We provided the draft report to the BOP for review and requested written comments. The BOP’s written response is included as Appendix XI of this report. The BOP agreed with all of our recommendations and proposed corrective action appropriate to resolve the recommendations. However, in its only comment on the extensive content of the draft report, the BOP objected to a sentence on page 55 reading “The BOP institutions did not provide necessary medical care to inmates.” This sentence was included in the draft report as a very brief summary of Finding 1, which is also referenced on page 55. In response to the BOP’s statement, we reviewed our draft report’s language on page 55 and revised it to summarize more precisely Finding 1. The revised statement on 55 now reads “The BOP’s institutions did not always provide recommended preventative medical services to inmates.”

We provide below our analysis of the BOP’s response to the recommendations.

1. Resolved. We recommended the BOP establish procedures for collecting and evaluating data for each current and future health care initiative to assess whether individual initiatives are cost-effective and producing the desired results. The BOP agreed and stated that it will establish protocols for collecting and evaluating data. The recommendation can be closed when we review the procedures the BOP establishes to assess the cost effectiveness of its initiatives.

2. Resolved. We recommended the BOP review the medical services that the OIG and the BOP’s Program Review Division identified as not always provided to inmates and determine whether those medical services are necessary, or whether the medical service requirement should be removed from the Clinical Practice Guidelines. The BOP agreed with the recommendation. It stated that in January 2008, it reviewed all of its Clinical Practice Guidelines and identified certain guidelines for revision. The BOP also stated that it will highlight its Program Review Division’s quarterly reports in on-line training sessions, with the first session taking place in April 2008. We request that the BOP provide us with a list of guidelines identified for revision and the time frame for accomplishing the revisions. The recommendation can be closed when we review revisions to the Clinical Practice Guidelines.

3. Resolved. We recommended the BOP issue clarifying guidance to the institutions regarding the medical services that the BOP decides are necessary for BOP medical providers to perform. The BOP agreed and stated that by April 2008 it will issue guidance to its institutions underscoring the importance of the Clinical Practice Guidelines. The recommendation can be closed when we review the BOP’s clarifying guidance.

4. Resolved. We recommended the BOP strengthen management controls to ensure proper administration of BOP medical contracts by providing guidance and procedures to all BOP institutions. The BOP agreed and stated that by April 2008 it will issue guidance to all Bureau Contracting Officers and Health Services Administrators regarding medical contract administration procedures. The recommendation can be closed when we review the BOP’s guidance.

5. Resolved. We recommended the BOP develop a process to use the program summary reports prepared by the Program Review Division to develop or clarify agency-wide guidance on systemic deficiencies found during program reviews. The BOP agreed and stated that it will issue guidance regarding systemic deficiencies found during program reviews through periodic on-line training sessions, the first of which will begin in May 2008. The recommendation can be closed when we receive documentation showing the BOP has developed a process and issued guidance.

6. Resolved. We recommended the BOP ensure initial privileges, practice agreements, or protocols are established for all practitioners, as applicable. The BOP agreed and stated that by April 1, 2008, it will issue guidance clarifying to institutions the importance of ensuring that applicable privileges, practice agreements, protocols, and peer reviews are handled in a timely manner, and the potential consequences of failure to do so. While we agree that clarified guidance is, in part, appropriate to address this recommendation, it is not clear to us how the issuance of clarified guidance alone will ensure the establishment of privileges, practice agreements, and protocols. We believe that ensuring the establishment of these items requires a mechanism such as testing during program reviews, submission of periodic certification statements, submission of periodic reports by institutions, or some other appropriate verification technique. We request that the BOP explain how the implementation of the clarified guidance will be verified. The recommendation can be closed when we review the BOP’s clarifying guidance and documentation for the verification mechanism.

7. Resolved. We recommended that the BOP ensure privileges, practice agreements, and protocols are reevaluated and renewed in a timely manner. The BOP agreed and stated that the guidance it plans in response to Recommendation 6 will also address this recommendation. As with Recommendation 6, we agree that clarified guidance is, in part, appropriate to address this recommendation, but it is not clear to us how the issuance of clarified guidance alone will ensure that privileges, practice agreements, and protocols are reevaluated and renewed in a timely manner. We believe a verification technique also is needed for this recommendation, and we request that the BOP explain how the implementation of the clarified guidance will be verified. The recommendation can be closed when we review the BOP’s clarifying guidance and documentation for the verification mechanism.

8. Resolved. We recommended the BOP ensure that practitioners are not allowed to practice medicine in BOP institutions without current privileges, practice agreements, or protocols. The BOP agreed and stated that the guidance it plans in response to Recommendation 6 will also address this recommendation. As with Recommendation 6, we agree that clarified guidance is, in part, appropriate to address this recommendation, but it is not clear to us how the issuance of clarified guidance alone will ensure that practitioners are not allowed to practice absent current privileges, practice agreements, or protocols. We believe a verification technique also is needed for this recommendation, and we request that the BOP explain how the implementation of the clarified guidance will be verified. The recommendation can be closed when we review the BOP’s clarifying guidance and documentation for the verification mechanism.

9. Resolved. We recommended the BOP ensure that peer reviews of all providers are performed within the prescribed time frames. The BOP agreed and stated that the guidance it plans in response to Recommendation 6 will also address this recommendation. As with Recommendation 6, we agree that clarified guidance is, in part, appropriate to address this recommendation, but it is not clear to us how the issuance of clarified guidance alone will ensure that peer reviews are performed within the prescribed time frames. We believe a verification technique also is needed for this recommendation, and we request that the BOP explain how the implementation of the clarified guidance will be verified. The recommendation can be closed when we review the BOP’s clarifying guidance and documentation for the verification mechanism.

10. Resolved. We recommended to the BOP that, until the training program on accumulating and reporting performance data is implemented, it issue guidance to all institutions on how to accumulate and report data for the health care performance measures to ensure consistency in the way institutions collect and report performance data. We also recommended that, once the training program is fully developed, the BOP ensure that appropriate institution staff receives the training. The BOP agreed and stated that by May 1, 2008, it will issue guidance to all institutions on how to accumulate and report data for the health care performance measures to ensure consistency in the way institutions collect and report performance data. Data collections and reporting will also be addressed in on-line training. The recommendation can be closed when we review the BOP’s guidance to institutions and receive documentation showing that appropriate institution staff have received the on-line training.

11. Resolved. We recommended the BOP establish a process for reviewing the health care performance measures reported by institutions that includes actions that will be taken when institutions are not meeting the target performance levels. The BOP agreed and stated that it issued a memorandum on February 12, 2008, to all Bureau Wardens, notifying them of changes to the national performance measures and reiterating the policy requirement to collect and report these measures. An on-line training session for institution Health Services staff was conducted February 13, 2008, to discuss the changes and the reporting requirements. The BOP stated that the Health Services Division’s Office of Quality Management will be collecting and reviewing this data semiannually and reporting to the Regional Medical Directors when institutions are not meeting the expected target levels. The BOP stated that Regional Medical Directors will ensure that national performance measures are addressed at each institution under their oversight. The BOP further stated that Regional Medical Directors will assess target level failures, provide recommendations for improvement, and follow-up during Clinical Director peer reviews. The recommendation can be closed when we review the February 12, 2008, memorandum and documentation for the on-line training conducted on February 13, 2008, showing the subjects covered.