary.

Each inmate death (except those legally authorized by execution)

requires a systematic review at the institution and Central

Office level. The reviews must use a death report packet

consisting of standard elements including the Mortality Review

form on BOPDOCS (BP-S563.044).

a. 24-hour Death Notice. Within 24 hours of an inmate's

death, or the next duty day, if the death occurs on a weekend or

holiday, the CD is to send a GroupWise message to the Medical

Director’s attention with the following information:

! Name, age, and register number of inmate;

! Date and preliminary cause of death;

! Place of death;

! Brief clinical synopsis of events leading to death

(including staff response);

! Past medical history; and

! Whether an autopsy will be performed.

If the death occurred in the community hospital, length of

hospitalization or emergency care provided must be included. A

24-hour report is required to report all legally ordered

executions (see Attachment D).

The 24 hour death notification also applies to inmates who die

while in the custody of a contract or secure private correctional

institution and those in Community Correction Centers (CCC).

Submitting these 24 hour reports is the responsibility of the

contract facility’s management, or the appropriate Community

Corrections Manager.

! The message is to be routed to BOP MED SVC and BOP HSD

OQM, with a copy to the Regional HSA, and the

appropriate Clinical Consultant.

! CCC deaths will also be reported to the appropriate

Unit Manager at the deceased inmate’s designated

institution.

b. Mortality Review Committee. Each institution is to

establish a Mortality Review Committee made-up of various members

depending upon the institution’s mission. For MRCs, the

Mortality Review Committee must consist of:

P6013.01

1/15/2005

Page 12

! The CD;

! A staff physician;

! The institution Quality Improvement Coordinator;

! The HSA;

! The Director of Nursing; and

! Any other staff the CD deems appropriate.

For non-medical institutions, the Mortality Review Committee

will include:

! The CD;

! The HSA;

! An MLP; and

! The appropriate Associate Warden.

Other staff may participate if deemed necessary. The CD is to

serve as chairperson.

If an inmate has any mental health problems, the Psychology

Department is to be included in the mortality review and

appropriate mental health information must be included in the

mortality review report.

Where possible, Mortality Review Committee members should not

have been involved in the inmate's treatment. Deaths by legal

execution do not require the Mortality Review Committee’s review

or completion of the Multi-Level Mortality Review Report

(BP-S563), only 24-hour notification of death is required.

The Mortality Review Committee will:

(1) Review the report packet, the health record, and

interview staff to obtain all the facts of the case;

(2) Analyze the complete report, identifying for

individuals and systems their respective strengths and

weaknesses for the clinical care immediately

surrounding the death, and the quality of care for at

least six months preceding the death; and

(3) Evaluate both individual and system performance

immediately proximate to the death, specifically:

! Alert and response times;

! Communications;

! Transportation;

! Clinical skills (especially the use of CPR or

other appropriate protocols);

P6013.01

1/15/2005

Page 13

! Equipment, supplies, and pharmaceuticals; and

! Documentation, especially in the health record.

In discussing this factor, the MRC will clearly

distinguish, if possible, lack of documentation

from failure to provide care.

(4) Evaluate individual and system performance in the days

or months preceding the death, specifically;

! Documentation;

! Working vs. final diagnosis;

! Appropriateness and timeliness of diagnostics and

treatment regimens; and

! Complicating factors, either human or system, in

the overall care that may have affected the

outcome.

The MRC will document, by summary report, the discussion of

these factors, as well as any others deemed appropriate.

Highlighting positive aspects of the case is as important as

detailing deficiencies. The report will conclude with

recommendations for commendations or corrective action.

c. Multi-Level Mortality Review Report (BP-S563). The

Mortality Review Committee will complete the Mortality Review

Report in its entirety, and send it, accompanied by the original

health record, to the Central Office, OQM within 30 days. Only a

copy of the Mortality Review Report is to be sent to the

appropriate Regional Director.

The Mortality Review Report will contain, at least, the

following:

(1) A comprehensive clinical summary of the case, including

a history, diagnosis, current treatment plan, sequence

of events leading to death, and the cause of death;

(2) A summary of activities by institution staff, including

who responded, how quickly, and what they did. This

should also report any significant events or activities

that accompanied the death, including the activities of

other staff from the institution and the community;

(3) Designator and CCM’s reports;

(4) Autopsy report, toxicology report, and death

certificate (if pending receipt of these reports, send

as soon as possible);

P6013.01

1/15/2005

Page 14

(5) If the inmate was admitted to a community hospital, the

attending physician’s report and other pertinent

information. If the discharge/death summary is not

available in a timely manner, the CD’s narrative

summary will relate any information obtained verbally

from the attending community physicians and health care

staff;

(6) Unless circumstances strongly indicate otherwise, staff

names should not be used in the report, titles should

be substituted;

(7) If Psychology Services was following the case,

pertinent case records will be included when forwarding

the file to the Central Office including the full

Psychological Reconstruction of Suicides; and

(8) The reports, documentation, and summaries will be

designated confidential. Only staff with a need to

know will see the contents.

The Warden will review and sign the Mortality Review Report.

Although the Warden may comment on the report, it will be

forwarded as prepared by the Mortality Review Committee.

! If certain portions of the death file, such as the

death certificate, are unavailable, they should be

forwarded as soon as practicable to OQM with any

revisions or addendums necessary to the Mortality

Review Report.

d. Quality Improvement Opportunities. If the Mortality Review

Committee finds opportunities to improve the quality of care, the

plan of action for improvement will be incorporated in the

institution’s Quality Improvement Program. The follow-up on the

quality improvement action must be reported in the Quality

Improvement Committee’s meeting minutes.

The appropriate Regional HSA (RHSA) and Clinical Specialty

Consultant will monitor institution progress in implementing

corrective measures, ensuring these measures are implemented

satisfactorily.

e. The Office of Quality Management Review. The Medical

Director is to refer the Mortality Review to the OQM for

evaluation. The OQM will:

P6013.01

1/15/2005

Page 15

(1) Review the entire packet, comparing the MRC’s report

with the accompanying information. If needed, OQM will

discuss the case with the institution staff and/or

RHSA/Clinical Specialty Consultant.

(2) Have an external physician consultant review the

Mortality Review Report and any accompanying

information. The external consultant is to:

! Review all mortality records quarterly;

! Report to OQM on strengths and weaknesses in

health care delivery; and

! Provide recommendations.

(3) Provide the external consultant’s review findings to

the Regional Directors and CEOs. If the external

consultant recommends improvement action at the

institution, the institution must document compliance

with these recommendations, and report action taken to

comply, within 90 days, to the Medical Director.

(4) Monitor the follow-up of the recommendations and the

plan to improve care through the Program Review process

and the appropriate RHSA and Clinical Specialty

Consultant.

(5) Prepare system-wide trend analysis.

/s/

Harley G. Lappin

Director

P6013.01

1/15/2005

Attachment A, Page 1

Quality Improvement Tracking (PDCA)

Process:______________________________________________

Priority Issues Relative to Which Functions: (check all applicable) Status Codes

1 = High Risk Assessment of Patient Health promotion/Disease

Prevention

Continuum of Care R Resolved

2 = High Volume Treatment of Patients Infection Control Nutritional Care U Unresolved

3 = Problem Prone Education/Patient/

Family

Management of Information Human Resources UR Un-resolvable

Leadership Quality Improvement Patient Rights/Ethics RDP Resolved to Degree Possible

Environment of Care RM Resolved but Cont. to

Monitor

Activity Being Considered by: (check one) Dimensions of Quality:

Team Name of Team Efficacy Continuity Efficiency

Dept. Name of Department: Appropriateness Safety Availability

Timeliness Effectiveness Respect & Caring

DATE N O. PLAN

What do you plan to do?

Objectives?

DO

What are you doing

to meet your

objectives? What

actions?

CHECK

How effective is the action

you took?

ACT

If the actions are completed

and working, are you ready to

make them policy?

STATUS

CODE

P6013.01

1/15/2005

Attachment A, Page 2

INSTRUCTIONS

Process

Fill in Process line with description of what you are working toward improving, i.e. Medication Administration.

Priority

Is the process high risk, high volume, problem prone or any combination thereof? Check appropriate boxes.

Issues Relative to Which Function

Select functional areas of the standards that the process applies to, i.e. for Med. Admin. You would select Treatment of

patient, Assessment of Patients, Management of Information.

Dimension of Quality

What are you working towards improving? Is it the timeliness of a service, effectiveness of a procedure, appropriateness of a

treatment, availability of a service, etc.? This is what you are measuring.

Date

Date of updated form

PDCA.

This form starts with Plan & Do. As it is updated, add data in the Check & Act columns. Not every planned activity is

progressing at same pace. Some may be at Do stage for awhile, while another may progress to the Act stage quickly.

Example: PLAN

What is your plan?

#1. Do a survey of staff on. . .

#2. Make a flow chart of process.

#3. Develop a policy/procedure on. . .

#4. Educate staff on process changes.

Example: DO

What are you doing?

For #1. Survey mailed out December 10 to all staff, due on December 20 .th th

For #2. Flow chart being developed by Rehab. of current process.

For #3. Pharmacy & medical staff preparing draft of policy.

For #4. Blank - U

Example: CHECK

Is what you are doing working?

For #1. Survey response 50%. Outcome is: ____

For #2. Flow chart complete & shows bottlenecks.

For #3. Policy still in draft version.

For #4. Blank - U

Example: ACT

For #1. Survey completed & evaluation completed.

For #2. Flow chart complete & process bottlenecks identified.

For #3. Policy approved.

For #4. Education of all staff completed.

Status Code Box & Column

With each update indicate status of each Plan item. Some items may be unresolvable.

P6013.01

1/15/2005

Attachment B, Page 1

Federal Bureau of Prisons

Health Care Rights and Responsibilities

While in the custody of the Federal Bureau of Prisons you have the right to receive health care in a

manner that recognizes your basic human rights, and you also accept the responsibility to cooperate

with your health care plans and respect the basic human rights of your health care providers.

Your Health Care Rights: Your Responsibilities:

1. You have the right to access health care services 1. You have the responsibility to comply with the

based on the local procedures at your institution. health care policies of your institution, and follow

Health services include medical, dental and all recommended treatment plans established for you, by

support services. If inmate co-pay system exists in health care providers. You have the responsibility

your institution, Health Services cannot be denied to pay an identified fee for any health care

due to lack (verified)of personal funds to pay for encounter initiated by yourself, excluding emergency

your care. care. You will also pay the fee for the care of any

other inmate on whom you intentionally inflict bodily

harm or injury.

2. You have the right to know the name and 2. You have the responsibility to treat these

professional status of your health care providers and providers as professionals and follow their

to be treated with respect, consideration and instructions to maintain and improve your overall

dignity. health.

3. You have the right to address any concern 3. You have the responsibility to address your

regarding your health care to any member of the concerns in the accepted format, such as the Inmate

institution staff including the physician, the Health Request to Staff Member form, main line, or the

Services Administrator, members of your Unit Team, accepted Inmate Grievance Procedures.

the Associate Warden and the Warden.

P6013.01

1/15/2005

Attachment B, Page 2

Your Health Care Rights: Your Responsibilities:

4. You have the right to provide the Bureau of 4. You have the responsibility to provide the Bureau

Prisons with Advance Directives or a Living Will that of Prisons with accurate information to complete this

would provide the Bureau of Prisons with instructions agreement.

if you are admitted as an inpatient to a hospital.

5. You have the right to be provided with information 5. You have the responsibility to keep this

regarding your diagnosis, treatment and prognosis. information confidential.

This includes the right to be informed of health care

outcomes that differ significantly from the

anticipated outcome.

6. You have the right to obtain copies of certain 6. You have the responsibility to be familiar with

releasable portions of your health record. the current policy and abide by such to obtain these

records.

7. You have the right to be examined in privacy. 7. You have the responsibility to comply with

security procedures should security be required

during your examination.

P6013.01

1/15/2005

Attachment B, Page 3

Your Health Care Rights: Your Responsibilities:

8. You have the right to participate in health 8. You have the responsibility to maintain your

promotion and disease prevention programs, including health and not to endanger yourself, or others, by

those providing education regarding infectious participating in activity that could result in the

diseases. spreading or catching an infectious disease.

9. You have the right to report complaints of pain to 9. You have the responsibility to communicate with

your health care provider, have your pain assessed your health care provider honestly regarding your

and managed in a timely and medically acceptable pain and your concerns about your pain. You also have

manner, be provided information about pain and pain the responsibility to adhere to the prescribed

management, as well as information on the limitations treatment plan and medical restrictions. It is your

and side effects of pain treatments. responsibility to keep your provider informed of both

positive and negative changes in your condition to

assure timely follow up.

10. You have the right to receive prescribed 10. You have the responsibility to be honest with

medications and treatments in a timely manner, your health care provider(s), to comply with

consistent with the recommendations of the prescribed treatments and follow prescription orders.

prescribing health care provider. You also have the responsibility not to provide any

other person your medication or other prescribed

item.

11. You have the right to be provided healthy and 11. You have the responsibility to eat healthy and

nutritious food. You have the right to instruction not abuse or waste food or drink.

regarding a healthy diet.

12. You have the right to request a routine physical 12. You have the responsibility to notify medical

examination, as defined by Bureau of Prisons' Policy. staff that you wish to have an examination.

(If you are under the age of 50, once every two

years; if over the age of 50, once a year and within

one year of your release).

13. You have the right to dental care as defined in 13. You have the responsibility to maintain your oral

Bureau of Prisons' Policy to include preventative hygiene and health.

services, emergency care and routine care.

P6013.01

1/15/2005

Attachment B, Page 4

Your Health Care Rights: Your Responsibilities:

14. You have the right to a safe, clean and healthy 14. You have the responsibility to maintain the

environment, including smoke-free living areas. cleanliness of personal and common areas and safety

in consideration of others. You have the

responsibility to follow smoking regulations.

15. You have the right to refuse medical treatment in 15. You have the responsibility to notify health

accordance with Bureau of Prisons' Policy. Refusal services regarding any ill-effects that occur as a

of certain diagnostic tests for infectious diseases result of your refusal. You also accept the

can result in administrative action against you. You responsibility to sign the treatment refusal form.

have the right to be counseled regarding the possible

ill-effects of refusing medical treatment.

P6013.01

1/15/2005

Attachment C, Page 1

ROOT CAUSE ANALYSIS OF SUSPECT SENTINEL EVENT

Federal Bureau of Prisons

Complete this form when submitting a root cause analysis to address a suspected

Sentinel Event. Submit this report to the Office of Quality Management, Health

Services Division within 45 days of the suspected Sentinel Event. Institutions are

encouraged to complete this process for “near misses” but are not required to

submit those to the OQM/HSD.

Institution:

Date of Report:

Name of Patient:

Reg. No.

Provide a brief description of event:

1. This event resulted in: (Must check one)

Un-anticipated death

Serious physical or psychological injury, such as loss of

limb or function (or risk thereof).

2. Which of the following sub categories apply to this event? (Must

check at least one)

Suicide of a patient under constant supervision in a BOP

facility.

Death of a patient in restraints

Medication error resulting in death, paralysis or coma of a

patient.

Surgery on the wrong patient, wrong side or wrong body part

Patient fall that results in death or major permanent loss

of function.

3. Was the event directly related to the patient’s illness or

underlying condition? Yes No

P6013.01

1/15/2005

Attachment C, Page 2

4. Were any of the following factors a significant contributor to

this event? (Check all that apply)

Staffing or other human factors

Equipment

Underlying systems or processes

Environmental factors

5. For any of the factors you selected in Item #4, provide details

as to why:

6. Identify any risk points and their potential contributions to

this event:

7. Determine what potential improvements in processes or systems

that would tend to decrease the likelihood of such events in the

future:

8. Provide details of established plan to address identified

opportunities for improvement:

P6013.01

1/15/2005

Attachment C, Page 3

9. Who is responsible for implementation of improvement plans?

10. When will improvement actions be implemented?

11. How will the effectiveness of improvement actions be evaluated?