Review of mental health screening at intake
Internal Audit Report
378-1-261
February 23, 2012
Table of Contents
Executive Summary
The Review of Mental Health Screening at Intake is being conducted as part of Correctional Service Canada’s (CSC) Internal Audit Branch (IAB) 2009-2012 Audit Plan. The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.
On April 20, 2007 the Government of Canada announced the appointment of an Independent Review Panel to assess the operational priorities, strategies and business plans of Correctional Service Canada (CSC) with the ultimate goal of enhancing public safety. The Panel's report, A Roadmap to Strengthening Public Safety, was released on October 31, 2007 and made recommendations regarding mental health. In particular, they recommended that “a comprehensive and recognized mental health assessment system be incorporated into the intake assessment process”.
The review was national in scope and included the mental health intake practices in five regions for male offenders and in three regions for female offenders. The approach included a combination of interviews of both management and front line staff, and an examination of relevant legislation, policies, processes and information systems. It also included a review of a sample of offender files. This review did not attempt to assess the quality of the health care or screening provided.
The fieldwork was conducted during the period June 2011 to October 2011.
Conclusion
The review concluded that the management framework over the mental health screening of offenders at intake meets departmental expectations and is working as intended, with the following areas identified for improvement:
- Challenges with respecting the timelines for mental health screening at intake;
- No formal mechanism or systematized process in place to convey the status of an offender’s mental health screening;
- No monthly regional reception centre performance reports; and
- No reporting of performance information related to immediate needs interview.
Recommendations have been made in the report to address areas for improvement. Management has reviewed and agrees with the findings contained in this report and a Management Action Plan has been developed to address the recommendations (see Annex F).
1.0 Introduction
The Review of Mental Health Screening at Intake is being conducted as part of Correctional Service Canada’s (CSC) Internal Audit Branch (IAB) 2009-2012 Audit Plan. The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.
Background
On April 20, 2007 the Government of Canada announced the appointment of an Independent Review Panel to assess the operational priorities, strategies and business plans of Correctional Service Canada (CSC) with the ultimate goal of enhancing public safety. The Panel's report, A Roadmap to Strengthening Public Safety, was released on October 31, 2007. In this report, the Panel made a number of recommendations regarding mental health. In particular, they recommended that “a comprehensive and recognized mental health assessment system be incorporated into the intake assessment process, so that a treatment strategy that is fully integrated with programming can be developed1”.
The Correctional Service Canada’s Mental Health Strategy, dated July 16, 2010, notes that new intakes are presenting with higher levels of mental health issues. It also details new practices in support of the Mental Health Strategy, such as: professional development for correctional and mental health staff; support tools (i.e., guidelines, case scenarios and templates) to support front-line staff; CSC mental health research initiatives; and performance measurement to monitor progress in implementing the strategy.
Based on CSC policies applicable to this area [See Annex B for more detail] the following screening activities are required:
- Immediate needs interview (within the first 24 hrs) – usually administered by correctional officers (CXs) or correctional managers (CMs);
- Intake health status assessment (within the first 24 hrs) – administered by nurses within Health Services;
- Comprehensive nursing assessment (within first 14 days) - administered by nurses within Health Services; and
- Computerized Mental Health Intake Screening System (CoMHISS) testing (administered between 3 days and first 14 days) – administered by staff from Psychology.
The Computerized Mental Health Screening System (CoMHISS) tool is part of the Mental Health Strategy and the Institutional Mental Health Initiative (IMHI). CoMHISS has the following objectives2:
- Early identification of offenders who are exhibiting symptoms that may be associated with a mental health disorder.
- Follow-up/Continuity of Care - Once identified, these offenders will be referred for further follow-up and/or mental health assessment and intervention. The information obtained through this assessment will help to inform the correctional plan and case management processes from intake to release planning.
- Collect accurate mental health data as a basis for mental health interventions and the long-term planning of CSC mental health care.
According to the 2010 Mental Health Strategy document, CoMHISS is fully functional in all 16 CSC intake assessment sites. Intake screening results are documented in CoMHISS, as well as the Offender Management System (OMS) and are put on offender psychology files.
An assessment, including suicide risk screening, is completed by a community parole officer, typically within five working days of the offender receiving a federal sentence, while the offender is in the custody of provincial authorities. However, as this screening occurs prior to the intake process at a regional reception centre, it is outside the scope of the current review.
During the timeframe January 1st, 2011 to March 31st, 2011 a total of 1,880 new offenders (1,785 males and 95 females) entered CSC institutions. See Table A below for new offender admissions per region during this timeframe.
| Region | |||||||
|---|---|---|---|---|---|---|---|
| Sex | ATLANTIC | QUÉBEC | ONTARIO | PRAIRIE | PACIFIC | TOTAL | |
| Male | n | 208 | 384 | 429 | 565 | 199 | 1785 |
| % | (11.7) | (21.5) | (24.0) | (31.7) | (11.1) | ||
| Female | n | 16 | 11 | 30 | 19 | 19 | 95 |
| % | (16.8) | (11.6) | (31.6) | (20) | (20) | ||
| Total | n | 224 | 395 | 459 | 584 | 218 | 1880 |
% | (12) | (21) | (24.4) | (31.1) | (11.6) | ||
Note. Percentages may not always sum up to 100% due to rounding.
Source: OMS query report all the new admissions from Jan 1, 2011 to March 31, 2011.
Legislation and Policy Instruments
The department’s Mental Health (MH) screening at intake process is governed by a number of legislative and policy instruments. The Corrections and Conditional Release Act (CCRA) and the Corrections and Conditional Release Regulations (CCRR)prescribe the way in which CSC manages the custody of offenders. In this legislation, the following sections of law are relevant to this review:
- Sections 85 to 89 of the CCRA legislation; and
- Corrections and Conditional Release Regulations, Section 17 and 102. (1).
In addition to the above legislation, the following CSC Commissioner’s Directives (CD’s) and policy instruments are also relevant to this review:
- CD 705 - Intake Assessment Process;
- Case Management Bulletin, dated October 22, 2010, regarding Psychological Assessments;
- CD 705-5 - Supplementary Intake Assessments
- Computerized Mental Health Intake Screening System (CoMHISS) - National Guidelines;
- CD 705-3 – Immediate Needs and Admission Interviews, including Appendix A – Content Guidelines - Immediate Needs Suicide Risk Checklist; and
- CD 800 - Health Services
- CD 803 – Consent to Health Services Assessment, Treatment and Release of Information
- CD 835 - Health Care Records
- CD 840 - Psychological Services
- CD 843 – Management of Inmate Self-Injurious and Suicidal Behaviour
- CD 850 - Mental Health Services
2.0 Review Objectives and Scope
2.1 Review Objectives
The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.
The Review Criteria are described in Annex A. The various processes related to mental health screening of offenders at intake are described in Annex B.
2.2 Review Scope
The review was national in scope and included the mental health screening at intake practices, described in Annex B, in five regions for male offenders and in three regions for female offenders. Annex C lists the sites examined. This review did not attempt to assess the quality of the health care or screening provided.
The review included an examination of directions and guidelines, roles and responsibilities, adequacy of training and the reporting and monitoring mechanisms in place for mental health screening at intake.
The fieldwork was conducted during the period June 2011 to October 2011.
3.0 Review Approach and Methodology
The approach included a combination of interviews of both management (in five regions) and front line staff (in three regions), and an examination of relevant legislation, policies, processes and information systems (i.e., OMS and CoMHISS). It also included a review of a sample of 100 OMS files and a sample of physical health and psychological files for new offenders (placed directly from a reception centre), for the period January 1st, 2011 to March 31st, 2011.
Annex D lists and describes the techniques used to gather evidence to complete this Review.
5.0 Overall Conclusion
The review concluded that the management framework over the mental health screening of offenders at intake meets departmental expectations and is working as intended.
The review has also identified areas for improvement and recommended actions.
A Management Action Plan addressing the recommendations is found in Annex F.
Identified areas for improvement include:
- Challenges with respecting the timelines for:
- the immediate needs interview in one region (24 hours);
- the comprehensive nursing assessment (14 days);
- the CoMHISS assessment (14 days); and
- follow-up services flagged by the CoMHISS assessment process.
- No formal mechanism or systematized process in place to convey the status of an offender’s mental health screening;
- No monthly regional reception centre performance reports; and
- No reporting of performance information related to immediate needs interview.
Annex A
| Objectives | Criteria |
|---|---|
1.0 The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of inmates at intake meets departmental expectations and is working as intended. | 1.1 Policy Framework - The implemented management framework relating to mental health screening of offenders at intake is consistent with CSC policies. 1.3 Training – Adequate training is provided. 1.4 Thoroughness/Timeliness of services – Consistent with CSC’s management framework, screening of offenders at intake respects established timelines and offenders are referred for timely mental health services when mental health concerns are identified at intake. 1.5 Monitoring & Reporting - Monitoring practices and controls are adequate to ensure compliance with management framework for mental health screening of offenders at intake. Performance information is regularly reported. |
Annex B
| Process Steps | Responsible Organization | Responsible CSC Staff | Time Frame | Mental Health Referral | CD Reference | Forms/Systems Used | Context |
|---|---|---|---|---|---|---|---|
1. | Institution OPI - AW Interventions | Correctional Officer/ | Within 24 hours of arrival at Reception Centre | MH referral made by CX to Psychology Department if offender presents with serious mental health concerns | CD 705-3 | Flag for MH - 705 referral on OMS | Referral made to psychologist when CX is concerned that there may be MH concerns requiring urgent attention of Psychology Department |
| CSC Form 450 | Psychological Services - Referral to Psychologist CSC - form 450 | ||||||
2. | Health Care Services | Physical Health Care Nurse | Preliminary assessment within first 24 hour | MH referral made by Nurse to psychologist (Psychology Department) if offender presents with mental health concerns | CD 800 (page 5) CSC Form 450 | Psychological Services -Referral to Psychologist CSC - form 450 Flag for suicide risk referral on OMS | MH screening by Physical Health Nurse |
| Comprehensive assessment within 14 days | MH referral made by Nurse to psychologist (Psychology Department) if offender presents with mental health concerns | CD 800 CSC Form 450 | Psychological Services -Referral to Psychologist CSC - form 450 Flag for suicide risk referral on OMS ( NB Screening information put on offender Physical Health Care paper file | ||||
3. | Institution OPI - AW Interventions | CoMHISS administered by (i.e., mental health nurse, psychologist, psychology testing assistant or any other mental health professional | Between 72 hours and 14 days of admission | MH referral made to Psychology Department if offender presents with serious MH issues | CoMHISS Guidelines | CoMHISS | Automated CoMHISS records allow for tracking/monitoring and management reporting |
| CSC Form 450 | Psychological Services -Referral to Psychologist CSC - form 450 Flag for suicide risk referral on OMS |
Immediate (Mental Health) Needs Interview
Every offender should be interviewed within 24 hours of arrival at the institution to identify areas of need that require immediate attention including suicide risk and self-harm. This information is entered as “alerts”, “flags” or “needs” in the Offender Management System (OMS) as required.
Intake Health Status Assessment (24 hrs)
Within 24 hours of arrival at a CSC institution, every offender must be offered an assessment. The intake assessment must, at a minimum, screen for the following and make any necessary referrals to the appropriate health care professional: (mental health focus)
- acute medical or mental health conditions;
- conditions requiring continuing treatment (including mental health) ; and
- activity limitations8
Comprehensive Nursing Assessment (14 days)
Within 14 days of arrival at a CSC institution each offender must be offered a comprehensive health assessment. The comprehensive health assessment consists of: (mental health focus)
- inmate's health status (present, historical and family);
- health education and promotion programs to meet the identified health needs of individual inmates and specific inmate groups; and
- referral to other health care professionals if deemed appropriate.9
Computerized Mental Health Intake Screening System (CoMHISS)
Within 14 days of arrival at a CSC institution (but after the first 72 hours) each offender must be offered CoMHISS which is 3 computerized tests intended to provide a standardized approach to identifying offenders that require a more in-depth mental health assessment and/or intervention10.
Annex C
| Region | Sites |
|---|---|
Atlantic |
|
Québec |
|
Ontario |
|
Prairies |
|
Pacific |
|
Annex D
Review Methodology
Interviews: Interviews were conducted with the Warden, Deputy Warden (DW), Assistant Warden, Interventions (AWI), Chief of Health Services, Chief Psychologist, as well as a cross section of front line workers who were involved in the screening process, i.e., Correctional Managers (CMs), Correctional Officers (CXs), Nurses (physical and mental health) and Psychologists. Meetings were also held with the Assistant Commissioner, Health Services and Directors General, Health Services and Clinical Services and members of their staff at the National level.
Review of Documentation: Relevant documentation such as: CDs, process documentation, procedure manuals and management reports were reviewed.
Testing/File Review: Review of the Offender Management System (OMS) and CoMHISS records and management reports; and review a sample of physical health and psychology files for new offenders (direct from reception centre) for period January 1st , 2011 to March 31st , 2011, in order to determine if treatment had been identified and provided.
During the period January 1st, 2011 to March 31st, 2011 a total of 1,880 new offenders (1,785 males and 95 females) entered CSC institutions. A sample of 100 OMS records for male offenders from all five regions was reviewed. With the exception of the Prairie region, males typically spend 90 days in a regional reception centre undergoing screening before being sent to an institution to serve their sentence.
Female offenders usually receive mental health screening at the institution, which are all multi-level, where they start serving their sentence. Due to the much smaller numbers of female offenders coupled with the different resourcing levels in Women’s institutions, new female offenders have a lower risk to receive inadequate mental health screening than the male offenders. For these reasons and given the possible implications on a larger number of offenders, the focus of the OMS samples and health/psychology file review has been on male offenders.
Sample and Site Selection
Due to the moderate level of assurance required for this review, the review team used a judgmental sampling approach when defining sample size and location.
Reception centers for men and the multi-level institutions responsible for women offenders were examined in three regions: Pacific, Prairie, and Atlantic. In Ontario and Quebec regions, only management interviews at the men’s reception centres were performed.
Due to the small sample sizes, the sample results should be viewed as indicative and not statistically significant. As the primary purpose of the samples was to confirm the reasonableness of data included in the various management reports, this report primarily presents the information included in the management reports.
We also examined health files and psychology files in order to determine if offenders who are referred for mental health services receive the services in a timely manner at both the reception centre and after they are transferred to a receiving institution where they will start serving out the remainder of their sentence. In the region we tested, the majority of new offenders go from the regional reception centre to one receiving institution. In order to test follow up care, we selected a sample of 33 offenders who entered into the reception centre (during the period January 1st, 2011 to March 31st, 2011) and began serving their sentence at the primary receiving institution. The psychology and health files were examined in order to determine if referrals were made and follow on treatment was received.
Annex E
Timeliness/Thoroughness of Screening
| Region | ||||||||
|---|---|---|---|---|---|---|---|---|
| Vacancies | ATLANTIC | QUEBEC | ONTARIO | PRAIRIE | PACIFIC | NHQ | TOTAL | |
| Nurses: Positions | n | 101 | 175 | 159 | 174 | 141 | 18 | 767 |
| Vacancy Rate | n | 3 | 11 | 4 | 11 | 10 | 2 | 41 |
| % | (3.0) | (6.3) | (2.5) | (6.3) | (7.1) | (11.1) | (5.3) | |
| Psychologists: Positions | n | 37 | 74 | 84 | 78 | 43 | 5 | 323 |
| Vacancy Rate | n | 6 | 4 | 30 | 16 | 0 | 0 | 57 |
| % | (16.2) | (5.4) | (35.7) | (20.5) | (0) | (0) | (17.4) | |
Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.
| Region | |||||||
|---|---|---|---|---|---|---|---|
| ATLANTIC | QUEBEC | ONTARIO | PRAIRIE | PACIFIC | TOTAL | ||
Total Number | 40 | 10 | 10 | 10 | 30 | 100 | |
Completed on time | n | 18 | 10 | 10 | 10 | 30 | 78 |
| % | (45) | (100) | (100) | (100) | (100) | (78) | |
Completed but late | n | 22 | 0 | 0 | 0 | 0 | 22 |
| % | (55) | (0) | (0) | (0) | (0) | (55) | |
| Not completed | n | 0 | 0 | 0 | 0 | 0 | 0 |
| % | (0) | (0) | (0) | (0) | (0) | (0) | |
| Average Days Late | days | 3.6 | Compliant | Compliant | Compliant | Compliant | |
Source: OMS File Review
| Region | |||||||
|---|---|---|---|---|---|---|---|
| Nursing Assessment Within 24 hours | ATLANTIC | QUEBEC | ONTARIO | PRAIRIES | PACIFIC | TOTAL | |
| Total Number | n | 333 | 740 | 954 | 1160 | 354 | 3541 |
| Completed on time | n | 330 | 721 | 875 | 1096 | 333 | 3355 |
| % | (99.1) | (97.4) | (91.7) | (94.5) | (94.1) | (94.7) | |
| Completed but late | n | 2 | 6 | 53 | 33 | 18 | 112 |
| % | (0.6) | (0.8) | (5.6) | (2.8) | (5.1) | (3.2) | |
| Not completed | n | 1 | 13 | 26 | 31 | 3 | 74 |
| % | (0.3) | (1.8) | (2.7) | (2.7) | (0.8) | (2,1) | |
Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.
| Region | |||||||
|---|---|---|---|---|---|---|---|
| Form 12454 Section II-23 | ATLANTIC | QUEBEC | ONTARIO | PRAIRIE | PACIFIC | TOTAL | |
| Total Number | n | 329 | 740 | 954 | 1156 | 353 | 3532 |
| Completed on time | n | 315 | 267 | 274 | 837 | 244 | 1937 |
| % | (95.7) | (36.1) | (28.7) | (72.4) | (69.1) | (54.8) | |
| Completed but late | n | 8 | 360 | 428 | 197 | 94 | 1087 |
| % | (2.4) | (48.6) | (44.9) | (17.0) | (26.6) | (30.8) | |
| Not completed | n | 6 | 113 | 252 | 122 | 15 | 508 |
| % | (1.8) | (15.3) | (26.4) | (10.6) | (4.2) | (14.4) | |
Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.
| Region | |||||||
|---|---|---|---|---|---|---|---|
| ATLANTIC | QUEBEC | ONTARIO | PRAIRIES | PACIFIC | TOTAL | ||
| Total new WoC | n | 567 | 1061 | 1495 | 1635 | 491 | 5249 |
| Total new WoC screened by CoMHISS | n | 472 | 828 | 807 | 1287 | 462 | 3856 |
| % | (83.2) | (78.0) | (53.9) | (78.7) | (94,1) | (73,5) | |
| Screened within timeframes | n | 315 | 470 | 492 | 829 | 445 | 2551 |
| % | (55.6) | (44.3) | (32.9) | (50.7) | (90.6) | (48.6) | |
| Screened but late | n | 157 | 358 | 315 | 458 | 17 | 1305 |
| % | (27.7) | (33.7) | (21.1) | (28.0) | (3.5) | (24.9) | |
| Refused to participate in screening | n | 42 | 121 | 69 | 146 | 7 | 385 |
| % | (7.4) | (11.4) | (4.6) | (8.9) | (1.4) | (7.3) | |
| Total new WoC not screened by CoMHISS (excludes refusals) | n | 53 | 112 | 619 | 202 | 22 | 1 008 |
| % | (9.3) | (10.6) | (41.4) | (12.4) | (4.5) | (19.2) | |
Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.
| Region | |||||||
|---|---|---|---|---|---|---|---|
| ATLANTIC | QUEBEC | ONTARIO | PRAIRIES | PACIFIC | TOTAL | ||
| Total number of offenders screened by CoMHISS | n | 498 | 983 | 914 | 1394 | 486 | 4275 |
| Offenders flagged | n | 339 | 598 | 523 | 893 | 299 | 2652 |
| % | (68.1) | (60.8) | (57.2) | (64.1) | (61.5) | (62.0) | |
| *Offenders excluded from analysis | n | 15 | 64 | 12 | 77 | 23 | 191 |
| Offenders flagged who received follow-up | n | 254 | 435 | 310 | 575 | 191 | 1765 |
| % | (78.4) | (81.5) | (60.7) | (70.5) | (69.2) | (71.7) | |
Note. At least 71.7% of offenders identified by CoMHISS received follow-up services. As per CD 705, supplementary mental health assessments shall be completed 50 calendar days after admission or 40 calendar days from referral. As such, some offenders flagged by CoMHISS would not be expected to have received institutional mental health service until after the March 31, 2011 cut-off considered in this report.
Note. Percentages may not always sum up to 100% due to rounding.
*Note: Offenders were excluded from the analysis if their identifying information such as their FPS number, name and date of birth could not be validated against OMS data. Those excluded were subtracted from the denominator of the number of offenders flagged by COMHISS before calculating follow-up compliance.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.
Annex F
Review of Mental Health Screening at Intake
Management Action Plan (MAP)
| Recommendation: | Recommendation No. 1 The Assistant Commissioner, Health Services, based on a review of the appropriateness of timelines, should adjust current timelines for the Comprehensive Nursing Assessment and CoMHISS to address identified causes of delays in timeliness, determine the impact of any changes, and implement the revised standard, as required. |
|---|---|
| Management Response / Position: |  Accepted Accepted in part Rejected |
| Action(s) | Deliverable(s) | Approach | Accountability | Timeline for Implementation |
|---|---|---|---|---|
What action(s) has / will be taken to address this recommendation? | Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) | How does this approach address the recommendation? | Who is responsible for implementing this action(s)? | When will action(s) be completed to fully address the recommendation? |
The ACHS will conduct a review of the relevant policies and clinical practice documents, taking into consideration the rationale for the 14 days timeframe for the Comprehensive Nursing Assessment and CoMHISS, and the possible implications of changing timeframes on other processes and procedures. | A review outlining the possible implications of a timeframes change will be completed | The review will determine whether a change to the timeframe is justified | ACHS | June 2012 |
The ACHS, based on the review, will implement new timeframes if warranted | Changes to the existing timeframe in all the relevant CSC systems and documents, if required. | Timeframes will be adjusted if warranted. | ACHS | October 2012 |
| Recommendation: | Recommendation No. 2 The Regional Deputy Commissioners, in collaboration with the Regional Directors, Health Services, should identify and implement measures to improve the timelines of mental health screening at intake. |
|---|---|
| Management Response / Position: | Accepted Accepted in part Rejected |
| Action(s) | Deliverable(s) | Approach | Accountability | Timeline for Implementation |
|---|---|---|---|---|
What action(s) has / will be taken to address this recommendation? | Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) | How does this approach address the recommendation? | Who is responsible for implementing this action(s)? | When will action(s) be completed to fully address the recommendation? |
1.a) RDCs, in collaboration with RDs Health Services, will review their intake process from a Mental Health screening perspective and identify challenges, issues and solutions to improve the timeliness of mental health screening at intake. The review will focus on the Comprehensive Nursing Assessment (14 days), the CoMHISS testing (3-14 days) and the Immediate Needs Interview (Atlantic Region) | Each Reception Unit (16) will produce a summary of findings. | Identifying challenges, issues and solutions to improve the timeliness of mental health screening at intake will identify concrete actions to put in place in each reception unit and consequently improve the timeliness of their screening process. | June 2012 | |
1.b) RDCs, in collaboration with RDs Health Services, will implement corrective measures, adapted to each reception unit needs, to improve the timeliness of mental health screening at intake | Site specific changes to increase timeliness. | Implementing measures to address the operational challenges that interfere with the timeliness of mental health screening at intake will improve our compliance rate with timeframes. | RDCs | June 2012 – Onward |
1.c) ACHS will continue to monitor and report compliance statistics on a quarterly basis on the timeliness of mental health screening | Mental health performance quarterly reports | Regular monitoring and reporting will ensure solutions lead to improve timeliness of mental health screening | ACHS | Ongoing |
| Recommendation: | Recommendation No. 3 The Assistant Commissioner, Health Services and the Assistant Commissioner, Correctional Operations and Programs with the help of the Senior Deputy Commissioner, given her information management responsibilities, should identify options for leveraging information to track dates of completion of mental health screening and to alert institutional management of late completions. This information should be aggregated to produce a monthly regional reception centre performance report. |
|---|---|
| Management Response / Position: | Accepted Accepted in part Rejected |
| Action(s) | Deliverable(s) | Approach | Accountability | Timeline for Implementation |
|---|---|---|---|---|
What action(s) has / will be taken to address this recommendation? | Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) | How does this approach address the recommendation? | Who is responsible for implementing this action(s)? | When will action(s) be completed to fully address the recommendation? |
1.a) ACHS, in collaboration with ACCOP and SDC, will identify possible options to develop a system to electronically record dates of completion of mental health screening (4) and alert management to late completions. The options should also allow the aggregation of information to produce monthly regional reception centre performance reports. | Possible options are identified. | An electronic system will allow for performance monitoring at the individual offender, regional, and national levels. | ACHS | May 2012 |
1.b) SDC will develop a system to electronically record dates of completion of mental health screening (4) and alert management to late completions. The solution will allow the aggregation of information to produce monthly regional reception centre performance reports | National roll out of the solution | SDC | Targeting Fall 2012 OMS release | |
2. In the interim, prior to the development of the system, RDCs, in collaboration with ACCOP and ACHS, will have Managers Assessment Intervention at Intake Units manually track dates of completion of mental health screening and alert reception centre management of late completions. | Quality assurance MAIs in place and the template for tracking and reporting of information developed | As an interim measure, completion of screening measures (4) will be reported manually | RDCs | June 2012 |
3. a) In the interim, the ACHS, in collaboration with ACCOP and ACPR, will identify a process to extract the information on the performance of the immediate needs suicide checklist. | The process is identified | Identification of the process will allow HSPMP 2011-2012 to include information on the performance of the Immediate needs suicide checklist. | ACHS | February 2012 |
3. b) The ACHS will then amalgamate the performance statistics (CoMHISS and nursing assessment) together in the same report and distributed to Regions on a quarterly basis. | Quarterly reports will integrate mental health screening compliance data, beginning in Q4 FY 2011-12. | Integration of existing but separate performance reports will provide regional management with more comprehensive mental health screening data for ongoing quality improvement. | ACHS | August 2012 |
| Recommendation: | Recommendation No. 4 The Assistant Commissioner, Health Services, in collaboration with the Assistant Commissioner, Correctional Operations and Programs, should ensure that the HSPMP 2011-2012 includes information on the performance of the immediate needs interview. |
|---|---|
| Management Response / Position: | Accepted Accepted in part Rejected |
| Action(s) | Deliverable(s) | Approach | Accountability | Timeline for Implementation |
|---|---|---|---|---|
What action(s) has / will be taken to address this recommendation? | Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) | How does this approach address the recommendation? | Who is responsible for implementing this action(s)? | When will action(s) be completed to fully address the recommendation? |
1.a) ACHS, in collaboration with ACCOP and ACPR, will identify a process to extract the information on the performance of the immediate needs suicide checklist. The feasibility of integrating the data from the four activities together to generate a single measure of compliance will be determined. | The process is identified | Identification of the process will allow HSPMP 2011-2012 to include information on the performance of the Immediate needs suicide checklist | ACHS | February 2012 |
1.b) ACHS, contingent to the process identified to extract and integrate the information on the performance of the immediate needs suicide checklist, will include this information in the HSPMP 2011-2012 | Performance information of the immediate needs suicide checklist will be included in the HSPMP 2011-2012 | ACHS | November 2012 |
1 A Roadmap to Strengthening Public Safety, (Recommendation #50, p. 225).
2 Computerized Mental Health Screening System (CoMHISS) National Guidelines, (Introduction #2, p.3)
3 Institutional Mental Health Service (Primary Care) Guidelines, (Integration with Clinical Services (CS) (Health Services), p.9)
4 Recommendation requires management’s attention, oversight and monitoring.
5 Institutional Mental Health Service (Primary Care) Guidelines, (Transfer and Termination of Care, p.20)
6Recommendation requires management’s attention, oversight and monitoring.
7 Recommendation requires management’s attention, oversight and monitoring.
8 CD 800 (paragraph 20)
9 CD 800 (paragraph 21)
10 2010-2011 HSPMP, Page 25.
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