Journal of Palliative Care & Medicine
Open Access

Specialized palliative care; Patient perspective; Health information technology; Quality indicators; Stakeholder engagement

Introduction

As the number of older persons in jail grows across the world, providing palliative care to this group is becoming increasingly important [1-5]. Compassionate release should always be the first option considered for persons in jail who require palliative or end-oflife care. The reality of the many impediments to release at the end of life, however, demands the provision of high quality basic palliative care within jails [6-8]. People in jail should have fast access to an appropriate specialised palliative care service, such as one within a tertiary hospital, if their palliative care needs beyond the limits of basic palliative care or if they deteriorate rapidly. While many of these people's basic palliative care requirements are met internally by correctional healthcare staff, [9] giving care to individuals with complicated or growing palliative care needs is more difficult in the prison setting [10]. Despite these rising demands, there is no regulated method to providing palliative care in prisons, and there is little data on the quality and accessibility of prison-based palliative care for people in need [11]. Routine monitoring and reporting of jail healthcare using quality indicators is underutilised in comparison to other healthcare settings, [12] making it difficult to evaluate the care that individuals in prison get. Creating agreedupon criteria and quality indicators for palliative care in prisons is a critical step towards making high-quality palliative care accessible and equitable. Quality indicators encourage openness and accountability while aiming to enhance specific outcomes [13,14]. It is difficult to identify areas where treatment does not satisfy patient requirements or conform with established standards without quality indicators that clearly assess and compare healthcare to an agreed-upon baseline. Lessons gathered from comparable attempts in other situations within the community can be used to design these indicators.

Examining the few published jail healthcare indicator sets, as well as community-based palliative care indicators, will aid in the construction of prison-based palliative care indicators.

Evidence gathering: data availability

The scarcity of standardised data for comparing countries in both community palliative care [15,16] and general jail healthcare [17,18] is a significant impediment to the creation and implementation of palliative care indicators. Even in nations classified as offering high quality palliative care, national palliative care-oriented datasets in the community are not universally implemented, despite the fact that enhancing standardised data collecting for service improvement is a generally acknowledged aim [15]. Even within established systems where data on palliative care activities is routinely gathered, uneven reporting within and across services makes assessing palliative care quality problematic [19,20]. Jail health data is highly regarded internationally [21-24], but it is inconsistently recorded and difficult to acquire [17], restricting performance evaluation inside jail healthcare systems [18,21-25]. Improving data collecting items and tactics is a critical first step towards implementing quality indicators.

It is necessary to increase the ability to collect frequent, clinically valuable data on the organisation, methods, and results of prisonbased palliative care [21]. Health information technology, which incorporates automated data extraction from electronic health records, is a cost-effective alternative to time-consuming human data retrieval, and it allows for greater flexibility in the frequency and emphasis of data gathering. However, in the penal system, these elements are frequently missing or underutilised [22]. While these changes are being implemented, the initial creation of indicators should be pragmatic in order to accommodate for limited resources and health information systems. Emphasis should be placed on indicators that utilize readily available data from existing systems, accurately reflect palliative care within the prison context, and are widely recognized as effective measures of health in community settings [17]. This will encourage the gradual and long-term establishment of data collecting, extraction, analysis, and feedback mechanisms for improving palliative care quality.

Finding the right balance: indicators

Another critical factor to consider is the sort of indicators to be generated. Currently, both the community palliative care and the jail indicator sets include an unbalanced distribution of variables that assess the structure of the healthcare system, the process of care and care activities, and the outcomes of patients who receive treatment [13]. Community palliative care indicators have tended to focus on palliative care procedures and outcomes rather than structural measurements, which have risen over time [15]. Process variables that characterised care delivery were significantly valued by prison-based indicators.

While it is acknowledged that an indicator set does not require an equal quantity of each kind, each indicator type adds unique and significant information about healthcare, and employing some combination of the three balances each's strengths and limitations. As a result, given the prison setting's lack of outcomes indicators, the expanding emphasis on outcomes indicators in community palliative care sets should be better mirrored in future jail-based palliative care indicators. Though patient-reported outcome and experience measures are arguably more difficult to assess, more difficult to interpret, and do not always directly translate to improvement strategies, they provide an important holistic reflection of healthcare quality rather than a single process within a larger system. Structural metrics of quality palliative care may also be useful in understanding differences in facility and equipment among correctional institutions, provinces, and nations. Staffing and equipment shortages are widespread, but resource and organisational metrics are rarely included in existing jail quality indicator sets. Establishing benchmarks for fundamental training in palliative care for healthcare professionals, guaranteeing the presence of essential equipment like pressure mattresses and accessible features within the physical environment, and evaluating the percentage of correctional facilities that meet these criteria can contribute to the widespread availability of essential components of palliative care in all prisons. As a result, persons may be less likely to be admitted to the hospital for palliative care requirements that would generally be addressed outside of an acute care setting. Indicator development to reflect environmental changes Given the variations in demographics and medical conditions between palliative care populations in the community and prisons, and the absence of evidence-based clinical guidelines specifically tailored for correctional settings, it is probable that the future development of indicator sets for prison palliative care will necessitate a blend of adopting community indicators and consensus-driven adaptation or creation of indicators specifically designed for the prison environment. Greater national and international coordination, as proposed in the community [15], would reduce duplication of effort in constructing prison palliative care indicator sets. There are no clear parameters describing how to determine which existing community-based indicators are appropriate for use in the prison environment, which elements are acceptable to adapt. Without clear criteria to standardise these options, newly created sets may deviate from the research base and community care standards, causing prison-based quality metrics to no longer represent best-practice care. In the absence of evidencebased recommendations, extensive, iterative engagement with a wide range of stakeholders will ensure that indicators created are practicable, focus on acknowledged special requirements within the prison system and population, and are suitable for application across many prison systems. Co-designing indicators with important external and internal correctional stakeholders will assist to focus development on prisonspecific palliative care health challenges and ensuring that all new indicators, when feasible, meet evidence-based community standards. Involvement of persons who have been through incarceration should also be examined to enhance the inclusion of the patient perspective, which is becoming more important in community-based healthcare assessment. Mechanisms such as 'citizen's juries' made up of individuals in jail, which were recently utilised for defining health priorities in Australian prisons, may be a helpful tool for incorporating the patient voice. Conclusion Standardised, prison-based palliative care indicators will give vital data to expand the spectrum of service and enhance its quality and accessibility. A collaborative approach to indicator production would lessen the cost of producing indicators and allow core indicators to be gathered and compared across regions or nations, while still allowing for the inclusion of indicators relevant to local requirements. Prioritisation is critical during the early phases of development since practical factors will restrict the number of indicators that can be operationalized. The best sustainable strategy to a complete indicator collection will be to start small with simple, clinically meaningful metrics and build on incremental gains. It will be easier to close the growing gap between patient need and reachable treatment by taking practical steps to improve palliative care in jails that draw on lessons learned in the community.

Acknowledgement

Not applicable.

Conflict of Interest

There are no conflicts of interest.

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