Chapter 1 – Health Care Governance and Administration

Policy

• The California Department of Corrections and Rehabilitation (CDCR), Division of Health Care Services (DHCS), and California Correctional Health Care Services (CCHCS) [referred to jointly in this policy as “Health Care Services (HCS)”] shall promote organizational decision-making that is standardized and systematic, incorporates a broad range of perspectives, and creates alignment with the strategic vision, mission, and goals of the organization.

• HCS shall maintain a standardized governance structure, driven by its Governing Body (GB) at the highest level, and consisting of multi-disciplinary leadership teams at headquarters and institution levels that will guide the statewide strategic vision and performance objectives for the organization.  The governance structure shall also encompass standardized systems, processes, and procedures for key governance functions including, but not limited to:

  • Strategic planning at the enterprise, region, and institution levels, and within specific programs and departments to ensure that all levels of the organization are aligned in pursuing strategic goals.

  • Elevation of critical program concerns.

  • Making decisions, including mechanisms for gathering input from stakeholders and staff at various reporting levels throughout the organization, and conflict resolution.

  • Developing and vetting statewide policies and guidelines to ensure appropriate multi-disciplinary participation, high-quality products, and acceptance among staff implementing the policies or guidelines.

  • Communicating important organizational messages quickly and efficiently throughout the organization.

  • Routinely evaluating and improving program performance and holding leadership accountable for outcomes.

  • Sustaining processes that work well.

  • Providing orientation, ongoing development, and feedback for key leaders within the organization.

  • Maintaining the quality and safety of patient care through performance evaluation and improvement including peer review, quality management, and patient safety and risk management systems.

Purpose

• To:

• Ensure delivery of appropriate, quality health care in a cost-effective manner with minimized risk to patients;

• Manage and consider the needs and expectations of stakeholders;
  

• Respond appropriately to changes in government and the health care industry, including changes in patient demographics and case mix, financial constraints, advances in research and technology, public expectations, and legal and regulatory mandates;

• Preserve quality of care and economic viability over time; and

• Adhere to federal and state laws and regulations.

Responsibility

• The Undersecretary, Health Care Services, and Directors of CCHCS are responsible for statewide planning, implementation, and evaluation of the governance structure and processes.

• HCS departmental leadership at all levels of the organization, within the scope of their authority, are responsible to support and participate fully in the governance structure and processes and to ensure their staff are aware of and adhere to governance processes and procedures.

Procedure Overview

• The GB is the highest-level committee in the network of headquarters and institution committees that makes up the HCS organizational governance structure and has ultimate oversight but delegates decision authority to the local GBs and other committees as needed.  Within the HCS Governance Structure, the GB is ultimately accountable for quality patient care and treatment and services provided by employees and contractors.  Among other tasks, the GB defines the strategic direction of the organization, determines the organizational structure and delivery system design, ensures that the organization has sufficient resources to accomplish strategic goals including prepared and competent staff, and continuously evaluates and improves performance ensuring accountability, particularly among key leaders and licensed clinicians.

• The membership of the GB is comprised of the highest-level executives within HCS as well as the leaders from essential stakeholder groups.  The GB shall set the tone for the organizational communication, culture, leadership, and strategic direction.  The GB shall also determine how the organization will achieve strategic goals and make critical decisions regarding delivery system design and department and program structure and resourcing.  The GB shall evaluate organizational performance on an ongoing basis and set improvement priorities for the organization.

Procedure

• Committee Scope and Responsibilities

  • The GB performs the following functions:

    • Strategic Direction

      • At least annually, conduct an organizational assessment to plan and manage change, analyzing the evolving needs of the patient population; organizational strengths and weaknesses; trends in government, the health care industry, and technology; legal and regulatory issues; and potential risks to the organization.

      • Define a clear vision for the organization, incorporating input from staff and stakeholders.

      • Publish the organization’s strategic plan and update at least annually to include the organization’s vision, mission, values, and strategic goals.

      • Ensure communication of the strategic plan to all levels of the organization.

      • Create a responsible, accountable environment of teamwork and continuous improvement that enables the organization to fulfill its mission and meet or exceed goals.

      • Determine the system for communicating important organizational messages through all reporting levels and periodically assess the effectiveness of communication methods.

      • Foster collaboration and coordination within the organization and with stakeholders in the public and private sector.

      • Create partnerships with other federal and state agencies, correctional organizations, non-profit groups, and other stakeholders to create synergies, leverage resources, and improve care.

      • Provide for and comply with the organization’s Code of Conduct.

    • Organizational Structure and Delivery System Design

      • Provide a framework to accomplish the goals of the strategic plan including resource allocation and organizational policies.

      • Determine the model of care that will be used to provide services to patients and the services that will be offered including the design of institution missions for cost-effective care.

      • Define and document the organization’s major programs and departments, the scope of services and goals for each major program and department, the organizational reporting structure and lines of authority within the organization, and span of control of key leadership positions.

      • Approve regulations and statewide policies and procedures.

      • Establish a system for conflict resolution between programs or departments.

    • Resources

      • Direct sufficient resources to attain the organization’s mission and vision, and meet strategic goals.

      • Plan and manage the organization’s budget including budget projections, approval of Budget Change Concepts and Proposals, Finance Letters and other revisions to the Governor’s Budget, and ongoing oversight and strategic management of spending deficits and surplus.

      • Approve:

        • Staffing formulas and matrices.

        • The statewide plan for staff recruitment, retention, development, and continuing education as well as the model for identifying and assessing civil service and contract staff competencies.

        • Master contracts for statewide services.

        • The statewide plan for facility modifications.

        • Statewide information systems and data infrastructure design.

      • Develop and coach leaders at every level of the organization to fulfill the organization’s mission and vision and meet strategic goals.

    • Performance Evaluation and Improvement – Health Care System

      • Maintain the quality and safety of patient care and promote performance evaluation and improvement.

      • Approve the design of the quality management and patient safety and risk management systems including the systems used to measure the performance of the organization’s governance, management, clinical, and support functions.

      • Ensure the organization’s participation in legally required public reporting and national quality measurement efforts.

      • Approve improvement priorities for the organization.

      • Assess the organization’s performance on an ongoing basis, intervening as necessary to ensure performance objectives and strategic goals are achieved.

      • Determine mechanisms and provide individual areas of the organization with regular feedback on their progress toward strategic goals.

      • Individual GB members: Personally participate in improvement initiatives.

      • Evaluate the effectiveness of quality management, patient safety, and risk management systems including the performance evaluation system, improvement projects, tools and techniques, and efforts to build improvement capacity through staff development and support modifications to these systems to make them more effective.

      • Review and approve an annual aggregate report of the Root Cause Analyses completed each year including the nature of the system failures they revealed and the actions taken to mitigate risk.

    • Evaluation and Improvement – Professional Practice

      • Approve policies governing statewide credentialing, privileging, and peer review processes (routine and non-routine) for licensed medical providers as well as professional ethics policies.

      • Evaluate the effectiveness of the professional practice system in establishing and maintaining a high quality clinical workforce.

      • Oversee and direct as needed the Health Care Executive Committee (HCEC) performance of the following:

        • Acting on all recommendations and Final Proposed Actions, which may include accepting findings and recommendations, accepting findings and determining a different Final Proposed Action, remanding matters for additional investigation or deliberation, and rescinding or terminating peer review and privileging actions.

        • Ensuring that licensed medical providers subject to HCEC review have been provided due process during that review and that HCEC findings and actions are supported by “substantial evidence.”

• Committee Membership

  • The following staff shall serve as standing members of the Health Care Services’ GB:

    • Federal Court Receiver

    • Undersecretary, Health Care Services

    • Director, Health Care Services

    • Director, Health Care Policy and Administration

    • Director, Corrections Services

    • Director, Division of Adult Institutions

    • Director, Legislation, ISUDT, and Communications

    • Director, Information Technology Services Division

    • Chief Counsel, CCHCS Office of Legal Affairs (advisory role only)

  • Any changes or additions to the membership shall be approved by the GB.

  • Standing members shall not designate attendance at GB meetings or voting proxy to anyone without the prior approval of the Chairperson, and only where necessary to allow the GB to conduct business.  If a quorum is present at a GB meeting, a request to designate an alternate individual to attend a meeting or to vote shall be disapproved. Any approved designee shall not be any lower than at the Director level organizationally.

  • The GB may invite guest participants to meetings at any time that additional insight, expertise, or testimony is needed to support discussion and decision-making.

  • Guests are only permitted with prior authorization from the GB Chairperson [refer to Section (e)(2)(G)].

  • Members of the GB are required to:

    • Understand the scope and purpose of the GB.

    • Review all materials in advance of GB meetings.

    • Present on agenda topics as requested by the Chairperson or other committee members.

    • Provide input in discussions.

    • Vote on motions.

    • Complete action items assigned to their by specific deadlines.

    • Serve as a performance improvement champion, demonstrating visible leadership by directly participating in high-priority improvement initiatives.

    • Notify the Chairperson of planned absences so that the Chairperson may determine whether a quorum of the GB will be present for the meeting at which a member or members may be absent and consider whether it would be appropriate or necessary for the absent member(s) to designate an alternate attendee.

  • The Director, Health Care Services, shall serve as the GB Chairperson.  The Chairperson retains all the responsibilities of a GB member and also ensures that:

    • The GB meets at least quarterly and as often as necessary to manage the required Committee Scope and Responsibilities as outlined in Section (e)(1).

    • Agenda topics are consistent with the Committee Scope and Responsibilities.

    • Meetings do not proceed unless a quorum is present.

    • Meeting materials are distributed to GB members at least three calendar days in advance of meetings.

    • A formal record of all GB meetings is kept including committee topics, discussion, conclusions and resolutions, and actions.

• Committee Voting

  • A quorum shall exist when a simple majority of the voting membership is present. A quorum is necessary to conduct the business of the GB. A member may attend, participate in, and be counted towards a quorum via telephone conference call. In the event of a tie, the Chairperson shall be allotted an additional vote in order to break the stalemate.

  • Each GB voting member shall have one vote on any matter that comes before the GB.  Only duly appointed members or approved designees shall vote on GB matters. A motion carries when it receives a simple majority of the vote.

  • All voting members may vote on any matters coming before the GB regardless of the subject matter, program area, or health care discipline at issue.

  • The GB may use electronic voting to address urgent issues that require action prior to the next scheduled meeting or to resolve an existing agenda item.

  • Parliamentary Law and Rules of Order for the 21st Century (Lochrie), most recent edition, shall govern parliamentary procedures.

• Meeting Frequency

  • The GB shall meet at least quarterly and as often as necessary to manage the required Committee Scope and Responsibilities as outlined in Section (e)(1).  The Chairperson may schedule special meetings of the GB at their discretion.

• Documentation and Confidentiality Provisions

  • The proceedings and records of the GB shall be confidential and protected from discovery to the extent permitted by law.

• Conflict of Interest

  • Regular voting members of the GB, as CDCR and CCHCS employees, shall comply with applicable laws and regulations regarding disclosure of outside employment, enterprises or activities, and prohibitions against engaging in conflicts of interest.  These include the California Code of Regulations, Title 15, Sections 3409 and 3413 as well as pertinent provisions of the Government Code, Public Contracts Code, and the Fair Political Practices Act (FPPA).  Among other things, these requirements prohibit CDCR and CCHCS employees from deriving any compensation from any entity doing or seeking to do business with the state.

  • Concurrently with their annual completion and submission of the Statement of Economic Interests (Form 700) pursuant to the FPPA, members of the GB shall provide a copy of their submitted Form 700 to the GB Chairperson to be kept on file for reference in the event that a member’s ability to participate in a GB decision may be impacted by an actual or potential conflict of interest.

  • If any matter of business before the GB represents an actual or potential conflict of interest for any member, they shall disclose the conflict or potential conflict to the GB and recuse themself from participating in any discussion or voting on the matter creating the conflict or potential conflict.

  • Final decisions regarding conflict of interest questions shall be decided by the GB Chairperson.  In the event that the GB Chairperson has an actual or perceived conflict of interest, final decisions regarding the conflict of interest shall be decided by the Undersecretary, Health Care Services.

• Closed Session

  • When considering matters from the HCEC, the GB may meet in closed session.  The GB may exclude from its meeting any person the GB deems not authorized to participate in discussion regarding credentialing, privileging, or peer review matters.  When considering matters from the HCEC, the confidentiality of those matters is protected by Evidence Code Section 1157.

Policy

• Where mandated by Title 22 of the California Code of Regulations (i.e., for those licensed facilities with a Correctional Treatment Center) or where required by an accrediting organization such as the Joint Commission, institutions shall have a Local Governing Body (LGB). 

• The LGB shall act at the institutional level for the California Department of Correction and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) Governing Body (GB), ensuring that:

  • Decision-making pertaining to the delivery of health care services at the institutional level are standardized and systematic, incorporates multi-disciplinary input, and is aligned with the CDCR and CCHCS’s strategic vision, mission, and goals for health care and rehabilitation.

  • Resources are allocated in accordance with priorities, goals, and direction of the CDCR and CCHCS and the needs of the incarcerated population.

  • There is a local system for elevating barriers to successful implementation of programs and initiatives that cannot be resolved locally and to share innovative work at the local level that could be beneficial to other institutions. 

  • Institution communication methods provide staff the information necessary to provide high quality health care services. 

  • The quality management and patients safety systems are evaluated annually and are both efficient and effective, and the institution culture promotes continuous improvement, which includes, but is not limited to, health equity, constant collaboration across program areas, open recognition of quality problems, and patient-centered services.

Purpose

• Ensure delivery of appropriate, quality health care in a cost-effective manner with minimized risk to patients;

• Manage and consider the needs and expectations of stakeholders;

• Respond appropriately to changes in government and the health care industry, including changes in patient demographics and case mix, financial constraints, advances in research and technology, public expectations, and legal and regulatory mandates;

• Preserve quality of care and economic viability over time; and

• Adhere to federal and state laws and regulations.

Responsibility

• The Chief Executive Officer (CEO) is responsible for planning, implementation, and evaluation of the health care governance structure and processes within the institution.

• The CEO and Warden are ultimately responsible for ensuring other programs within the institution participate and support the governance structure to operate effectively and efficiently. 

• CDCR and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, are responsible to support and participate fully in the governance structure and processes and to ensure their staff are aware of and adhere to governance processes and procedures.

Procedure Overview

• The LGB is the highest-level committee in the network of institution committees that makes up the local health care governance structure. 

• The LGB is ultimately accountable for quality patient care, treatment, and services provided by employees and contractors at the institution.  Among other tasks, the LGB defines the strategic direction of health care services within the institution, implements changes to the organizational structure and health care delivery system design, and ensures that the institution has sufficient resources to accomplish strategic goals, including prepared and competent staff.  The LGB ensures that there are adequate systems in place to continuously evaluate and improve performance, ensuring accountability, particularly among key leaders and licensed clinicians.  The LGB shall set the tone for the institution related to health care communication, culture, leadership, and strategic direction. 

• The membership of the LGB is comprised of the highest-level health care executives as well as the leaders from other major program areas within the institution.

Procedure

• Committee Scope and Responsibilities

  • The LGB performs the following functions:

  • Strategic Direction

    • Oversees implementation of health care-related programs and initiatives, in alignment with the CDCR and CCHCS’s mission, vision, and goals for the delivery of health care services.

    • Establishes an effective system for developing and vetting local operating procedures to ensure appropriate multi-disciplinary participation, high-quality products, and acceptance among staff implementing the procedures.

    • Appointment of a health care administrator whose qualifications, authority and duties shall be defined in a written statement adopted by the LGB.

    • Appointment of a Medical Director, or at institutions with Mental Health Crisis Bed units or Psychiatric Inpatient Programs if the Chief Psychiatrist (CP) is not the Medical Director, delegation of clinical responsibilities of the Medical Director to the CP.

    • Approves local operating procedures consistent with statewide policies to enable access to and continuity of high quality patient care and as required by Title 22 regulations at least annually.

    • Establishes an effective system for elevating critical program concerns to higher levels of the organization.

    • Establishes a system for conflict resolution between programs and departments.

  • Resource Allocation

    • Directs sufficient resources to attain the organization’s mission and vision and meet strategic goals.

    • Plans and manages the organization’s budget including budget projections and provides ongoing oversight and strategic management of spending deficits and surplus.

    • Implements:

      • Staffing formulas and matrices.

      • Notification of appointment and reappointment of health care professionals to the health care staff.

      • Staff recruitment, retention, development, and continuing education as well as the model for identifying and assessing civil service and contract staff competencies, per the statewide plan.

      • Processes to ensure the confidentiality of written actions taken on health care staff.

      • Contracts for health care services, per statewide master contracts and, as appropriate, locally-generated contracts. 

      • Facility modifications per the statewide plan and repairs as required through local resources.

      • Information systems and data infrastructure design per statewide direction.

    • Develops and coaches leaders at every level of the institution to fulfill the organization’s mission and vision and meet strategic goals.

  • Communication

    • Communicates the organization’s vision, strategic goals, and associated timeframes to staff, the patient population, and other key stakeholders.

    • Determines the system for communicating important organizational messages through all reporting levels quickly and efficiently and periodically assesses the effectiveness of communication methods.

    • Creates partnerships with other federal and state agencies, correctional organizations, non-profit groups, and other stakeholders to create synergies, leverage resources, and improve care.

  • Performance Evaluation and Improvement – Health Care System and Patient Safety Culture

    • Creates a responsible, accountable environment of collaboration and continuous improvement that enables the organization to fulfill its mission and meet or exceed its goals.

    • Fosters cooperation and coordination within the organization and with stakeholders in the public and private sector.

    • Provides for and complies with the organization’s Code of Conduct.

    • Maintains the quality and safety of patient care and promotes performance evaluation and improvement.

    • Oversees implementation of the quality management, patient safety and risk management systems including the systems used to measure the performance of the organization’s governance, management, clinical, and support functions.

    • Ensures the organization’s participation in legally required public reporting and the organization’s quality measurement efforts.

    • Approves improvement priorities for the organization.

    • Determines mechanisms for and provides individual areas of the organization with regular feedback on progress toward strategic goals.

    • Facilitates personal participation of individual LGB members in improvement initiatives.

    • Evaluates the effectiveness of quality management, patient safety, and risk management systems at least annually, including the performance evaluation system, improvement projects, tools and techniques, and efforts to build improvement capacity through staff development while supporting modifications to these systems to make them more effective.

  • Performance Evaluation and Improvement – Professional Practice

    • Implements local credentialing and privileging procedures in accordance with statewide credentialing and privileging policies, peer review processes (routine and non-routine) for licensed medical providers as well as professional ethics policies.

    • Assigns to the medical staff, or when appropriate, to the CEO or designee reasonable authority for implementing mechanisms to improve the quality and appropriateness of patient care, and may also assign to the medical staff or chiefs of the relevant clinical disciplines responsibility for the clinical performance of individuals with delineated privileges, and supports these activities and mechanisms.

    • Evaluates the effectiveness of the professional practice system in establishing and maintaining a high quality clinical workforce.

  • Accountability

    • Assures that health care staff rules and regulations are subject to LGB approval, which approval shall not be unreasonably withheld; and that health care staff are permitted to appeal decisions they feel are unfair or wrong.

• Committee Membership

  • The following staff shall serve as voting members of the LGB:

    • CEO (Chairperson)

    • Warden or designee (Associate Warden for Health Care or Chief Deputy Warden)

    • Associate Warden, Business Services

    • Associate Warden, Central Services

    • Associate Warden, Health Care

    • Chief Support Executive

    • Chief of Mental Health

    • CP, or a designated Psychiatrist (in absence of CP)

    • Health Program Manager III, Dental Services

    • Supervising Dentist

    • Chief Medical Executive (CME)

    • Chief Nurse Executive

    • Health Program Manager III, Quality Management

  • The term of the appointment for LGB members shall be the duration of their appointment to their respective positions.

  • Standing members shall not designate attendance at LGB meetings or voting proxy to anyone without the prior approval of the Chairperson, and only when necessary to allow the GB to conduct business. 

  • The LGB may invite guest participants to meetings at any time that additional insight, expertise, or testimony is needed to support discussion and decision-making.

  • Guests are only permitted with prior authorization from the LGB Chairperson.

  • Members of the LGB are required to:

    • Understand the scope and purpose of the LGB.

    • Review all meeting materials in advance of LGB meetings.

    • Present on agenda topics as requested by the Chairperson or other committee members.

    • Provide input in discussions.

    • Vote on motions.

    • Complete action items assigned by specific deadlines.

    • Serve as a performance improvement champion, demonstrating visible leadership by directly participating in high-priority improvement initiatives.

    • Notify the Chairperson of planned absences so that the Chairperson may determine whether a quorum of the LGB shall be present for the meeting at which a member or members may be absent and consider whether it would be appropriate or necessary for the absent member(s) to designate an alternate attendee.

  • The CEO shall serve as the LGB Chairperson.  The Chairperson retains all the responsibilities of a LGB member and also ensures that:

    • The LGB meets at least quarterly and as often as necessary to manage the required Committee Scope and Responsibilities as outlined in Section (e)(1).

    • Agenda topics are consistent Section (e)(1).

    • Meetings do not proceed unless a quorum is present.

    • Meeting materials are distributed to LGB members at least three calendar days in advance of meetings.

    • A formal record of all LGB meetings is kept including committee topics, discussion, conclusions and resolutions, and actions.

• Committee Voting

  • A quorum shall exist when a simple majority of the voting membership is present. A quorum is necessary to conduct the business of the LGB. A member may attend, participate in, and be counted towards a quorum via telephone conference call. In the event of a tie, the Chairperson may vote in order to break the stalemate.

  • Each voting member shall have one vote on any matter that comes before the LGB. Only duly appointed members or approved designees shall vote on LGB matters. A motion carries when it receives a simple majority of the vote.

  • All voting members may vote on any matters coming before the LGB regardless of the subject matter, program area, or health care discipline at issue.

  • The LGB may use electronic voting to address urgent issues that require action prior to the next scheduled meeting or to resolve an existing agenda item.

  • Parliamentary Law and Rules of Order for the 21st Century (Lochrie), most recent edition, will govern parliamentary procedures.

• Meeting Frequency

  • The LGB shall meet at least quarterly and as often as necessary to manage the required Committee Scope and Responsibilities.  The Chairperson may schedule special meetings of the LGB at their discretion.

• Documentation and Confidentiality Provisions

  • The proceedings and records of the LGB shall be confidential and protected from discovery to the extent permitted by law.

• Conflict of Interest

  • Regular voting members of the LGB, as CDCR and CCHCS employees, shall comply with applicable laws,  regulations, and departmental policies regarding disclosure of outside employment, enterprises or activities, and prohibitions against engaging in conflicts of interest.  These include the California Code of Regulations, Title 15, Sections 3409 and 3413 as well as pertinent provisions of the Government Code, Public Contracts Code, and the Fair Political Practices Act (FPPA). These requirements prohibit CDCR and CCHCS employees from deriving any compensation and gifts from any entity doing or seeking to do business with the state.

  • Concurrently with their annual completion and submission of the Statement of Economic Interests (Form 700) pursuant to the FPPA, members of the LGB shall provide a copy of their submitted Form 700 to the LGB Chairperson to be kept on file for reference in the event that a member’s ability to participate in a LGB decision may be impacted by an actual or potential conflict of interest.

  • If any matter of business before the LGB represents an actual or potential conflict of interest for any member, they shall disclose the conflict or potential conflict to the LGB and recuse themselves from participating in any discussion or voting on the matter creating the conflict or potential conflict.

  • Final decisions regarding conflict of interest questions shall be decided by the LGB Chairperson.  In the event that the LGB Chairperson has an actual or perceived conflict of interest, final decisions regarding the conflict of interest shall be decided by the Regional Health Care Executive overseeing the institution.

• Closed Session

  • When considering professional practice matters, the LGB may meet in closed session.  The LGB may exclude from its meeting any person the LGB deems not authorized to participate in discussion regarding credentialing, privileging, or peer review matters.  When considering professional practice matters, the confidentiality of those matters is protected by Evidence Code Section 1157.

• Delegated Authority

  • The LGB shall implement requirements set forth by the statewide GB at a local level.

  • During the absence of the CME or CP, the Medical Officer of the Day, the Physician on Call, or Psychiatrist On-Call shall act with authority in clinical matters, and, when indicated, the administrator shall act with authority in administrative matters.

Procedure Overview

• California Correctional Health Care Services (CCHCS) shall maintain a Complete Care Oversight Team (CCOT) committee to oversee statewide implementation of the Complete Care Model (CCM) for delivery of patient health care services. This committee is responsible for leading, coordinating, and communicating health care initiatives including the appropriate design and deployment of technical tools and systems (e.g., the Electronic Health Record System) to support safe, timely, and cost-effective patient care.

Procedure

• The CCOT ensures full implementation of the CCM at all California Department of Corrections and Rehabilitation adult institutions by performing the following functions:

• Committee Functions

  • Strategic Direction

    • Ensure the organization’s approach to health care services delivery applies the foundational principles and requirements set forth in the Health Care Department Operations Manual, Section 3.1.1, Complete Care Model.

    • Establish standards for the CCM and add new or modify standards based on new information or technology, best practices, or changes in evidence-based practices.

    • Plan and prioritize CCM implementation and improvement strategies in alignment with organizational goals and priorities.

    • Provide input to system-wide performance improvement objectives in the CCHCS Performance Improvement Plan.

  • Evaluation and Improvement

    • Review the Health Care Services Dashboard and other data and information to monitor delivery system performance.

    • Develop performance metrics and assessment tools.

    • Design and implement statewide initiatives, collaboratives, and other improvement activities to fully implement the CCM.

    • Use community literature, industry standards, and evidence-based strategies to standardize and integrate health care delivery processes.

    • Identify and redesign processes that pose safety risks to patients and staff or impede full implementation of the CCM.

    • Develop change packages promoting the use of improvement tools and techniques and decision support such as workflows, forms, user guides, implementation plans, checklists and more.

    • Identify and disseminate CCM best practices.

    • Evaluate resources supporting CCM implementation including, but not limited to:

      • Staffing

      • Equipment and supplies

      • Information technology

      • Physical plant

      • Policies, laws, and regulations

    • Recommend changes to relevant programs and stakeholders to resolve barriers to successful implementation.

  • Communication and Coordination

    • Ensure there is a mechanism for communicating the progress of CCM implementation and system performance to all levels of the organization.

    • Use existing forums at institutions, regional offices, and headquarters to share lessons learned including best practices.

    • Partner with committees, workgroups, and program areas at all levels of the organization to redesign health care processes and facilitate CCM implementation and improvements.

    • Refer CCM issues and concerns to other policy-making bodies and relevant committees as appropriate to support policy changes and inform resource management decisions.

    • Report progress of the CCM implementation and delivery system performance to the CCHCS Quality Management Committee at least quarterly.

  • Orientation and Training

    • Develop and implement training and staff development programs to help health care staff become oriented to and maintain up-to-date knowledge of the CCM principles and associated systems and processes.

    • Establish a structure for ongoing technical assistance by health care staff at headquarters and regional levels.

    • Provide regular feedback to institutions on their progress towards successful implementation of the CCM.

    • Promote a high performance culture of teamwork and continuous learning, improvement, and innovation.

• Membership and Meetings

  • Chairperson(s):  One or more CCOT members shall be selected to serve as chairperson(s) from the current CCOT membership for a period of at least 12 months.  The chairperson(s) responsibilities are to ensure the following:

    • CCOT meetings occur regularly;

    • Meeting agendas reflect the responsibilities and actions described in this procedure;

    • Decisions are documented and communicated to relevant stakeholders as appropriate including agenda topics, discussion, conclusions/resolutions, and actions;

    • New CCOT members receive orientation to their new role and responsibilities; and

    • Each voting member chooses a designee to serve in their stead when necessary.

  • Voting Members:  Regional Health Care Executives shall serve as voting members of the CCOT as well as Deputy Directors from the following CCHCS programs:

    • Business Services

    • Corrections Services

    • Dental Program

    • Information Technology Services

    • CCHCS Office of Legal Affairs

    • Medical Services

    • Mental Health Program

    • Nursing Services

    • Pharmacy Services

    • Policy and Risk Management Services

    • Quality Management Program

    • Resource Management

  • Non-voting Members, Designees, and Other Participants:  Non-voting members, such as subject matter experts, presenters, and guests may attend as appropriate and as approved by the CCOT Chairperson.

  • Voting and Quorum:  Each member has one vote, and a quorum shall exist when a simple majority of the voting membership is present.

  • Meeting Frequency:  The CCOT shall meet as often as necessary to cover the responsibilities and actions described in this procedure, but no less frequently than monthly.

  • CCOT Subcommittees and Workgroups:  The CCOT shall establish standing subcommittees and ad hoc workgroups to plan and develop or modify existing clinical program policies and processes; opine on resource requirements; and to coordinate and oversee changes or new designs in decision support and documentation within the Electronic Health Records System and reports used to manage patient populations, clinical operations, and organizational performance.

Policy

• The California Correctional Health Care Services (CCHCS) shall maintain a Clinical Documentation and Decision Support (CDADS) Committee to ensure clinical documentation and decision-making support tools are evidence-based and promote best practices within CCHCS. The CDADS committee is responsible for the following:

• Overseeing the research and development or the adaptation of existing evidence-based standards of care, including but not limited to clinical guidelines and pathways, procedures, and protocols in order to promote evidence-based practices for patients under care of the California Department of Corrections and Rehabilitation (CDCR).

• Facilitating the dissemination of updated clinical guidance through the CCHCS Health Care Regulations and Policy Section (RPS).

• Coordinating with other relevant committees, as indicated.

• Consulting on documentation and clinical decision-making tools within the electronic health record system (EHRS) to promote best practices and ensure integration of standards of care into the EHRS.

• Regularly monitoring and evaluating implementation of standards of care.

Responsibility

• Statewide

  • The Deputy Director (DD), Medical Services, and the Deputy Medical Executive (DME), Policy and Provider Workforce, are responsible for the statewide planning, implementation, and evaluation of the CDADS policy and procedure.

• Regional

  • Regional leadership is responsible for reviewing and providing feedback for documentation and decision support, as requested by the CDADS Committee, within the designated timeframes as well as facilitating dissemination of the guidelines to the appropriate staff.

• Institution

  • Health care leadership is responsible for the following:

  • Reviewing and providing feedback for documentation and decision support, as requested by the CDADS Committee, within the designated timeframes.

  • Facilitating dissemination of guidelines to appropriate staff and implementation of evidence-based practice to the appropriate staff.

  • Ongoing monitoring to ensure sustainable incorporation into their practice utilizing designated patient care tools.

Procedure

• Clinical Documentation and Decision Support Committee Membership and Meetings

  • The chairperson shall be a DME or Assistant DME appointed by the DD, Medical Services. The chairperson shall assist the DD, Medical Services in the selection of other members of the CDADS Committee when multiple candidates may be available.

  • The Continuing Health Care Education Planning Committee Chairperson shall serve as chairperson’s designee if the appointed chairperson of the CDADS Committee is unavailable to attend a committee meeting.

  • The chairperson and members serve on the committee for two-year, terms and may serve multiple terms with approval by the chairperson and DD, Medical Services. To ensure program continuity, terms shall be staggered so that no more than 50 percent of voting members will change in any given year.

  • Voting members (and alternate designees) shall be appointed by the DD, Medical Services from among CCHCS and CDCR staff nominated by clinical managers or supervisors for each discipline:

    • Two Medical Services physician managers or designees

    • Two headquarters Quality Management physician managers or designees

    • Statewide Chief Nurse Executive or designee

    • Two Chief or Senior Psychiatrists (headquarters or institution)

    • One Senior or Chief Psychologist (headquarters or institution)

    • One Chief Dentist (headquarters) or Supervising Dentist

    • One Physician & Surgeon (headquarters or Institution)

    • Statewide Chief, Pharmacy Services or designee

    • Two Statewide or Regional Pharmacy Services Managers

    • Four Institutional or Regional physician managers or designees

    • One Supervising Psychiatric Social Worker from the Statewide Mental Health Program (headquarters or institution)

    • One Advanced Practice Provider (headquarters or institution)

    • Chair, Continuing Health Care Education Planning Committee

  • CDADS Committee members may choose a designee to serve in their stead. Designees shall be approved by the chairperson.

  • Non-voting members of the CDADS Committee, non-members, and guests shall be approved by the chairperson.

  • Meetings

    • The CDADS Committee shall meet at least monthly unless there are no agenda items for discussion.

    • Each voting member shall have one vote. A quorum shall exist when at least nine voting members are present.

    • The chairperson may serve as a voting member if needed to meet quorum.

    • Committee actions shall be approved by a majority vote.

    • Meetings via teleconference shall be made available to members of the CDADS Committee. Meetings via teleconference shall be conducted in the same manner as an in-person meeting.

    • The CDADS Committee may use electronic voting to address issues when it is determined that waiting until the next scheduled meeting is suboptimal. Electronic voting may be used to resolve an existing agenda item or to address an urgent or emergent new agenda item. Issues addressed via electronic voting shall be approved by a majority vote. Electronic voting communications shall be maintained in digital format.

  • Conflict of Interest

  • A CDADS Committee voting member shall not participate in any decision if they have a personal conflict of interest.

    • A personal conflict is defined as a professional, financial, or other obligation or interest that is likely to limit the member’s ability to participate impartially in decision-making.

    • A member shall disclose to the chairperson any potential or actual conflicts of interest prior to the discussion of any agenda item involving the subject of the conflict or actual conflict.

      • The chairperson shall determine whether a conflict exists and is material, and if it is, bring it to the attention of the committee.

      • The committee shall then determine whether the conflict exists and is material, and in the presence of an existing material conflict, exclude the member with the conflict from participation in discussion or decision-making on the agenda item. Alternatively, the member may recuse themselves from the discussion of and decision-making on the agenda item.

    • If the committee has reasonable cause to believe a member has failed to disclose an actual or potential conflict of interest, they shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose.

      • If, after hearing the member’s response and after making any further inquiries as warranted by the circumstances, the committee shall determine whether the member may participate in any discussion or decision-making and whether any further action might be warranted, such as removal from the committee, or referral to the member hiring authority for further action.

• CDADS Scope of Review

  • The CDADS Committee is authorized to take the following actions:

  • Oversee, adopt, review, or make clinical recommendations to guidelines, care guides, and patient education materials to meet the needs of patients, making appropriate adaptations in consideration of safety and security, and other issues which apply in the correctional environment.

  • Review literature, as needed, including published guidelines, to ensure documentation for review is consistent with community standards.

  • Review and make recommendations on additional health care guidance from other disciplines, when requested, including treatment protocols, procedures, related education or training programs, and accompanying patient education materials specific to patient care issues.

  • Use experience of medical experts to inform recommendations when medical literature or research is unavailable in certain areas of care.

• Review Process

  • All clinical decision support material to be reviewed by the CDADS Committee shall be submitted to the committee support staff via email at CCHCS-CDADS@cdcr.ca.gov.

  • The committee shall review and approve clinical decision support materials detailed above in consultation with appropriate subject matter experts and CCHCS programs.

  • If not approved, the committee shall provide reasons for denial or deferral to the submitting program with recommended changes for all materials that are reviewed and not approved.

  • Upon resubmission of edited materials, the committee may either place the edited material on a subsequent committee agenda or provide approval via electronic voting.

  • Upon approval by the committee, any materials containing medication or pharmaceutical recommendations shall be forwarded to the Pharmacy and Therapeutics (P&T) Committee for review and other relevant committees, if indicated. The P&T Committee shall review the materials and recommend:

    • Approval;

    • Approval with revisions; or

    • Disapproval with revisions.

  • Any recommendations from other committees shall be communicated to the CDADS support staff who shall forward them to the submitting program. Edited material shall be returned to the CDADS email address above and will follow the process in Section (c)(3)(D).

  • Upon completion of review by the P&T Committee or other relevant committees and CDADS Committee approval, all materials will follow the established workflow developed by RPS for dissemination of updated clinical guidance.

Background

• California Correctional Health Care Services (CCHCS) delivers a continuum of health care services to patients by different professional disciplines across multiple levels of care in both outpatient and inpatient settings. In order to improve care and avoid unnecessary morbidity, mortality and costs, health care and correctional staff need to implement sustainable strategies that:

  • Improve processes and systems to ensure high reliability and sustainability.

  • Strengthen continuity and coordination of care.

  • Strengthen communication and collaboration among all professional disciplines and with the patient.

• An overarching strategy that CCHCS has endorsed to improve patient care and system performance is the establishment of a primary care management model, which is a collaborative care model that is different than the traditional medical model that organizes services around acute and episodic events. Rather, the primary care model provides continuous services to patients with chronic and complex physical and behavioral health conditions who disproportionately drive risk and resources.

• The Primary Care Model is based on a number of nationally recognized models and paradigms that emphasize:

  • Risk stratification of individual patients and patient populations using a classification system that determines each patient’s health care risk and places the patient at a facility best equipped to manage his or her health care needs in a cost effective manner.

  • A Comprehensive patient focus.

  • Interdisciplinary and consistent team-based care.

  • Evidence-based practices.

  • Active patient involvement and self-management.

  • Decision support and information systems to assist in managing individual patients and patient populations, and facilitating continuous improvements in patient outcomes, clinical practice and processes of care.

Policy

• Consistent with private and public health care industry standards, CCHCS maintains a Quality Management (QM) Program to continuously evaluate and improve the performance of the health care system. The design of the QM Program draws from nationally recognized quality improvement organizations, principles, concepts, and models.

• To support health care staff in consistently delivering timely, effective, efficient, and safe care, the QM Program:

  • Supports the identification of performance improvement priorities, and requires development of performance improvement plans and objectives at statewide and institution levels.

  • Provides structures, processes, tools and techniques to analyze and redesign health care processes and manage change.

  • Assists institutions in establishing, improving, and sustaining an integrated health care delivery system.

  • Maintains a performance evaluation program, including an organization Health Care Services Dashboard (Dashboard), and ongoing business intelligence to assess critical health care processes and outcomes, identifying potential areas for improvement, and evaluating performance at all levels of the organization.

  • Requires and provides Patient Registries, evidence-based guidelines, training, and deployment of improvement models and tools such as Focus-Plan-Do-Study-Act (Focus-PDSA) as elements of the performance improvement program.

  • Promotes a culture of teamwork and continuous learning and innovation.

• The scope of the QM Program includes clinical operations, clinical practice, and program administration across all health care delivery settings. The specific priorities of the QM Program change but always strategically focus on key performance areas that most impact the access, quality, safety, utilization, cost, and value concerns.

Purpose

• To support continuous health care system evaluation and positive change in order to:

• Improve patient outcomes.

• Improve health care quality, cost effectiveness, and patient and staff safety.

• Improve cost-efficiencies and value-added work, and reduce waste.

• Comply with legal and regulatory requirements.

Responsibility

• Chief Executive Officers (CEOs) oversee implementation of the QM Program at the local level, and participate in statewide strategic planning and implementation and evaluation of statewide initiatives. Institutions may have a local Chief Quality Officer who provides subject matter expertise and supports implementation of the QM Program locally.

• The Receiver, CCHCS, and Director, Division of Correctional Health Care Services delegate responsibility for statewide planning, implementation, and evaluation of the QM Program to the statewide Chief Quality Officer.

Quality Management Program

• Identifying Improvement Priorities and Strategic Alignment

  • Overview

    • Improvement efforts are most effective when all levels of an organization are informed of improvement priorities and rally around a core set of improvement goals. To this end, the QM Program facilitates the setting of improvement priorities at the statewide level and provides support to institutions as they identify institution-specific priorities, communicate priorities to health care staff, and ensure that program planning and day-to-day operations align with improvement priorities.

  • Priority-Setting Process

    • Each year, CCHCS reviews health care areas considered to be high risk, high volume, high cost, and problem-prone and identifies organization-wide improvement priorities. CCHCS incorporates the highest-priority program areas or topics into a performance improvement plan, with one or more performance objectives established for all priority improvement areas. The development and pre-implementation vetting process involves health care leadership as well as external stakeholders. This same priority-setting process occurs at each institution:

    • Taking into consideration statewide strategic priorities and the Primary Care Model, institutions identify institution-specific improvement priorities and performance objectives, customizing an institution improvement plan for the facility’s health care mission, resources, and the needs of the patient population which is vetted through statewide leadership via the Quality Management Committee (QMC) and other forums.

    • The QM Program promotes the establishment of clear and measurable performance objectives for all improvement initiatives and sustainability planning to ensure that successful improvement strategies and positive results can be reproduced consistently in the future.

    • Upon developing an annual improvement plan, institution leadership is responsible for communicating improvement priorities to staff at all levels of the health care system and helping staff understand their role in achieving improvement objectives.

    • Institution leadership also guides the process of strategic alignment, by which managers and supervisors determine how program operations and day-to-day supervision will support performance objectives, and how care teams and other staff incorporate improvement activities for priority areas into day-to-day work.

• Performance Evaluation

  • Overview

    • To assess the impact of change management efforts and progress toward performance objectives, CCHCS uses an objective and systematic process to measure and evaluate health care system performance. Taking into consideration the organizational mission and patient population risks and needs, CCHCS determines the clinical and administrative processes that are most important to measure, and chooses structural, process, and outcome measures critical for ongoing monitoring of the health care system and identification of quality improvement opportunities.

    • In determining performance measures, CCHCS considers the science or evidence supporting the selected measures, and comparable measures used broadly in the health care industry, including those employed by the Healthcare Effectiveness and Information Set and the Agency for Healthcare Research and Quality. Among other factors, the CCHCS takes into account the performance of other health care organizations and past organizational performance during the establishment of performance objectives.

  • Performance Evaluation

    • CCHCS consolidates key performance measures essential to fulfilling the organization’s mission in the Dashboard, a monthly organization-wide report widely distributed to health care staff. All performance improvement plan objectives are benchmarked and monitored through the Dashboard. The Dashboard provides performance data at statewide and institution levels, and trends performance over time.

    • In addition to the monthly Dashboard, CCHCS uses other methods to evaluate performance and inform decisions about improvement priorities, including, but not limited to:

      • Periodic performance reports and special studies, including morbidity and mortality analysis.

      • A health incident reporting system and a defined process for the tracking, analysis, and reporting of sentinel events.

      • Standardized audit tools to evaluate the quality of care and assess adherence to practice guidelines, policies and procedures, and federal and state laws.

      • Patient Registries or “exception reports” that identify individual patients who have not received services per treatment guidelines or who have abnormal findings.

    • CCHCS ensures that there are appropriate processes in place to validate performance data, particularly when:

      • A new measure is introduced or an existing measure is substantially changed.

      • Data will be made public on the internet or through other mechanisms.

      • There are unexpected changes in the data reported for an existing measure.

      • Data sources change (e.g., paper-based records become electronic).

  • Performance Data Validation

    • Validation processes may include, but are not limited to, use of statistically-valid samples, redundant data collection by independent parties, and corrective actions to address data discrepancies.

• Performance Improvement Models, Tools, and Training

  • Overview

    • Consistent with health care industry standards, the QM Program uses the science of process improvement and change management, including techniques and tools, to assist health care staff in establishing and maintaining an integrated health care delivery system and achieving objectives outlined in improvement plans. The CCHCS QM Program promotes:

    • Establishing clear and measurable objectives for all improvement initiatives.

    • Using decision support such as care guides, chart review tools, forms, and checklists, and staff development programs, such as continuing education presentations, workshops, and on-the-job training to remind care teams of evidence-based guidelines and reinforce new health care processes.

    • Using information systems, such as the Dashboard, Institution Scorecard, Patient Registries, provider profiles, performance reports, and tracking systems to support proactive administrative and clinical management.

    • Re-evaluating critical health care processes on a regular and ad hoc basis through mechanisms such as Root Cause Analysis and Failure Mode and Effects Analysis, and redesigning processes and systems to improve outcomes.

    • Engaging patients as active and responsible participants in the health care process through patient education and self-management programs, and partnership with peer educators and incarcerated person groups such as Men’s/Women’s Advisory Council.

    • Formally documenting new processes, such as in a local operating procedure, ongoing use of decision support, orientation for new staff, and regular training updates for continuing staff to promote lasting and sustainable change.

  • Improvement Models

    • CCHCS uses the Cycle of Change Model as a framework for design and implementation of improvement initiatives at both the state and institution levels. The Cycle of Change Model is based on a number of Performance/QM models and the Chronic Care Model that support behavioral change and sustainable business processes that promote the Primary Care Model. Under the Cycle of Change, institutions:

      • Identify improvement priorities,

      • Set performance objectives,

      • Clarify performance expectations and create decision support to help staff meet performance expectations,

      • Provide training and staff development,

      • Provide targeted technical assistance from managers, supervisors, designated mentors or “champions” or other staff in areas where performance continues to lag, and

      • Regularly re-assess performance to determine progress toward performance objectives.

    • Within the health care and quality improvement industries, there are other established methods which include statistical analysis, Root Cause Analysis, the Model for Improvement, Lean Model, Six Sigma, Focus-PDSA, Failure Mode and Effects Analysis, Process Flow Diagramming, and Cause and Effect Diagramming for analysis of performance problems, development of solutions, and testing and evaluating interventions.

    • These improvement models provide a framework for redesigning health care processes and implementing improvement initiatives at the point of care, such as incorporating decision support and information systems into day-to-day practice.

  • Training on Quality Improvement Techniques

    • CCHCS, through the QM Program, is responsible for educating health care staff about improvement models, helping staff to develop the skills to use these models, and developing toolkits that support health care staff step-by-step through the application of an improvement model or concept.

• Technical Assistance from Headquarters and Regional Staff

  • CCHCS staff based at headquarters and at regional levels support institutions as they redesign health care processes and establish well-functioning QM Programs.

  • Among other activities, headquarters-based staff and regional teams from various disciplines and program areas:

    • Assist institutions in identifying improvement priorities and developing improvement plans.

    • Review program performance data, evaluate the effectiveness of quality improvement interventions, assess the performance of the integrated health care services delivery system, and determine progress toward performance objectives.

    • Perform quality of care reviews and assist institutions in planning and implementing activities to improve the quality of clinical practice.

    • Support the institution in taking action when quality or safety problems are identified including, but not limited to, sharing best practices and participating in improvement teams.

    • Assist institutions in preparations for licensing surveys, audits by external stakeholders, and inspections, and as they develop and manage implementation of improvement plans.

    • Promote adherence to policies, evidence-based guidelines, and standards of care through development of decision support tools and staff development programs, among other strategies.

    • Ensure dissemination of relevant, accurate, and timely performance information to institution management and staff.

    • Review QM governance activities and recommend program changes or further activity.

    • Identify, disseminate, and adapt best practices.

    • Support local staff development programs to orient all health care staff to the QM Program, promote the skills necessary to perform quality improvement work at institutions, and empower staff at all reporting levels to participate in quality improvement.

Quality Management Program Governance

• Overview

  • The QM Program includes a management structure composed of inter-disciplinary committees and teams at statewide and local levels to support organizational communication, coordination, control and change. The organization’s leadership uses the QM Program management structure to:

    • Plan, implement, evaluate and improve the health care system’s performance.

    • Oversee quality improvement and patient safety initiatives.

    • Coordinate improvement activities across programs and disciplines.

    • Communicate strategic direction and measurement information.

    • Ensure orientation and training of staff as it relates to performance and quality improvement.

    • Promote a culture of continuous learning and innovation.

  • The committee network serves as a supplement to the traditional reporting structure at headquarters and at individual institutions, providing regular interdisciplinary forums for managers, supervisors, and line staff to manage improvement activities.

• Quality Management Committees

  • The statewide QMC meets at least quarterly and the institution QMC meets at least monthly to determine improvement priorities and strategies, regularly review performance data and take action to improve performance, coordinate the activities of committees and teams that focus on process and performance improvement, and ensure that staff are trained in quality improvement concepts, tools, and techniques.

  • Quality Management Committees ensure that staff at the headquarters and local level receives the orientation and training necessary to participate in improvement activities and apply improvement skills, such as problem analysis and system redesign, in their day-to-day work.

  • At the institution level, a defined network of program subcommittees, many of which are required by departmental policy or health care licensing regulations, perform the same types of activities as the institution QMC, but within a discreet program area, with reporting requirements to the institution QMC. Appendix 1, Program Specific Subcommittees, provides a matrix of program-specific subcommittees with references to requirements in department policy and state law. Figure 1 shows common subcommittees at the institution level.

  • All standing performance committees and subcommittees have the capacity to form Quality Improvement Teams (QITs), which are time-limited, multi-disciplinary teams convened to analyze and address a particular program or process performance problem. QITs will provide regular updates to the committee that chartered them including a final report at the close of the improvement initiative.

  • All local QMCs report to and receive direction from the statewide QMC. At some institutions, the QMC also reports to a Local Governing Body to meet regulatory requirements, which can serve as an opportunity to promote strategic management of the health care system and prison by the CEO, Warden, and their leadership.

  • Figure 1: Institution Quality Management Program Governance

  • 

Purpose

• To maintain a statewide Quality Management Committee (QMC) to provide oversight to the California Correctional Health Care Services (CCHCS) Quality Management (QM) Program. The structure and processes described in this procedure are designed to:

• Support implementation of a sustainable, high-performing, integrated health care services delivery system.

• Promote continuous health care system evaluation and improvement.

• Promote a culture of teamwork and continuous learning and innovation.

Responsibility

• The Statewide Chief Quality Officer (CQO) is responsible for statewide planning, implementation, evaluation and improvement of the QM Program.

Procedure

• Overview

  • The statewide QMC:

    • Oversees organization-wide performance management activities, across programs and disciplines, and provides oversight to critical functions within the performance management system including statewide planning, prioritization, design and development of tools and training, evaluation, and improvement.

    • Ensures that the organization’s approach to performance improvement is strategic and, where appropriate, standardized.

    • Oversees efforts to build statewide quality improvement capacity including initiatives to promote skills development at individual institutions and organization-wide in areas such as program evaluation, problem analysis, prioritization of improvement initiatives, and use of evidence-based approaches to performance improvement.

    • Establishes standardized improvement tools, techniques and processes, and supports efforts to implement an organizational culture of continuous learning and improvement.

    • Serves as a supplement to the traditional reporting structure, providing regular interdisciplinary forums for managers, supervisors, and line staff to manage improvement activities.

  • The scope of the statewide QMC is separate and distinctly different from the statewide Medical Peer Review Committee (MPRC). The statewide MPRC evaluates and monitors individual clinician practice issues while the statewide QMC oversees organization-wide system performance and improvement activities.

• Statewide Quality Management Committees Activities

  • The statewide QMC works with field leadership, headquarters program-specific subcommittees and workgroups to:

  • Support institutions in the successful implementation of an integrated health care delivery system through improvement initiatives, onsite technical assistance, assessments, and other activities.

  • Establish/update improvement plan with statewide improvement priorities and objectives.

  • Support institutions in identifying improvement priorities and achieving strategic alignment between improvement priorities and day-to-day program activities.

  • Manage statewide improvement initiatives designed to accomplish annual performance objectives.

  • Provide oversight to the statewide performance measurement system, including selection of measures, and ensure dissemination of relevant, accurate, and timely measurement information to headquarters and institution staff through the Dashboard and Institution Scorecards, including standardized processes for data reporting and validation.

  • Support the implementation of the statewide patient safety program, including a health incident reporting system and a defined process for the tracking and analysis of significant events including but not limited to sentinel events.

  • Coordinate with relevant committees and program areas at headquarters and regional level that oversee statewide program policy and operations to share performance information and implement improvement initiatives (e.g. Joint Clinical Executive Team and Clinical Operations Team).

  • Coordinate technical assistance activities by staff at headquarters and regional teams designed to support improvement initiatives.

  • Refer issues to other committees or programs, such as the statewide MPRC, when they do not fall under the purview of the QMC.

  • Implement statewide training and staff development programs to orient all health care staff to the QM Program, promote the development of quality improvement skills, and support staff at all reporting levels to participate in quality improvement.

  • Establish uniform processes and tools for the analysis of system performance problems, development of solutions, and testing and evaluation of interventions.

  • Establish forums for sharing lessons learned and disseminating best practices.

  • Actively foster an organizational culture of continuous learning, improvement, and innovation by clearly communicating performance improvement principles to staff; evaluating CCHCS governance structures and processes, policies, procedures, practices, training programs, and communications against those principles; and providing input to ensure alignment.

  • Establish a process to periodically review the statewide QM Program to evaluate the overall effectiveness of the QM Program.

• QMC Membership and Meeting

  • QMC Chairperson

    • The statewide CQO and another executive leader chosen by the QMC members shall serve as Co-Chairpersons. The Co-Chairpersons are responsible for ensuring that the QMC meets at least quarterly, the committee agenda reflects the responsibilities and actions described in this procedure, and committee decisions are appropriately documented.

  • QMC Voting Members

    • Deputy Director, Statewide Mental Health Program

    • Deputy Director, Statewide Dental Program

    • Statewide, Chief Nurse Executive

    • Statewide, Chief Medical Executive

    • Director, Allied Health Services

    • Deputy Director, Medical Services

    • Deputy Director, Strategic Management

    • Director, Policy and Risk Management Services

    • Chief Information Officer, Information Technology Services

    • Deputy Director, Human Resources

    • Director, Administrative Support Services

    • Director, Corrections Services

    • Chief Executive Officer(s)

    • Statewide, Chief Quality Officer

    • Representative, Division of Adult Institutions

    • Other members nominated by one of the voting members and approved by the QMC. All voting members may choose a designee to serve in their stead.

  • QMC Meetings

    • The committee shall meet no less than quarterly. Each member has one vote and a quorum is designated as 50% of members.

    • The committee shall document each meeting through formal minutes and provide them to QMC members for review no later than one week prior to the next meeting.

  • Reporting Structure

    • The statewide QMC reports to the highest ranking health care official and executive staff at least annually on progress in meeting annual performance improvement objectives and patient safety goals.

    • Statewide program-specific subcommittees and institution QMCs shall report quality improvement and patient safety activities to the statewide QMC at least annually or more often as appropriate.

  • QMC and Subcommittees

    • The statewide QMC shall coordinate and communicate with subcommittees to establish and sustain a high-performing health care system consistent with the Primary Care Model and existing policies and procedures, state and federal law, and community standards of care. Examples of subcommittees may include:

      • Patient Safety Program

      • Mental Health Program

      • Dental Program

      • Medical Program

      • Pharmacy and Therapeutics

      • Diagnostic Services

      • Utilization Management

      • Health Information Management

      • Continuing Medical Education

      • Clinical Guidelines

      • Resource Management

    • Each Subcommittee Chairperson is responsible for reporting subcommittee program performance improvement activities, such as development and implementation of initiatives and improvement projects, to the statewide QMC on a routine basis through appropriate documentation (e.g., minutes) and verbal reporting.

    • All subcommittees shall meet at least as frequently as required in existing policy.

Purpose

• To describe strategies, processes, tools, and a governance structure that institutions use to plan, prioritize, develop, implement, and evaluate performance improvement initiatives and sustain improvements.

Responsibility

• The Institution Chief Executive Officer (CEO) is responsible for implementation of this procedure.

Procedure

• Performance Improvement Plan

  • Integrated Health Care Services Delivery System

    • Implementation of an integrated health care services delivery system with a strong primary care foundation has been identified as an overarching strategy for improving care and avoiding unnecessary morbidity, mortality, and costs. Health care staff at each institution are responsible for implementing care processes necessary for a sustainable integrated health care delivery system including, but not limited to, processes to:

    • Identify the health risk of each patient and ensure that the patient is placed at an institution and/or treatment setting with the capacity to address his or her health care needs, per an automated Clinical Risk Classification process.

    • Establish consistent interdisciplinary care teams that assume primary responsibility for the patients assigned to them.

    • Provide care coordination for patients as they move from one treatment setting to another, including transitions between care teams, and across levels of care.

    • Ensure that care teams work across disciplines to co-manage each patient as appropriate to his or her health needs.

    • Ensure care teams have necessary resources and information, such as updated health records, specialty care reports, discharge summaries, diagnostic study results, and patient registries, to provide planned care for patients.

    • Provide evidence-based care that is consistent with current guidelines and community standards.

    • Enhance access to services through open access appointments or other scheduling strategies, after-hours care, and effective communication techniques.

    • Ensure that patients have timely and consistent access to medications.

    • Use Patient Registries to manage subpopulations with specific health risk factors or chronic disease, including high risk patients and mental health patients that are high utilizers of services.

    • Promote patient self-management to improve outcomes.

  • Priority-Setting Process

    • Each year, institutions shall review health care areas considered to be high risk, high volume, high cost, and problem-prone, and identify improvement priorities taking into consideration statewide strategic priorities and customizing the plan for the facility’s health care mission, resources, and the needs of the patient population. The annual performance improvement plan shall include the following elements:

    • Priority areas for improvement to be targeted by institution staff in the coming year.

    • Performance objectives for each priority area (generally six to twelve) and associated timeframes.

    • Improvement strategies that will be used to achieve performance objectives.

  • Development of an Annual Performance Improvement Plan

    • As a first step in developing an improvement plan, each California Department of Corrections and Rehabilitation institution shall evaluate the health care delivery system and identify gaps in areas such as those listed above.

    • Each institution shall prioritize areas to be targeted in improvement initiatives, set measurable performance objectives for each area, and determine which strategies the institution will use to achieve objectives.

    • Upon developing an improvement plan for the year, institution leadership shall take steps to inform institution staff about the improvement priorities for the year and help managers, supervisors, and line staff to identify specific ways they might contribute to improvement efforts as part of their current duties. To this end, institution leadership is responsible for:

      • Communicating improvement priorities to staff at all levels of the health care system.

      • Helping staff understand their role in achieving improvement objectives.

      • Guiding the process of strategic alignment by which managers and supervisors determine how program operations and day-to-day supervision will support performance objectives and how care teams and other staff incorporate improvement activities for priority areas into their day-to-day work.

      • Updating health care staff about any changes to the improvement plan that occur throughout the year.

      • Keeping institution staff apprised of progress toward meeting objectives in the annual improvement plan.

• Performance Evaluation

  • Overview

    • As part of the development of an annual improvement plan, each institution shall determine performance measures and objectives for each priority area identified in the improvement plan. Progress toward the achievement of improvement objectives should be monitored at least monthly and regularly conveyed to all health care staff. To make data as useful as possible as a catalyst for change, institutions may consider generating reports that break down performance by:

    • Clinic or care team.

    • Primary Care Provider, Primary Mental Health Clinician, Psychiatrist, or Dentist.

    • Patient subpopulation (e.g., high risk or mental health high utilizers) or other meaningful subgroup.

    • This may help health care staff determine which locations, staff, or patients might receive improvement interventions first, and is generally useful in identifying care teams or individual providers who might present best practices.

  • Health Care Services Dashboard

    • For the purposes of identifying opportunities for improvement and potential patient safety concerns, institutions are also required, through Quality Management Committee (QMC) meetings, Quality Improvement Team (QIT) meetings, and other forums, to monitor the performance of critical clinical and administrative processes monthly through the Health Care Services Dashboard (Dashboard).

    • The Dashboard includes institution-level performance data, trended over time, in the form of Institution Scorecards, trended composites, and other data displays. Some of the Dashboard data is derived from institution reports.

    • To ensure that Dashboard data is as useful as possible in informing management decisions, institutions shall take action to ensure accuracy in data reporting including:

      • Ensuring that staff applies standardized methods for data collection, in accordance with statewide policies, procedures, and detailed instructions.

      • Ensuring that staff collecting data are appropriately trained.

      • Periodic data validation through redundant data collection by an independent reviewer (e.g. for clinical practice reviews) and/or checking database information against another data source, such as patient charts to double-check accuracy of health care scheduling data.

      • Conducting inter-rater reliability analysis for reviewers of qualitative data.

      • Use of statistically-valid samples.

  • Performance Reports

    • In addition to the monthly Dashboard, California Correctional Health Care Services (CCHCS) issues periodic performance reports and special studies including morbidity and mortality analysis.

    • Institution CEOs are responsible for ensuring that these reports are broadly distributed to health care staff and discussed in various meeting forums such as staff meetings and quality improvement committee meetings.

  • Patient Registries

    • CCHCS provides lists of patients with targeted dental, mental health, and/or medical conditions to institution staff, updated at least monthly.

    • Patient Registries often include an alert function where patients with abnormal findings or who are missing services required by CCHCS guidelines are highlighted. Institution care teams are required to review registries at least monthly (and more often as appropriate) and take action to follow-up with patients as necessary to improve patient outcomes.

  • Data Integrity

    • When an institution determines that there may be a problem with data accuracy, the institution shall immediately notify the QM Section and shall institute corrective actions to ensure data reliability.

• Quality Improvement Techniques, Tools and Training

  • Consistent with health care industry standards, institutions shall use improvement processes, techniques, and tools to assist health care staff in establishing and maintaining an integrated health care delivery system, achieving objectives outlined in annual improvement plans, and regularly evaluating and redesigning health care processes. Institutions shall:

    • Establish clear and measurable objectives for all improvement projects.

    • Re-evaluate critical health care processes on a regular basis and redesign operations to implement an integrated health care delivery system and improve outcomes and efficiency.

    • Apply improvement models used widely in the health care and quality improvement industries such as Root Cause Analysis, the Model for Improvement, Lean Model, Six Sigma, Focus-Plan-Do-Study-Act, Failure Mode and Effects Analysis, Process Flow Diagramming, and Cause and Effect Diagramming to analyze performance problems, develop solutions, and test and evaluate interventions.

    • Use Patient Registries to identify and manage high risk patients and patients with specific chronic conditions and standardized decision support tools disseminated by the QM Program such as care guides and quality of care review tools, in the application of improvement processes and techniques.

    • Take steps to sustain improvements when an initiative has proven successful such as memorializing new processes in Local Operating Procedures (LOP) or documenting new staff roles in duty statements.

    • Orient and train staff on QM Program structures, processes, and tools and ensure that staff attends statewide training programs designed to build improvement skills in the field.

    • Take actions to promote a culture of teamwork and continuous learning and innovation.

  • The Cycle of Change described in the Quality Management Program Overview presents a framework for the design and implementation of institution improvement initiatives, incorporating the principles described above.

Quality Management Program Governance

• Overview

  • Each institution shall maintain an interdisciplinary QM Program structure to monitor and direct performance evaluation and improvement activities. The management structure includes standing committees at two levels:

    • An institution QMC that plays a central role in coordinating performance evaluation and improvement activities institution-wide, providing overall strategic direction for the institution quality QM system and communicating performance improvement activities to the statewide QMC.

    • Subcommittees that evaluate performance at the program level, develop program-specific improvement plans and manage implementation of improvement initiatives. Image 1 provides a schematic of the management structure overseen by the institution QMC.

  • The institution QMC or any subcommittee may convene a QIT, a multi-disciplinary team charged with addressing a particular improvement opportunity. QITs typically exist for the duration of the improvement project and disband upon completion.

  • Other forums such as staff meetings, weekly provider meetings, Primary Care Team huddles, and monthly all Primary Care Team meetings serve as important conduits of performance improvement information and support implementation of improvement initiatives including, but not limited to:

    • Ensuring all staff understand the elements of the integrated health care services delivery system consistent with the Primary Care Model and the QM system.

    • Communicating annual improvement priorities and objectives.

    • Reviewing performance data, particularly at the clinic or provider level.

    • Disseminating decision support tools and conveying expectations for use.

    • Conducting staff development activities consistent with priority improvement areas.

    • Developing and implementing improvement initiatives, including process redesign, that align with the institution’s improvement priorities and may be specific to a discipline (e.g., health records technicians) or work location (e.g., Yard B).

    • Sharing best practices.

    • Figure 1: Institution Quality Management Program Governance – Standing Committees

• Institution Quality Management Committee

  • Overview

    • In general, the institution QMC provides oversight to local performance improvement activities and ensures that health care programs operate in adherence with applicable laws, regulations, policies, procedures, and standards of care; the institution QMC serves as a hub for change management, collaboration, and coordination across programs and disciplines as activities relate to performance management and improvement, and serves as a conduit of improvement and patient safety information from the institution to headquarters.

    • Among other responsibilities, the institution QMC:

      • Evaluates the performance of the integrated health care services delivery system at the institution, including CCHCS Primary Care Model, and directs efforts to improve care.

      • Sets improvement priorities, regularly evaluates program performance and takes action to make improvements, and coordinates the work of multiple standing committees focusing on particular health care programs or functions.

      • Ensures that institution staff is trained in quality improvement concepts, processes, and tools, promotes a culture of continuous learning and improvement at the institution.

    • The scope of the institution QMC is separate and distinctly different from the organized medical staff. The role of an organized medical staff at the institution, if it exists, is peer review and addressing individual clinician practice issues in conjunction with management while the institution QMC oversees organization-wide system performance and improvement activities, which requires involvement of all disciplines and line staff, supervisors and managers. (refer to Image 1)

  • Committee Actions

    • Specifically, the institution QMC takes on the following actions:

    • Strategic Direction

      • Identifies institution-specific improvement priorities and objectives through the development of an annual performance improvement plan.

      • Aligns institution performance improvement activities with statewide improvement priorities and initiatives.

      • Provides feedback to the statewide QMC on statewide improvement priorities, performance metrics, and initiatives.

    • Program Evaluation and Improvement

      • Reviews program performance data, including the organizational Dashboard and Institution Scorecards, statewide performance reports, QIT reports, and reports by outside entities, including the Office of the Inspector General, court monitors, and the Prison Law Office, at least monthly.

      • Uses performance data to identify improvement opportunities, evaluate the effectiveness of quality improvement interventions in the Institution Performance Work Plan, and assess the performance of the integrated health care services delivery system, and determine progress toward performance objectives.

      • Takes action when quality or safety problems are identified incorporating new initiatives in the Institution Performance Work Plan, including assigning interdisciplinary QITs to analyze quality problems, select solutions, and implement quality improvement initiatives.

      • Approves local improvement initiatives for implementation institution-wide and monitor them through the Institution Performance Work Plan including development or modification of health care programs, pilot programs, changes to LOPs, training programs, and development or modification of decision support.

      • Provides oversight during licensing surveys, audits by external stakeholders, and inspections, develops and manages implementation of improvement plans.

      • Oversees implementation of policies, evidence-based guidelines and standards of care.

    • Communication and Coordination

      • Ensures dissemination of relevant, accurate, and timely performance information to institution management and staff.

      • Ensures that QMC, subcommittee, and workgroup activities are appropriately documented.

      • Coordinates and reviews subcommittee activities and recommends program changes or further subcommittee activity.

      • Ensures effective communication between local improvement committees, especially in areas of interdisciplinary responsibility or system-wide issues.

      • Identifies and disseminates best practices.

      • Coordinates annual review and approval of institution LOPs.

      • Refer issues to other committees or programs such as the statewide Medical Peer Review Committee when they do not fall under the purview of the QMC.

      • Reports institution performance improvement plans and activities and recommendations for state-level improvements, to the statewide QMC at least annually.

    • Orientation and Training

      • Implements and oversees a local staff development program to orient all health care staff to the QM Program, promote the skills necessary to perform quality improvement work at institutions, and empower staff at all reporting levels to participate in quality improvement.

  • QMC Membership, Meetings, and Reporting

    • QMC Chairperson

      • The institution CEO shall serve as QMC Chairperson.

      • The QMC Chairperson is responsible for ensuring that the QMC meets at least monthly.

      • The committee agenda reflects the responsibilities and actions described in this procedure, program subcommittees report per a designated schedule, and committee decisions are appropriately documented.

    • QMC Members

      • The institution QMC shall include the following voting members:

      • Chief Executive Officer

      • Institution CQO

      • Institution Chief Medical Executive

      • Institution Chief Nurse Executive

      • Institution Chief Support Executive

      • Chief, Mental Health Program

      • Health Program Manager III, Dental Program

      • Pharmacist-in-Charge

      • Associate Warden of Health Care

      • Chairpersons of QMC Subcommittees

      • Other members as deemed appropriate such as the Director of Nursing, Supervising Registered Nurse II, Correctional Health Care Services Administrator, Chief Psychiatrist, Supervising Dentist, Nurse Instructor, Public Health Nurse, Health Program Specialists, Standards Compliance Coordinator.

    • QMC Meeting Frequency

      • It is recommended that the institution QMC meet weekly. However, at a minimum, the committee shall meet no less than monthly.

    • QMC Minutes

      • The Institution QMC shall document each meeting through formal minutes that shall be provided to QMC members for review no later than three business days prior to the next QMC meeting.

    • QMC Reporting

      • The Institution QMC reports to and receives direction from the statewide QMC.

      • At some institutions, the QMC also reports to a Local Governing Body to meet regulatory requirements, which can serve as an opportunity to promote strategic management of the health care system and prison by the CEO, Warden and their leadership.

• QMC Subcommittees

  • Each institution shall maintain subcommittees to establish and sustain high-quality health care services within a defined program area consistent with existing policies and procedures, federal and state law, and community standards of care.

  • A number of standing subcommittees are required by departmental policy or state regulations. Other subcommittees may be established to review and improve performance of a specific program or resource area. Examples of common subcommittees include:

    • Medical Program

    • Mental Health Program, may include Suicide Prevention and Response (also see Patient Safety)

    • Dental Program

    • Pharmacy and Therapeutics

    • Utilization Management

    • Patient Safety

    • Licensed Inpatient Services focuses on compliance with Title 22 of the California Code of Regulations including Infection Control and Patient Care Policy Committees

    • Resource Management including Human Resources, Health Information Management and scheduling systems, Budgets and Physical Space.

  • Institutions with licensed facilities may also choose to incorporate the functions of a Patient Policy Committee into the QMC if appropriate.

  • Each Subcommittee Chairperson serves as a member of the QMC and is responsible for reporting subcommittee program performance improvement activities, such as development and implementation of initiatives and improvement projects, to the institution QMC on a routine basis through appropriate documentation (e.g., minutes) and verbal reporting.

  • All subcommittees shall meet as frequently as required in existing policy or state law and meeting minutes shall be completed and readily available for review.

• Quality Improvement Teams (QITs)

  • All standing performance committees and subcommittees have the capacity to form QITs which are time-limited, multi-disciplinary teams convened to analyze and address a particular program or process performance problem.

  • QITs shall provide regular updates to the committee that chartered them and a final report at the close of the improvement initiative.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a Statewide Patient Safety Program to identify and improve problematic health care processes by emphasizing the prevention, reduction, reporting, and analysis of health care incidents that if left unaddressed may result in adverse drug reactions, sentinel events, or preventable patient harm.

• The CCHCS Statewide Patient Safety Program encompasses:

  • Patient safety priorities that are reviewed and revised biennially to identify program objectives for statewide interventions and performance improvement activities.

  • A comprehensive multidisciplinary health care incident reporting and review process for identifying, reporting, and assessing health care incidents including sentinel events, in accordance with state law and health care industry best practices, to address potential systemic health care process issues and mitigate risk to patients, staff, and visitors.

  • A committee structure at headquarters to provide oversight to the Statewide Patient Safety Program, review patient safety reports and data, and take action to mitigate patient safety risks and prevent adverse patient outcomes.

  • A committee structure at each institution that oversees the local implementation of the Patient Safety Program by reviewing patient safety reports and data at the individual institution or care team level to identify and mitigate patient safety risks, and prevent adverse patient outcomes.

  • Regular communication in the form of patient safety alerts, aggregate reporting of findings and recommendations related to health care incidents or Root Cause Analyses (RCAs) that may be used to inform additional performance improvement efforts, patient safety initiatives, or recommendations to modify statewide policies and procedures.

  • Technical assistance, decision support tools (e.g., job aids, guides, forms, checklists, and flowcharts), and staff development and education programs to support problem analysis, RCA, and process redesign.

  • A patient safety culture that encourages staff to proactively identify and report health care incidents to mitigate risk to patients and emphasize continuous learning and improvement.

Purpose

• To protect patients, staff, and visitors from poor health outcomes due to flawed health care processes; improve health care quality and cost effectiveness; increase health care process efficiencies and reduce waste; and comply with legal and regulatory requirements.

Responsibility

• Statewide

  • California Department of Corrections and Rehabilitation (CDCR) and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available to ensure appropriate, timely, safe, and cost-effective health care for patients.

  • The Statewide Patient Safety Committee, a subcommittee of the Statewide Quality Management Committee, is responsible for providing oversight of the Patient Safety Program at the statewide level, identifying and communicating program priorities, and managing implementation of patient safety initiatives.

  • The Statewide Health Care Incident Review Committee, a subcommittee of the Statewide Patient Safety Committee, is responsible for providing oversight of the health care incident reporting system and RCA process at the statewide level, and identifying and communicating related data and trends.

• Regional

  • Regional Health Care Executives are responsible for implementation of this policy at the subset of institutions within an assigned region.

  • Regional Health Care Support Teams shall ensure health care staff utilize the centralized electronic Health Care Incident Reporting (eHCIR) system, and use incident data and trends to identify and take action to mitigate patient safety risks within an individual institution or across a region. Regional Health Care Support Teams shall provide oversight, support, and monitoring of RCAs assigned to institutions within their respective region.

• Institutional

  • The Chief Executive Officer (CEO), or designee, is responsible for implementation of this policy at the institution level.

  • Institution leadership teams including the CEO, Chief Support Executive, Chief Medical Executive, Chief Nurse Executive, Chief of Mental Health, and the Supervising Dentist are jointly responsible for the planning, implementation, evaluation, and monitoring of the local Patient Safety Program and ensuring adherence to the Patient Safety Program policy and procedures. Institution leadership teams are responsible for:

    • Ensuring the institution utilizes the institution Quality Management Committee or other designated local committee to identify and address problematic patient safety trends identified through the eHCIR system.

    • Ensuring staff have access to resources including equipment, supplies, and health information or reporting systems.

    • Encouraging and supporting timely reporting of health care incidents including sentinel events.

    • Identifying Patient Safety Champions to provide subject matter expertise and technical support to staff.

Procedure

• Patient Safety Program Committees and Plans

  • The Statewide Patient Safety Program shall maintain a Statewide Patient Safety Committee to provide oversight of the Patient Safety Program at the statewide level.

  • The Statewide Patient Safety Program shall identify program priorities on at least a biennial basis that describe the goals and objectives for the Patient Safety Program identified through system surveillance, health care incident reporting trends, root cause analysis findings and recommendations, and/or changes in community best practices.

• Statewide Health Care Incident Report Review

  • The Patient Safety Program shall conduct an initial review of all health care incidents reported to the eHCIR system to determine an appropriate disposition and ensure potential sentinel events or other anomalous health care incidents with an assigned severity level of 4 through 6 are referred for review by the Statewide Health Care Incident Review Committee (HCIRC).

• Statewide Patient Safety Committee

  • Responsibilities

    • The Statewide Patient Safety Committee (PSC) protects patient safety and improves the health care delivery system by:

    • Designing a surveillance system for the centralized collection and review of data pertinent to patient safety.

    • Maintaining an effective process for assessing, referring, and analyzing or making conclusions regarding reported health care incidents including, but not limited to:

      • A centralized eHCIR system for identifying and reporting patient safety issues, near misses, sentinel events, and other anomalous health care incidents.

      • A Health Care Incident Reporting Registry and Incident Summary accessible to select health care staff to ensure that institutions are informed of health care incident reports specific to their individual institution and patient care areas including licensed patient care areas which may require additional mandatory reporting to regulatory agencies.

      • A standardized process for the identification and examination of sentinel events using the RCA process and CCHCS RCA Tool Kit.

      • A process for referring health care incidents that involve blameworthy acts/reckless behaviors, including criminal activities, to the appropriate professional practice entities or hiring authority.

    • Reviewing program and surveillance data to identify problematic health care processes and establishing patient safety priorities and program objectives for statewide interventions and performance improvement activities.

    • Establishing a multidisciplinary Statewide HCIRC with headquarters level representation from all health care disciplines (i.e., Medical Services, Nursing Services, Pharmacy Services, Dental Services, and the Mental Health Program including Psychiatry) and custody.

    • Ensuring that Regional Health Care Executives designate Regional Health Care Support Teams to oversee the completion of RCAs assigned to institutions within their region and providing feedback and consultation as needed.

    • Collaborating with other program areas to redesign health care processes to improve patient safety.

    • Developing statewide training programs and decision support tools (e.g., tool kits, job aids, guides, forms, checklists, and flowcharts) to support patient safety surveillance, health care incident reporting and review, RCAs, and process redesign.

    • Coordinating patient safety activities with other committees and programs when appropriate including, but not limited to, the Statewide HCIRC, Mortality Review Committee, Systemwide Pharmacy and Therapeutics Committee, and Statewide Quality Management Committee (QMC).

    • Issuing a Patient Safety Dashboard at least quarterly that aggregates eHCIR data about health care incident reporting trends to inform continuous process improvement.

    • Issuing statewide patient safety alerts if a health care incident or trend reveal a problem that all institutions should immediately address or be aware of.

    • Supporting outreach and other activities that encourage reporting of all health care incidents including near misses, medication events, and sentinel events; and

    • Promoting an organizational culture of continuous learning and improvement.

  • Membership, Quorum Requirements, and Meeting Frequency

    • The Deputy Director, Quality Management, or designee, shall serve as chairperson of the Statewide PSC. The chairperson is responsible for ensuring that the statewide PSC meets regularly, the committee agenda reflects the responsibilities described in this procedure, and committee decisions are appropriately documented.

    • The statewide program lead in each respective health care discipline (i.e., Medical Services, Nursing Services, Pharmacy Services, Dental Services, and the Mental Health Program), as well as the program leads in California Correctional Health Care Services Office of Legal Affairs and Health Care Policy and Administration, shall select at least one headquarters designee to serve on the Statewide PSC. Other program representatives may be asked to serve as members at the discretion of the Statewide PSC.

    • All voting members may choose a designee to serve in their stead. Non-voting members, such as presenters and guests, may attend as appropriate and approved by the Statewide PSC.

    • Each member has one vote and a quorum exists when more than one-half of voting members are present.

    • The Statewide PSC shall meet at least quarterly or more often as necessary to carry out its responsibilities.

    • Electronic records of committee proceedings shall be kept in a secure location indefinitely.

  • Reporting Relationships

    • The Statewide PSC reports to the Statewide QMC, and provides oversight to the Statewide HCIRC.

• Statewide Health Care Incident Review Committee

  • Responsibilities

    • The Statewide HCIRC protects patient safety and improves the health care delivery system and shall:

    • Conduct a review of all health care incidents reported to the eHCIR system with an assigned severity level of 4 through 6, potential sentinel events, and any other anomalous health care incidents to determine the appropriate disposition and ensure that any immediate danger to patients, staff, or visitors is addressed.

    • Communicate information about health care incidents to the appropriate regional and institution program leads that are reported by a person or entity not employed at an institution, such as court experts.

    • Refer health care incidents with identified clinical practice concerns or blameworthy acts/reckless behavior to the appropriate peer review committee or hiring authority.

      • The HCIRC shall coordinate with institution leaders of the appropriate discipline to determine whether clinical staff involved in the health care incident should be removed from providing patient care pending further analysis of the event.

      • Health care incidents assigned an RCA that result in a referral to peer review or the hiring authority or temporary redirection of health care staff from direct patient care shall have the RCA continue without delay or deferral and the staff person(s) referred shall be excluded from the RCA process.

    • Identify sentinel events and assign RCAs, including collaboration with Regional Health Care Support Teams and institution leadership, to further inform the case prior to assignment, and when appropriate, recommend grouping multiple incidents that are similar in nature into an aggregate RCA.

    • Work with Regional Health Care Support Teams to ensure RCAs are completed, approved, and submitted within 45 business days of assignment.

    • Upon receipt of an RCA Report, coordinate with the institution and Regional Health Care Support Team within 15 business days to provide feedback, including requesting revisions and clarification to the RCA Report if the report does not meet requirements for a thorough and credible RCA.

    • Upon approval of the RCA Report, monitor progress of the RCA Plan of Action for at least four months, and coordinate with the Regional Health Care Support Team to provide additional support or intervene as needed;

    • Advocate for changes to statewide policies and procedures in accordance with findings from patient safety surveillance, health care incident trends, or RCA recommendations.

    • Promote an organizational culture of continuous learning and improvement.

  • Committee Membership, Quorum Requirements, and Meeting Frequency

    • The statewide program lead in each respective health care discipline (i.e., Medical Services, Nursing Services, Pharmacy Services, Dental Services, and the Mental Health Program including Psychiatry) and custody shall select at least one headquarters designee to serve on the Statewide HCIRC.

    • The Statewide PSC shall elect one or two HCIRC members to serve as chairperson(s). The responsibility of the chairperson(s) is to ensure that the HCIRC meets regularly, the committee agenda reflects the responsibilities described in this procedure, and committee decisions are appropriately documented.

    • All members may choose a designee to serve in their stead. Non-voting members, such as presenters and guests, may attend as appropriate and approved by the HCIRC.

    • Each member has one vote, and a quorum exists when at least three voting members are present.

    • The HCIRC shall meet each business day to carry out its responsibilities.

    • Electronic records of committee proceedings shall be kept in a secure location indefinitely.

  • Reporting Relationships

    • The Statewide HCIRC reports to the Statewide PSC.

• Regional Health Care Support Teams

  • Regional Health Care Executives shall designate Regional Health Care Support Teams that include regional representatives from Medical Services, Nursing Services, Pharmacy Services, Dental Services, and Mental Health Program, including Psychiatry, to provide support for institution RCAs as needed and on an individual case-by-case basis.

  • Regional Health Care Support Teams shall provide RCA consultation, guidance, facilitation, and follow-up to the subset of institutions within their assigned region including, but not limited to:

    • Reviewing health care incidents and collaborating with the Statewide HCIRC and institution leadership on identified sentinel events prior to the assignment of an RCA.

    • Ensuring institution RCA Teams are multidisciplinary and appropriate for the sentinel event under review.

    • Ensuring information is gathered including a chronology of the event before, during, and after the incident, as well as other relevant information, guidelines, best practices, and literature used to inform the brainstorming session and problem analysis.

    • Participating in brainstorming sessions, encouraging thorough discussion of factors contributing to the sentinel event, and ensuring that the fishbone diagram is complete and causal statements are sound.

    • Ensuring the RCA Team identifies root causes.

    • Ensuring that RCA Plans of Action adequately address the identified root causes and associated performance objectives are measurable, realistic, and attainable.

    • Reviewing draft RCA Reports and Plans of Action to ensure they are thorough and credible per CCHCS RCA Tool Kit guidelines.

    • Monitoring Plans of Action submitted by the institution to ensure progress is being made, determining whether additional support or intervention is necessary, and taking action as appropriate.

• Confidentiality

  • Protected Proceedings and Records

  • It is critical that the proceedings and records of the health care incident review process be maintained as confidential and not be made available to unauthorized persons or organizations.

  • All staff participating in the health care incident review process discussed in this procedure shall adhere to these provisions regarding confidentiality.

  • The records of the committees and staff responsible for the evaluation and improvement of the quality of patient care shall be maintained as confidential and protected from discovery to the extent permitted by law.

Policy

• California Correctional Health Care Services (CCHCS) shall complete an independent review of every death of individuals in the custody of the California Department of Corrections and Rehabilitation (CDCR), in an effort to promote a safe, high quality health care system.

Applicability

• This policy applies to all deaths occurring while in the custody of CDCR. In addition to the review conducted under this section, each death classified as a suicide or suspected suicide shall also receive a Suicide Case Review, pursuant to the current Mental Health Services Delivery System (MHSDS) Program Guide.

Purpose

• To utilize mortality data to mitigate patient harm within the department, to identify opportunities for improvement (OFI) related to patient safety, quality of health care services, patient outcomes, and to fulfill mandated reporting requirements.

Responsibility

• Statewide

  • CDCR and CCHCS leadership, at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place, and appropriate resources are available to ensure the mortality review and reporting process is maintained.

  • Headquarters (HQ) and regional executive representatives shall ensure progress is made on current mortality and morbidity initiatives and communicate new priorities to improve health care processes and patient outcomes and quality of services delivered.

  • Designated Medical Services Division (MSD) support staff shall comply with all federal and state reporting requirements. MSD support staff shall enter mortality review findings into the electronic Health Care Incident Reporting (eHCIR) system and produce daily and weekly mortality reports and any required reports.

• Regional

  • Regional Health Care Executives have overall responsibility for ensuring implementation of this policy at the subset of institutions within an assigned region.

• Institutional

  • The Chief Executive Officer (CEO) has overall responsibility for ensuring implementation of this policy at the assigned institution.

  • The institution is responsible for patient safety oversight as described in the Health Care Department Operations Manual (HCDOM), Section 1.2.7, Institution Patient Safety Program.

Procedure

• Daily Mortality Reporting from Institutions to Headquarters

  • All in-custody deaths shall be entered in the health record on the Initial Inmate Death Record no later than 1200 hours on the next business day following the patient’s death. For a suicide, an Initial Inmate Suicide Report shall also be completed, pursuant to the current MHSDS Program Guide.

  • Deaths occurring in the following locations shall be reported:

    • An institution

    • A fire camp

    • A contracted facility

    • In a county facility while out-to court

    • An outside hospital or other medical facility setting

    • A skilled nursing facility or other long-term care facility

    • A re-entry facility, if not paroled

    • In transit

  • Deaths occurring in the following locations and populations are not required to be reported:

    • Sacramento Control Office

    • Western Interstate Corrections Compact

    • Parole

    • County incarcerated persons being housed with CDCR

• Collecting Clinical Records for Review

  • Institution

    • Within five calendar days of the death, institution health records staff shall complete the scanning of any paper documents into the health record, including outside community documents related to emergency medical response and hospitalization.

  • Medical Services Division

    • Within five calendar days of the death, MSD support staff shall:

      • Contact the county coroner’s office to determine whether an autopsy will be conducted. If an autopsy is conducted, MSD support staff shall request the report from the county coroner and distribute the final report, when available to the institution. Final reports shall be distributed to the institution, HQ Health Information Management (HIM), and the Mental Health Program within seven calendar days of receipt. Reports shall be scanned into the health record by HQ HIM staff upon receipt.

      • Obtain the CDCR 837-A, B, and C, Crime/Incident Reports, from the Strategic Oversight Management System or request the reports from custody representatives at the institution where the death occurred.

      • Request CDCR 602 HC, Health Care Grievances, and responses for the six months prior to the death.

    • If the requested documents above are not received within five calendar days, MSD support staff shall notify the appropriate health care or custody staff to request assistance acquiring the documents.

• Institution Mortality Review

  • Within 30 calendar days of the death, the institution CEO, or designee(s), shall complete a multidisciplinary review of the significant events leading to the patient’s death.

  • The review shall focus on identifying OFI at the institution and be submitted to MSD support staff at mortalityreview@cdcr.ca.gov for inclusion in the final mortality review at the discretion of the HQ mortality reviewers.

• Headquarters Mortality Case Review

  • Each death shall be assigned to a nurse and provider reviewer.

    • The nurse reviewer shall be a Nurse Consultant Program Review Registered Nurse, assigned by the Deputy Director (DD), Nursing Services, or designee.

    • The provider reviewer shall be a board-certified physician or advanced practice provider assigned by the DD, Medical Services, or designee.

  • Initial training for all mortality case reviewers shall occur prior to starting mortality review responsibilities. Training shall be in accordance with the most current community standards for mortality review. Ongoing training shall be provided on an as-needed basis and periodically throughout the calendar year.

  • The nurse and provider reviewers shall complete the mortality review using the most current electronic form or data entry program.

  • The provider reviewer and the nurse reviewer shall coordinate in the reviewing of the deceased patient’s clinical records, which are relevant to the history of the patient’s cause of death, and use the information to complete the executive summary. This will include, at a minimum, records up to six months prior to the death; however, reviewers may include older records if necessary or relevant to determine the trajectory of the terminal event. Relevant records may include, but are not limited to:

    • Initial Inmate Death Record and Initial Inmate Suicide Report, if applicable.

    • Progress notes, diagnostic results, and other clinical information.

    • Records from an outside hospital or other medical facility.

    • CDCR 837-A, B, and C, Crime/Incident Reports.

    • Emergency response records.

    • Autopsy reports.

    • CDCR 602 HCs and subsequent responses.

    • Institution Multidisciplinary Mortality review.

  • The nurse reviewer shall document any findings related to the cause of death and any other possibly actionable findings that are discovered during the review and include relevant OFI received from the institution multidisciplinary review.

  • The provider reviewer shall add or modify the nurse review findings and OFI as needed in collaboration with the nurse reviewer.

  • If at any time during the review process, either reviewer identifies circumstances or processes that may represent an immediate patient safety issue, the nurse or the provider reviewer shall submit an eHCIR pursuant to the HCDOM, Section 1.2.6, Statewide Patient Safety Program, and the HCDOM, Section 1.2.7, Institution Patient Safety Program.

  • When a cause of death is unknown, including in potential drug overdose cases, reviewers shall work in collaboration with mental health case reviewers who are assigned to conduct reviews pursuant to the current MHSDS Program Guide to:

    • Collect and share information.

    • Determine if the cause of death could have been the result of suicide.

    • For suicides or suspected suicides, ensure timely sharing of information and findings.

    • Final mortality reports for suicides and final suicide reports shall be distributed to both disciplines.

  • For each death classified as a homicide or suspected homicide, if clarification is needed regarding custodial or security elements, a Division of Adult Institutions (DAI) staff shall be consulted.

  • The preliminary mortality reports shall be completed by reviewers within 60 calendar days of the death, absent a showing of good cause for an extension, in which case an extension may be granted by the DD, Medical Services, or designee.

• Regional and Institution Review

  • The preliminary mortality reports shall be submitted electronically to health care leadership for review.  Health care leadership staff are assigned headquarters Chief Nurse Executives and headquarter and regional physician managers who generally are supervisors for the provider reviewers.

  • Health care leadership shall review the report and accept or reject the mortality report within 14 calendar days of receipt.

    • If rejected, health care leadership shall facilitate any edits and necessary clarification with the nurse and provider reviewers.

  • The mortality review is considered final once health care leadership has accepted the report.

    • A final mortality report may be amended if new information that is material and relevant to the mortality review is obtained subsequent to the report being finalized. The amended report shall be submitted to health care leadership seven calendar days prior to redistributing to the stakeholders listed in Section (e)(6)(A). A response is not required from health care leadership unless the amended report is disputed.

• Mortality Report Distribution

  • Finalized original and amended mortality reports shall be distributed to the following stakeholders:

    • The relevant institution and regional executives responsible for the patient’s health care prior to death. If multiple institutions were involved with the health care of the patient during the period of review and there are findings from that time period, a report shall be submitted to the leadership of each institution and region that were involved.

    • The Health Care Incident Reporting Committee and Statewide Patient Safety Program, uploaded via the eHCIR system. If appropriate, a recommendation for review by the Health Care Reporting Committee or Statewide Patient Safety Program shall be included.

    • DAI and institution Warden, if related to a drug overdose, suicide, homicide, or other deaths where a potential custody-related opportunity for improvement was identified.

• Public Reporting

  • Upon the death of any person in departmental custody, MSD support staff shall provide the information identified in Section (e)(7)(B) below to the CCHCS Communications Office via the ServiceNow portal to facilitate posting on CCHCS’s public website.

  • Except as provided in Section (e)(7)(C) below, within 10 days of the death, the following information shall be posted on CCHCS’s public website:

    • The full name of the agency with custodial responsibility at the time of death.

    • The county in which the death occurred.

    • The facility in which the death occurred, and the location within that facility where the death occurred.

    • The race, gender, and age of the decedent.

    • The date on which the death occurred.

    • The custodial status of the decedent including, but not limited to, whether the person was awaiting arraignment, awaiting trial, or incarcerated.

    • The manner and means of death.

  • If CDCR seeks to notify the next of kin pursuant to the CDCR Department Operations Manual, Section 51070.10, Notification of Contact Listed and is unable to do so within 10 days of death, CDCR shall be given an additional 10 days to make good faith efforts to notify the next of kin before the information is publicly posted.

  • CCHCS shall update any publicly posted information within 30 days of a change of information.

• Conflict of Interest

  • A provider, nurse, or health care leader shall:

    • Not participate in any decision under the breach of professional clinical peer review process if the individual has a personal conflict of interest (COI) or has provided direct patient care to the decedent.

    • Disclose any potential and actual COI prior to participating in decision-making.

  • A personal COI is a professional, financial, or other obligation or interest that is likely to limit the reviewer’s ability to participate impartially in decision-making.

• Confidentiality

  • It is critical that the records of the mortality review process be maintained as confidential and not be made available to unauthorized persons or organizations.

  • All staff participating in the mortality review process discussed in this procedure shall adhere to these provisions regarding confidentiality.

  • The mortality review process is intended for improvements in the quality of patient care and shall be maintained as confidential and protected from discovery to the extent permitted by law.

Procedure Overview

• The California Correctional Health Care Services (CCHCS) Systemwide Pharmacy and Therapeutics (P&T) Committee shall:

  • Provide overall direction to Pharmacy Services at all California Department of Corrections and Rehabilitation (CDCR) institutions.

  • Report to the statewide Quality Management Committee (QMC).

  • Oversee subcommittees including, but not limited to, the Systemwide Medication Management Subcommittee and Drug Utilization Review Subcommittee.

• Institutions shall have a Medication Management Subcommittee that reports to the local QMC to oversee medication management practices including local medication storage, distribution, administration and utilization locally; however, changes to approved, standardized pharmacy policies and procedures, the standard practice model, and the CCHCS Drug Formulary must be approved by the Systemwide P&T Committee.  Recommended changes to policy, procedure, or the formulary shall be submitted to the Regional Deputy Medical Executive (DME) and Statewide Chief of Pharmacy Services for consideration by the Systemwide P&T Committee as appropriate.

Purpose

• To ensure the safe, rational, evidenced-based, cost-effective, standardized use of therapeutic drugs and develop policies and procedures related to medication management within the CDCR.

Procedure

• Membership

  • The chairperson is appointed by the Deputy Director, Medical Services, for a two-year term (eligible for reappointment) and shall be responsible for the Systemwide P&T Committee meeting.

  • The chairperson shall assist the Deputy Director, Medical Services, in selecting the other members of the Systemwide P&T Committee and determining terms of service.

  • Voting members shall include the following, or the members shall assign a designee with decision-making authority similar to the member that is unable to attend:

    • Deputy Director, Medical Services or designee at the executive level

    • Headquarters Deputy Medical Executive chairperson

    • Two Headquarters Physicians at the executive or management level

    • Four Institutional or Regional Physicians at the executive or management level

    • Deputy Director, Nursing Services or designee

    • One Headquarters Chief Nurse Executive

    • Deputy Director, Mental Health Services (if psychiatrist) or designated psychiatrist at the executive or management level

    • Statewide Chief Psychiatrist or designee

    • Statewide Chief Telepsychiatrist or designee

    • One Psychiatric Inpatient Program Chief Psychiatrist or designee

    • Deputy Director, Dental Services or designee

    • Statewide Chief, Pharmacy Services or designee

    • Two Pharmacy Services Managers

    • One Deputy Medical Executive, Quality Management or designee

  • The Systemwide P&T Committee shall maintain a list of permanent designees for voting members. Designees for voting members of the Systemwide P&T Committee are permitted. Prior notification to the chairperson at least three working days in advance is requested when a designee shall attend for a voting member.  All designees must sign a confidentiality statement pursuant to Section (c)(3)(D).

  • Non-voting members shall include:

    • Deputy Director, Fiscal Services, or designee, at the Assistant Deputy Director level

    • An attorney from the CCHCS Office of Legal Affairs (COLA), to be designated by COLA’s Director and Chief Counsel

    • Pharmaceutical Program Manager and Pharmaceutical Consultant II, Department of General Services

    • Support staff

  • Guests for Systemwide P&T Committee meetings are permitted.  Prior notification to the chairperson at least three working days in advance is requested.  All guests must sign conflict of interest and confidentiality forms pursuant to Section (c)(3)(D) and understand that their attendance is as an observer and comments during the meeting are at the discretion of the chairperson.

• Duties

  • The Systemwide P&T Committee is responsible for overseeing policies and procedures related to all aspects of medication use within CCHCS including, but not limited to:

  • Maintaining a formulary of medications, including standardizing the strengths and dosage forms for medications used across institutions.

  • Reviewing procurement and medication selection processes to promote cost-effective formulary management.

  • Conducting regular therapeutic category reviews for formulary selection.

  • Ensuring that pharmacy services address the health care and security needs of the institution.

  • Reviewing and monitoring medication usage and therapeutic use of medications within the CDCR.

  • Evaluating medication use and promoting safe medication practices.

  • Evaluating medication therapies and providing input to the development of disease management guidelines.

  • Reviewing and approving proposed changes to pharmacy policies. The Systemwide Medication Management Subcommittee shall be consulted for policymaking on any matters related to medication management processes.

• Meetings

  • The Systemwide P&T Committee shall meet at least quarterly or as often as necessary to carry out its responsibilities.

  • Meetings via teleconference shall be made available to members of the Systemwide P&T Committee.

  • A record of the proceedings shall be kept which records committee activities, recommendations, and attendance.

  • Confidentiality/Non-Conflict

    • The proceedings and records of the Systemwide P&T Committee shall be kept confidential and protected from discovery to the extent permitted by law.

    • Any attendees shall provide a completed copy of a Conflict of Interest Form and a Confidentiality and Non-Disclosure Agreement.  Completed copies of each document shall be maintained with the Systemwide P&T Committee records.  Members may not have any financial or business relationships with entities doing business with the State of California.

    • If any attendee has an interest that may affect or be perceived to affect the member’s independence of judgment, the member shall recuse themself from the voting process for the drug class or other agenda items concerned.  This recusal includes, but is not limited to, refraining from deliberation or debate, making recommendations, volunteering advice, and participating in the decision-making process in any way.

  • Voting

    • Each voting member shall have one vote.  A quorum is designated as 50 percent of voting members, excluding vacancies and abstentions.

    • Action on a motion requires the total number of votes to be equal to or greater than a quorum.

    • The Systemwide P&T Committee may use electronic voting to address issues when it is determined that waiting until the next scheduled meeting is suboptimal.  Electronic voting may be used to resolve an existing agenda item or to address an urgent or emergent new agenda item.

    • An abstention is considered a non-vote, and thus does not accrue to the total number of votes.

• Subcommittees

  • The Systemwide P&T Committee may charter standing subcommittees and establish ad hoc workgroups to plan and develop new or modify existing programs. The charter for each subcommittee shall be reviewed and updated as often as needed but no less than every two years. Standing subcommittees include, but are not limited to:

  • Systemwide Medication Management Subcommittee

    • The Systemwide Medication Management Subcommittee is a multidisciplinary group that works to ensure medication practices support the safety of the individuals served and improve the quality of care by developing and modifying processes as they relate to planning, procurement, ordering, preparing and dispensing, distribution, storage, and administering medications with the goal to reduce any potential harm that could be caused by medications.

  • Drug Utilization Review Subcommittee

    • The Drug Utilization Review Subcommittee shall:

    • Review prescription drug utilization and costs and identify clinical criteria, decision support, and methods for managing prescription drug cost and optimizing prescribing practices.

    • Develop and provide evidence-based recommendations to the Systemwide P&T Committee with respect to formulary selection, electronic health record system (EHRS) medication catalog availability, and use criteria or prior authorization criteria, if needed.

  • 340B Oversight Subcommittee

    • The 340B Oversight Subcommittee assists in monitoring, directing, and overseeing the CCHCS’ implementation of its 340B Program. The 340B Oversight Subcommittee’s reporting provides direction and ongoing surveillance of the organization’s 340B Program for compliance with policy and federal rules.

  • Nutrition Subcommittee

    • The Nutrition Subcommittee shall meet on an ad hoc basis when required to develop and provide evidence-based recommendations to the Systemwide P&T Committee with respect to enteral and parenteral nutrition and nutritional supplements that are deemed necessary to make available in the CCHCS Drug Formulary or make available in the EHRS medication catalog as a non-formulary item.

Policy

• California Correctional Health Care Services (CCHCS) and California Department of Corrections and Rehabilitation (CDCR) shall utilize a Medical Classification System (MCS) to serve as the system for considering medical factors in making patient placement decisions. The MCS shall be used to match patients’ medical needs with the capabilities of facilities and programs. The MCS is intended to:

• Ensure all patients are assigned Medical Classification Factors that allow matching of medical needs to institutions/facilities to support efficient bed management.

• Eliminate redundant and unnecessary forms, screenings, and evaluations.

• Reduce or prevent inefficiencies caused by disparity between patient medical needs and facility capabilities and resources.

• Provide department-wide capacity to profile the medical needs of the patient population.

Purpose

• To provide guidance to clinical and custody staff in considering medical factors in making patient placement decisions.

Responsibility

• The Chief Executive Officer, or designee, is responsible for the implementation, monitoring, and evaluation of this policy and its corresponding procedures.

• The Health Care Placement Oversight Program (HCPOP) at headquarters is responsible for various population management functions. HCPOP is responsible for maintaining a unit procedure, as well as for maintaining and issuing medical classification matrices and Decision Support Material.

Procedure

• Medical Classification Chrono General Process

  • Medical Classification Chrono (MCC)

    • Physical Description: The MCC is generated via the electronic MCC database. It is viewable in the Strategic Offender Management System (SOMS).

    • Distribution: A copy of the MCC shall be printed for the patient’s records; the transmission must ensure confidentiality.

    • Decision Support Material: Decision Support Material shall be updated as necessary under the authority of the Chief Medical Executive (CME) and the Chief Nurse Executive. Issues, questions, and suggestions regarding the materials shall be routed to the HCPOP. CCHCS and CDCR shall issue Decision Support Material that includes reference material regarding:

      • Criteria for medical risk determination

      • Criteria for nursing acuity determination

      • Pregnancy Program

      • Transplant Program

      • Hemodialysis Program

      • Therapeutic Diet Policy

      • CDCR 7410, Comprehensive Accommodation Chrono

      • CDCR 1845, Disability Placement Program Verification

  • Completing the MCC in the Reception Center (RC)

    • An MCC is completed at the time of the RC physical examination. If the Medical Classification Factors (Refer to Appendix 1, The Medical Classification Factors) change during the RC stay, a new MCC must be issued.

    • There may be situations where further clinical data are needed in order to make a clear determination of the appropriate Medical Classification Factors. In this case, the MCC is completed based on medical judgment. For example, the patient has cirrhosis, but the degree of stability and severity has not been assessed because laboratory studies are pending.

  • Relationship to CDCR 1845 and CDCR 7410

    • The CDCR 1845 provides details regarding disabilities that impact placement and assistive devices such as wheelchairs, walkers, and hearing aids.

    • The CDCR 7410 provides details regarding other patient needs such as lower bunks and bottom tiers. Many of these needs do not impact placement.

    • Specified Medical Classification Factors, if present, require a matching CDCR 1845 or CDCR 7410 in order to provide supporting details. These factors are marked with a superscript “1.”

  • Issuing an MCC

    • The MCC is normally completed by a Primary Care Provider (PCP) (Physician, Nurse Practitioner, or Physician Assistant). Chief Physicians & Surgeons (CP&S) and CMEs may also complete the MCC.

    • The PCP may need to seek input from nursing staff in order to accurately determine the Nursing Care Acuity (Refer to Appendix 1). Nursing staff is responsible for reporting changes in patient status to the PCP that result in a change in Medical Classification Factors.

    • In the case of an outside hospital admission or discharge, the CP&S or designee is responsible for completing the new MCC.

    • Overrides may only be requested through HCPOP. This is normally initiated by the institution Classification and Parole Representative (C&PR) or RC Correctional Counselor III (CC-III). Only a Regional Deputy Medical Executive (RDME) or designee may issue an Override MCC. (Refer to Section (d)(3)(F)3).

  • Triggers for Change in Classification

    • A new MCC is issued whenever the patient’s medical condition changes in a way that changes Medical Classification Factors (Level of Care, Classification Factors, Intensity of Services, Specialized Services, and/or Institutional-Environmental). Whenever a patient’s need for a medical level of care changes, either to higher or lower level, a new MCC shall be issued. Examples include admission to or discharge from a Correctional Treatment Center (CTC), placement into or return from an outside hospital stay, or a new requirement for medium-intensity nursing.

    • The MCC must be completed promptly on admission and again on discharge from an outside hospital stay in order to show the placement into a new level of care. This placement into a new level of care may require a telephone order from the on-call provider.

  • Temporary and Permanent Chronos

    • Permanent Chronos: A Permanent Chrono indicates that the Medical Classification Factors are not expected to change in the next six months. Automatic or periodic reclassification is not needed if the MCC is a Permanent Chrono.

    • Temporary Chronos: A Temporary Chrono indicates that the Medical Classification Factors are expected to change within six months or that an automatic requirement for Medical Reclassification is needed within six months.

      • Defined Expiration Date: An MCC with a defined expiration date will cease to be valid on that date. On the defined expiration date, the patient will no longer have a valid MCC, which will require issuance of a new MCC. A temporary MCC is used, for example, when a patient is pregnant and qualifies for the pregnancy program. The expiration date would be set by the estimated date of confinement or estimated delivery date.

      • Undefined Expiration Date: An MCC with an undefined expiration date is used, for example, when a patient is admitted to an acute care hospital for an acute disease whose course is not certain. The “temporary” designation indicates that the need is expected to be time-limited; however, the duration of the need is unpredictable. The MCC must be reviewed and re-issued within six months.

• Medical Classification Matrices

  • Medical Classification Planning Matrix

    • The Medical Classification Planning Matrix (MCPM) shows the Specialized Medical Bed (SMB) and medical program capacities and census at each CDCR institution. The MCPM allows CDCR to review and plan for an efficient match of Institution Attributes to the demand across the various custody levels and programs. Where custody program is important (e.g., Security Housing Unit, Special Needs Yard, Minimum Support Facility [MSF]), the MCPM includes information for that program.

    • The MCPM is maintained by HCPOP.

  • Medical Classification Matrix

    • The Medical Classification Matrix (MCM) is a tool that supports the task of matching a patient’s Medical Classification Factors with the available facility’s medical capabilities.

  • Maintaining and Issuing the Matrix

    • The MCM is maintained by HCPOP. As the availability of beds, programs, and other capacities change, HCPOP staff updates the MCM. The MCM is available via SOMS.

• Placement Authority

  • Routine Placements

    • Routine placements for patients classified with Outpatient level of care are done using the CDCR endorsement process. The MCM and the MCC provide inputs to the endorsement process.

    • Specialized Outpatient (SOP) endorsements to California Health Care Facility, Stockton (CHCF) shall be made by HCPOP. SOPs who are not endorsed to CHCF shall be endorsed to an intermediate institution. All SOP transfer endorsements require transfer referral from a classification committee prior to endorsement. When necessary, HCPOP is authorized to endorse SOP patients to a basic institution to accommodate required case factors, such as Enhanced Outpatient Program, when there are no available intermediate institutions commensurate with the patient’s case factors.

    • All SMB endorsements shall be made by HCPOP. At HCPOP’s request, patients with an SMB level of care shall be taken to committee prior to endorsement.

  • Medical Classification Factor Priorities

    • Decision support for using the MCM includes a tool that shows which Medical Classification Factors represent absolute requirements and which represent preferences (Refer to Appendix 2, Medical Classification Factor Priorities). For example, “Requires Electrical Access” is an absolute factor: a patient on life-support equipment that requires electricity must be in housing with electricity available. “Proximity to Tertiary Consultations” is a preference factor: a patient who needs a retinal specialist is best managed where the specialist is available nearby, but the patient can be managed at any institution as long as transportation to a very distant specialist can be accomplished.

    • The Medical Classification Factors listed as preferences on Appendix 2 can be overridden by a Classification Staff Representative (CSR) or a CC-III with endorsement authority as part of matching overall patient medical needs with facility capabilities in a particular institution. If a CSR approves a placement using a Medical Classification Factor listed as a preference on Appendix 2, the CSR approval noted on the CDC 128-G, Chrono Classification (Regular), must include the reason for using the flexibility provided by the preference.

    • The Medical Classification Factors marked as absolute can only be overridden by a new MCC marked as “Override” and completed by the responsible RDME (Refer to Section (d)(3)(F)3) at the request of the institution CME.

  • Medical Placement Based on Level of Care Medical Classification Factors

    • Placement of a patient into and from the level of care factors (Refer to Appendix 1) is done by medical staff without classification action as part of the patient care routine. Placement based on level of care factors does not require endorsement action. CDCR will be notified of a change in level of care via the MCC.

    • If the institution does not have the needed level of care but has a higher level of care, the patient is normally placed into the higher level of care. Mismatches in actual level of care compared with needed level of care shall be referred to HCPOP for population management.

    • Returns from a higher level of care outside CDCR institutions and facilities that require a level of care not available at the institution shall be noticed to HCPOP for potential medical endorsement.

  • Medical Endorsement

    • All patients requiring placement into an SMB as indicated by their medical level of care on the MCC shall be reviewed and endorsed by HCPOP. The patient may be placed immediately into an appropriate health care setting by institution medical staff. HCPOP shall consider permanent endorsement into an appropriate institution SMB within 45 days of the date the MCC is completed.

    • Patient transfers to SMBs do not require classification committee action, as the placement decision is made to provide necessary health care treatment or access; however, at HCPOP’s request, patients with an SMB level of care shall be taken to committee prior to endorsement.

  • Decision Support Materia

    • HCPOP shall issue and maintain Decision Support Material that includes:

    • Detailed guidance regarding this policy

    • Medical Classification Factor Priorities (Refer to Appendix 2)

    • Sample chrono

  • Processes for Resolving Ambiguity or Difference of Opinion

    • Concerns from CSR

      • Concerns from the CSR shall be resolved by a case conference between the Classification Services Unit, the Population Management Unit, the Class Action Management Unit, and HCPOP. If the issue cannot be resolved, the RDME shall be consulted.

    • Resolution of Inappropriate Placement

      • Concerns from nursing staff, custody staff, or providers that a placement is medically inappropriate must be forwarded to the institutional CME. If the CME determines that a medical placement was inappropriate based on the Medical Classification System policy or patient safety considerations, the CME must notify the RDME. The CME must provide appropriate clinical detail.

      • The RDME shall take appropriate action, in cooperation with HCPOP if necessary, to resolve the issue. HCPOP shall be notified of the issue and resolution for tracking and quality improvement purposes.

    • Override Process

      • The institution C&PR or RC CC-III shall request guidance from HCPOP and the Classification Services Unit by a case conference if it appears that a placement that meets all classification and medical requirements is not possible. The RDME shall be consulted if the issue cannot be resolved during the case conference. If the RDME determines that an override of one or more Medical Classification Factors is appropriate, the RDME shall issue an MCC with an override.

      • If the RDME cannot resolve the issue, it shall be referred to the Departmental Review Board. All overrides shall be noticed to HCPOP for action and tracking.

  • Required Training

    • Orientation to the Medical Classification System shall be included in the orientation of new classification staff, PCPs, nursing staff, and health records staff.

  • Quality Improvement

    • The institution CME is accountable for the accuracy of MCCs issued by that institution. The institutional Local Operating Procedure must include processes for monitoring the consistency, reliability, accuracy, and variability of the MCCs. The results of monitoring are provided to the institution Quality Management Committee (QMC), which forwards them to the statewide QMC.

    • The institution Classification Committee Chairperson is accountable for the accuracy of placement recommendations by the Classification Committee. The accountability process is the same as used for custody placements.

  • Local Operating Procedure

    • Each Chief Executive Officer is responsible for ensuring that the institution has an approved and current Local Operating Procedure that includes, at a minimum:

      • Description of Institution Attributes including the Institution Medical Grouping for the institution (Refer to Appendix 3, Institutional Medical Groupings).

      • Contact information for the C&PR, RC CC-III (if applicable), RDME, the HCPOP contact, and Institution Medical Executive.

      • MCCs including a description of:

        • Who completes the MCC and when.

        • Who is responsible to complete an MCC when a patient changes level of care within a facility (sending provider or receiving provider).

        • When the MCC is completed in the RC and whether laboratory results are required before it can be completed.

        • Detailed process for obtaining a new MCC when a temporary has expired.

        • Interaction between nursing and providers to accurately determine Nursing Care Acuity.

        • Changes in patient condition that prompt nursing to notify the provider for completion of an updated MCC.

      • Distribution

        • How the patient copy is handled and how confidentiality is ensured.

      • Decision Support Material

        • How Decision Support Material will be distributed, where it will be available, and how obsolete versions will be removed.

        • Local additions to Decision Support Material (if any) and process for approval, distribution, and revision.

        • Process for recommending changes to Decision Support Material.

      • Quality Improvement

        • Periodic sampling for accuracy and completeness.

        • Statement that required detail is entered into the “Comments” section.

        • Statement that confidential information is entered into the “Confidential Comments” and not the “Comments” section.

        • Patient movements based on incorrect MCCs that required a re-endorsement of the patient.

        • Patients with more than three changes to their MCC in seven days; results of CME review.

      • Local Training Plan

        • Description of who provides local training, staff who receive training, and frequency of training.

      • Approval Process

        • Description of the Local Operating Procedure approval process including any local sign-off.

        • Statement that final approval is obtained from the Regional Health Care Executive, acting in concert with the Regional Leadership Team.

  • Unit Procedures

    • Classification Services Unit

      • The Classification Services Unit is responsible for maintaining a unit procedure that includes, at a minimum, a description of the following:

      • Training plan for the Classification Services Unit, C&PRs, RC CC-IIIs, and CSRs.

      • Process for elevating suggestions regarding revision to the Medical Classification System.

      • Process and responsibilities for the case conference between the Classification Services Unit and HCPOP.

    • Health Care Placement Oversight Program

      • HCPOP is responsible for maintaining a unit procedure that includes, at a minimum, a description of the following:

      • Detailed processes for maintaining the MCPM.

      • Detailed processes for maintaining the MCM.

      • Process for elevating suggestions regarding revision to the Medical Classification System.

      • Detailed process for endorsing a patient to an appropriate institution SMB.

      • Detailed process for approval, distribution, and revision of Decision Support Material.

      • Process and responsibilities for the case conference between the Classification Services Unit and HCPOP.

      • Detailed process for resolution of inappropriate placements in concert with the RDME, including tracking of cause, resolution, and impact on the patient and the system and interface with the QMC.

      • Process for HCPOP to receive notification of overrides from the RDME, including tracking and reporting and interface with the QMC.

      • Training plan.

Policy

• The California Correctional Health Care Services’ (CCHCS) Utilization Management (UM) Program shall ensure the appropriate use of limited health care resources including, but not limited to, medical procedures, consultations with specialists, diagnostic studies, inpatient beds, and outpatient beds allocated for health programs to promote the best possible patient outcomes, eliminate unnecessary cost, and maintain consistency in the delivery of health care services. The UM Program shall:

  • Implement evidence-based medical necessity criteria statewide.

  • Manage requests for specialty services to reduce backlogs, wait times, custody and transport demands, and to improve timely access to care.

  • Manage care transitions for patients in community hospitals and specialized health care housing beds (e.g., Outpatient Housing Unit, Correctional Treatment Center, Skilled Nursing Facility) through care coordination and complex case management to optimize patient health outcomes and the use of resources.

  • Provide a centralized process for reviewing and analyzing clinical, financial, and operational data to identify trends and patterns in the use of contract medical services and health care beds within California Department of Corrections and Rehabilitation (CDCR).

  • Develop the statewide UM Improvement Work Plan at least biennially to include improvement priorities, performance objectives, and associated strategies and activities.

  • Maintain a committee structure at headquarters and in the field to provide oversight of the UM work plans and UM Program requirements.

Purpose

• The purpose of the UM Program is to optimize the value of contract medical services and the use of specialized health care housing by ensuring appropriate, timely, safe, and cost-effective care for patients who require specialty, hospital, emergency, skilled nursing, and diagnostic services and who are admitted to specialized health care housing within CDCR.

Responsibility

• Statewide

  • The Deputy Director, Medical Services, and Deputy Medical Executive, UM, are jointly responsible for the planning, implementation, evaluation, and monitoring of the UM Program at the statewide level.

  • CDCR and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and resources are available to ensure appropriate, timely, safe, and cost-effective care for patients.

  • The Headquarters UM Committee (HUMC) is a subcommittee of the statewide Quality Management Committee (QMC) and is responsible for providing oversight of the UM Program at the statewide level, identifying and communicating program goals, developing program-specific improvement plans, and overseeing and supporting implementation of improvement initiatives.

• Regional

  • Regional Health Care Executives are responsible for adherence to the UM Program policy and procedure at a subset of institutions within an assigned region.

  • The UM Nurse Consultant Program Reviewers are responsible for:

    • Regular monitoring of dashboards and patient registries to identify and address potential issues in accessing contract medical services.

    • Ensuring UM Registered Nurses are adequately trained on their role and responsibilities including the use of dashboards, patient registries, and other clinical decision support tools to support timely, safe, efficient, and cost-effective use of contract medical services and specialized health care housing beds at a subset of institutions within an assigned region.

• Institutional

  • The Chief Executive Officer (CEO), Chief Support Executive (CSE), Chief Medical Executive (CME), and Chief Nurse Executive (CNE) are responsible for the planning, implementation, evaluation, and monitoring of the UM Program and ensuring adherence to the UM Program policy and procedure at the institutional level.

  • The CSE has overall responsibility for the administrative and support functions of the health care system ensuring local policies and procedures align with and support the goals and objectives of the UM Program.

  • The CEO has overall responsibility for implementation and ongoing oversight of the health care system at the institution. The CEO may delegate decision-making authority to the CME and CNE for daily operations including, but not limited to, the following:

    • Ensuring that resources are effectively deployed to support timely, safe, efficient, and cost-effective use of contract medical services and specialized health care housing beds.

    • Providing access to equipment, supplies, health information systems, patient registries, patient summaries, and evidence-based guidelines.

    • Reviewing and comparing institution Care Team performance including:

      • The overall quality of services.

      • Health outcome data.

      • Assignment of consistent and adequate resources.

      • Utilization of dashboards, patient registries, patient summaries, and decision support tools.

      • Addressing issues as necessary.

    • Updating procedures, roles and responsibilities, and training as new tools and technology become available.

  • The CME is responsible for the overall medical management of patients and ensures resources are available to meet the needs of the population.

  • The CNE is responsible for managing and overseeing the daily operations of the scheduling system and coordinating the delivery of health care services by monitoring, identifying, and addressing barriers in accessing contract medical services.

  • All members of the institution leadership team are responsible for establishing an organizational culture that promotes interdisciplinary teamwork and continuous process improvement.

  • The Institution UM Committee (IUMC) is a subcommittee of the institution QMC and is responsible for oversight of the UM Program at the local level, developing program-specific improvement plans, and managing implementation of improvement initiatives.

  • The institution QMC reports to the statewide QMC and is responsible for coordinating institution-wide performance evaluation and improvement activities and communicating UM Program performance improvement activities to the statewide QMC.

Procedure Overview

• This procedure outlines major structures, processes, resources, and requirements of the UM Program.

Procedure

• Utilization Management Case Review Process

  • The UM Program shall require review of select patient cases that are high cost, high risk, exceptional, or complex. This process includes up to three levels of review and shall cover prospective, concurrent, and retrospective reviews. The UM case review process shall follow the procedure outlined in the Health Care Department Operations Manual (HCDOM), Section 3.1.11, Outpatient Specialty Services.

• Utilization Management Program Committees and Plans

  • Headquarters and institution committee structures shall be maintained to provide oversight of the UM Program. At least biennially, the statewide UM Program shall prepare an improvement plan that describes statewide priorities and performance objectives for the UM Program. The institution shall establish and maintain a UM Subcommittee Improvement Priorities List and Project Pipeline that tracks underperforming areas per the UM Measurement Plan, identifies other quality or patient safety issues related to UM processes, and assesses each issue to determine a risk score for prioritization and initiation of improvement activities.

• Institutional Utilization Management Committee

  • Responsibilities

    • The IUMC duties shall include, but are not limited to, the following:

      • Ensure compliance with the HCDOM for the Complete Care Model policies and procedures including systems and processes that support timely access, population health management, care coordination, and complex care management.

      • Ensure compliance with the UM Program policy and procedure and other related policies and procedures.

      • At least quarterly, review and analyze data including, but not limited to, dashboards, Health Care Incident and Potential Quality Issue reports, and UM operational reports to ensure timely, safe, efficient, and cost-effective access to specialized health care housing beds and to specialty, hospital, emergency, diagnostic, and other contract medical services.

      • Develop and monitor UM work plans that improve timely, safe, efficient, and cost-effective access to and utilization of specialty, hospital, emergency department, and other contract medical services.

      • Establish interdisciplinary workgroups to conduct Root Cause Analyses, and to assess and improve timely access to health care services including, but not limited to, specialty services, care coordination, and care management to ensure that these systems and processes are highly reliable over time.

      • Ensure that institutions’ health care staff receive training on the UM Program policy and procedure and that providers receive feedback regarding adherence to the policy and procedure.

      • Identify gaps in specialty provider network resources and provide this information to the HUMC through the institution QMC.

  • Membership

    • The IUMC shall consist of, but not be limited to, the following members:

      • CME (Chairperson)

      • CEO (health care)

      • CNE or Supervising Registered Nurse (SRN) III

      • CSE

      • Supervising Dentist

      • Chief Deputy Warden or Associate Warden for Health Care

      • Chief, Mental Health Services

      • Chief Psychiatrist

      • Chief Physician and Surgeon

      • SRN II staff involved with UM, Triage and Treatment Area, specialty services, and hospital services

  • Reporting Structure

    • The IUMC reports to the institution QMC. The IUMC shall submit timely and accurate reports at least quarterly to the institution QMC that include its major activities, accomplishments, requests for assistance and training, and recommendations that may include changes to contracts, policy, clinical criteria, or decision support.

  • Meetings

    • The IUMC shall meet as often as necessary to carry out its responsibilities, but not less frequently than monthly.

    • Meetings shall be conducted informally using a consensus approach. If a consensus cannot be reached on an agenda item, the Chairperson may call for a vote.

    • A quorum of members must be present at all meetings to ensure diversity of view point and well-rounded discussion. A quorum is met when a minimum of five members are in attendance, either in person or telephonically.

    • Records of committee proceedings shall be kept at a secure, accessible medical program site for a period of three years. At a minimum, the record shall describe all committee actions and recommendations.

    • The proceedings and records of the IUMC shall be confidential and protected from discovery to the extent permitted by law.

• Headquarters Utilization Management Committee

  • Responsibilities

    • The HUMC’s duties shall include, but are not limited to, the following:

      • Develop and ensure adherence to the UM Program policy and procedure and clinical criteria that define medical necessity.

      • Implement and oversee the Statewide UM Program Improvement Plan.

      • Develop and report UM Program performance indicators based on the Statewide UM Program Improvement Plan.

      • Analyze and report trends and patterns related to utilization and cost associated with contract medical services.

      • Establish interdisciplinary workgroups to assess and improve timely access to health care services including, but not limited to, specialty services, care coordination, and care management to ensure that these systems and processes are highly reliable over time.

      • Assess and recommend interventions to improve timeliness, safety, efficiency, and cost effectiveness of contract medical services and specialized health care housing.

      • Provide direction for specialty care referrals and bed usage through defining medical necessity, selecting appropriate referral, admission and discharge criteria, and setting statewide standards for UM.

      • Recommend strategies to modify provider network capacity and medical contracts.

      • Refer institution-specific concerns to the respective regional leadership and IUMC for appropriate action.

      • Refer to other headquarters committees for action as appropriate.

  • Membership

    • The HUMC shall consist of the following voting members:

      • Deputy Medical Executive, UM Program (Co-Chairperson)

      • Deputy Director, Field Operations, Corrections Services (Co-Chairperson)

      • Deputy Director, Business Services

      • Deputy Director, Dental

      • Deputy Director, Fiscal Services

      • Deputy Director, Mental Health Program

      • Deputy Director, Medical Services

      • Deputy Director, Nursing Services

      • Deputy Director, Quality Management

      • Regional Health Care Executives, Region I, II, III and IV

    • Members may designate another manager from their program area, and a Co-Chairperson may add additional members and invite other stakeholders as necessary.

  • Reporting Structure

    • The HUMC reports to the statewide QMC.

  • Meetings

    • The HUMC shall meet as often as necessary to carry out its responsibilities but not less frequently than bimonthly.

    • Meetings shall be conducted informally using a consensus approach. If a consensus cannot be reached on an agenda item, a Co-Chairperson may call for a vote.

    • A quorum of members must be present at all meetings to ensure diversity of view point and well-rounded discussion. A quorum is met when a minimum of 50 percent of the members are in attendance, either in person or telephonically.

    • Records of committee proceedings shall be kept at a secure, accessible medical program site for a period of three years. At a minimum, the record shall describe all committee actions and recommendations.

    • The proceedings and records of the HUMC shall be confidential and protected from discovery to the extent permitted by law.

Policy

• California Correctional Health Care Services (CCHCS) patients may request gender affirming surgery (GAS) or revision to GAS, in accordance with California Code of Regulations Title 15, Section 3999.200. Patient requests for GAS, including revisions to GAS shall be referred by the institution to the Gender Affirming Surgery Review Committee (GASRC).

Responsibility

• Statewide

  • CCHCS and California Department of Corrections and Rehabilitation (CDCR) departmental leadership, at all levels of the organization shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available so that care teams can successfully implement the GASRC policy.

  • CCHCS Deputy Director (DD), Medical Services, and the CDCR DD, Statewide Mental Health Program, are responsible for the statewide planning, implementation, and evaluation of the GASRC policy.

• Regional

  • Regional Health Care Executives are responsible for adherence to this procedure at the subset of institutions within an assigned region.

Procedure

• Referral Process

  • When a patient or staff member on behalf of a patient submits a verbal or written request for GAS to any health care staff, an appointment shall be scheduled with the primary care provider (PCP) within 30 calendar days.

  • The PCP shall submit an electronic Request For Service (eRFS) for GAS as treatment for Gender Dysphoria (GD) at the time of this initial visit.

  • If a GD diagnosis is not currently established by a mental health clinician, the PCP shall order a Mental Health Gender Dysphoria Diagnostic Evaluation, which is to be completed within five business days by utilizing the Mental Health Gender Dysphoria Diagnostic Criteria PowerForm in the Electronic Health Record Systems (EHRS).

    • The institution shall compile and submit all required information within 90 calendar days following the original eRFS generated for GAS, absent a showing of good cause for an extension, in which case an extension may be granted by the GASRC Co-Chairperson(s) or designee in consultation with GASRC voting or non-voting members if necessary.

    • The institution staff shall follow the referral guidelines and required information as outlined in the Referral for Consideration for Gender Affirming Surgery.

    • The institution shall neither recommend approval nor disapproval of the request for GAS at the first and second institutional levels of review.

• GASRC Membership and Meetings

  • Voting members (and alternate designees) shall be appointed by the DD, Medical Services, and the DD, Statewide Mental Health Program, as follows:

    • A minimum of three physicians or advanced practice providers (APPs) from Medical Services, at least one of which must be a physician;

    • A minimum of three psychiatrists from the Statewide Mental Health Program; and

    • A minimum of three psychologists or Licensed Clinical Social Workers (LCSW) from the Statewide Mental Health Program.

  • The two Co-Chairpersons shall be appointed by the DD, Medical Services, and the DD, Statewide Mental Health Program and shall consist of:

    • One Deputy Medical Executive (DME), Assistant DME, CME, or Chief Physician and Surgeon (CP&S); and

    • One Chief Psychologist, Senior Psychologist, Chief Psychiatrist, or Senior Psychiatrist.

    • The Co-Chairpersons are non-voting members, unless needed to reach a quorum as noted below.

    • The Co-Chairpersons may designate any voting member to chair the GASRC in their absence.

    • There must be at least one Co-Chairperson, or designee, present at each GASRC meeting.

  • Mandatory standardized training requirements approved by the GASRC shall be completed prior to serving as the committee Co-Chairperson, a voting member, or an alternate designee for the GASRC.

  • A quorum for purposes of voting shall include at least two psychologists or LCSWs, two psychiatrists, and two physicians or APPs from Medical Services. In reaching the quorum requirement, alternate designees of the same clinical discipline may be counted toward a quorum, and the Co-Chairpersons may serve as a member for their clinical discipline, if necessary, to reach a quorum.

    • In the event of a tie amongst voting members, the Co-Chairpersons have the option to request additional information and review the case additional time(s) at a future GASRC meeting.

  • Non-voting participants may include the author of the mental health evaluation (or designated Mental Health clinician), the author of the medical evaluation or a provider familiar with the patient’s physical health, and may include, if deemed appropriate for the discussion by the Co-Chairperson(s):

    • Institution medical, mental health, or nursing leadership.

    • Warden or designee.

    • The patient’s care team, including medical, mental health, or nursing.

    • Nursing representation from headquarters including, but not limited to, the Statewide Chief Nurse Executive or designee.

    • Other pertinent CCHCS or CDCR staff.

  • All voting members (including when there is more than required for a quorum) who are present at a GASRC meeting, vote to approve or not approve GAS, unless there are an even number of voting members, in which case the least senior voting member of the GASRC does not vote. Voting members with conflict of interest shall not vote [see Section (c)(3) below]. The Co-Chairpersons may also, at their sole discretion, postpone any meeting in which the number of available attendees will not achieve a quorum or allow for a full discussion and review.

  • The GASRC shall be scheduled to meet weekly unless there are no requests for the committee to consider.

• GASRC Conflict of Interest

  • A committee member shall not participate in the committee deliberation or vote on a case being reviewed if the member was a designated provider or author in the GASRC evaluation and review, or has provided longitudinal care for the patient in the past 12 months. This member may still present information to the committee and be available for questions.

  • The GASRC committee member shall self identify a potential conflict and voluntarily notify the committee chair and recuse themselves for that case(s).

• GASRC Scope of Review

  • Submissions for GAS shall be considered by the GASRC in the order in which they are received, absent extenuating circumstances approved by the Co-Chairpersons.

  • The GASRC shall review cases within 90 calendar days from receipt of the required information as outlined in the Referral for Consideration for Gender Affirming Surgery guidelines, absent extenuating circumstances.

  • The GASRC shall review, evaluate, and discuss the information provided by the institution (and the patient, if applicable) and obtain additional information as deemed necessary.

  • If the GASRC deems additional information is required prior to making a final decision, the GASRC review shall be deferred until the additional information is collected.

  • In the event that the GASRC requires additional information from a surgeon who specializes in GAS, the patient shall be scheduled for a consultation with the patient’s care team and the GASRC review deferred until such time that the consultation notes are available in the health record.

  • The following shall be considered by the GASRC when reviewing a GAS request, if applicable based on the current version of the World Professional Association for Transgender Health Standards of Care and the type of surgery requested:

    • The patient has been diagnosed with GD and diagnosis has been confirmed by a CDCR mental health provider; the diagnosis is supported with appropriate documentation and clinical justification as set forth by CCHCS policies and care guides.

    • Any known contraindications to surgery or other medical conditions that may impact surgical recovery, and whether medical or co-existing mental health conditions have been fully assessed and have been well-controlled for an appropriate amount of time relevant to the patient on a case-by-case basis.

    • The level of distress demonstrated by the patient. The GASRC shall review all relevant documents and determine whether the patient’s GD symptoms are primarily due to the conditions of confinement, mental illness, or any other factor. The GASRC shall consider whether available treatments other than GAS that are likely to improve or alleviate the patient’s symptoms.

    • There is no evidence suggestive of any external coercion or predation, and the desire for GAS is freely given by the patient.

    • The patient understands that appropriate housing placement will be reviewed on a case-by-case basis by CCHCS/CDCR staff. If applicable, the patient has been provided with necessary and relevant information to enable them to understand that their environment may be evaluated after GAS and any new environment may be unfamiliar and pose significant adaptive challenges.

    • Whether evidence exists that suggests the patient does not have the ability to successfully and safely transfer, and adjust medically and psychologically to their environment postoperatively.

    • If applicable to the GAS requested:

      • Whether the patient received 12 continuous months of medically supervised hormone therapy appropriate to their gender goals and whether the patient’s hormone levels meet the minimum requirements for the requested procedure (unless the patient has a medical contraindication, is unable or does not desire to take hormones, or the gender embodiment goals do not include hormone levels at a specific minimum threshold/range).

    • Any other information available, which may be relevant to the discussion or determination.

  • The findings of the committee shall be based on a majority vote of the members.

  • If additional information is obtained after the GASRC has issued an approval, but prior to the completion of the surgery, the GASRC can reconsider the approval if deemed necessary.

• GASRC Decisions

  • Once the GASRC has made a decision, a memorandum shall be completed conveying the decision and factors considered in the decision based on the criteria noted in Section (c)(4)(F) above, and specific information that the GASRC determines would be helpful to the patient and their care team to understand the decision. The decision memorandum shall be addressed to the CME and copies shall be provided to the following:

    • Patient

    • CP&S

    • Chief of Mental Health

    • Chief of Psychiatry

    • PCP

    • Mental Health Primary Clinician (MHPC), if applicable

    • Mental Health Primary Psychiatrist, if applicable

    • Utilization Management Registered Nurse

    • Applicable to approvals, designees from Health Care Invoicing and Direct Care Contracts

  • The decision memorandum shall be distributed by the GASRC support staff to the CME via email within seven calendar days from the GASRC decision, absent extenuating circumstances. The GASRC decision shall be entered into the health record via one of the committee Co-Chairpersons.

  • Patients who are approved for GAS shall be scheduled with their MHPC to discuss the findings of the GASRC within 14 calendar days of the decision entry in the EHRS. A copy of the GASRC decision memorandum shall be provided to the patient at that time. When an approval is entered into the EHRS, the patient shall then be scheduled for an initial visit with the surgeon.

  • Patients who are not approved for GAS shall be scheduled with their MHPC to discuss the findings of the GASRC within 14 calendar days of decision entry in the EHRS. A copy of the GASRC decision memorandum shall be provided to the patient at that time.

  • Patients who are not approved for GAS may submit a new request for GAS no sooner than one year after the date of the GASRC decision memorandum not approving the request unless new information is provided that was not previously considered at the time the GASRC reviewed the case.

  • The GASRC shall submit the GAS packet for patients that are approved or not approved to Health Information Management for scanning into the health record within seven calendar days of receipt of the signed GASRC decision memorandum. The packet shall include the following documents:

    • CDCR 7466, Gender Affirming Surgery Request checklist;

    • Mental health evaluation;

    • Medical evaluation;

    • The GASRC decision memorandum; and

    • Any other documents provided to the GASRC for review of the patient GAS referral.

Policy

• The Continuing Health Care Education (CHCE) Planning Committee provides oversight for the development, implementation, and dissemination of continuing medical education activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance of health care providers. Continuing Medical Education for health care providers improves the quality of care provided to patients. California Correctional Health Care Services (CCHCS) shall provide continuing education courses and activities which are eligible for Continuing Medical Education credits pursuant to requirements set forth in Business and Professions Code, Section 2190, et seq. and California Code of Regulations, Title 16, Section 1336, et seq.

Responsibility

• Statewide

  • California Correctional Health Care Services (CCHCS) Deputy Director (DD), Medical Services, and the Deputy Medical Executive (DME), Policy and Provider Workforce, are responsible for the statewide planning, implementation, and evaluation of the CHCE policy.

• Regional

  • The Regional leadership are responsible for ensuring that primary care providers and other applicable clinical staff attend Continuing Medical Education trainings and apply evidence-based recommendations to their practice as appropriate.

• Institution

  • Health care leadership is responsible for the following:

  • Overall health care staff adherence to this procedure at the institution within the appropriate discipline.

  • Health care staff participation in appropriate discipline-specific Continuing Medical Education trainings.

  • Implementation of evidence-based health care practices consistent with the content presented within Chief Medical Executive (CME) activities.

• Medical Services Division

  • Education and Training Unit (ETU) staff are responsible for responding to audits of CME activities and reviewing to ensure the activities meet all criteria if audited by the accrediting organization.

CHCE Planning Committee Membership and Meetings

• The Chair shall be a DME or Assistant DME appointed by the DD, Medical Services. The Chair shall assist the DD, Medical Services, in selecting members of the committee from among CCHCS/California Department of Corrections and Rehabilitation (CDCR) staff.

• Voting members (and alternate designees) shall be appointed by the DD, Medical Services, based on demonstrated expertise and active interest in CHCE from among CCHCS/CDCR staff nominated by relevant clinical leaders for each discipline:

  • Chair, Clinical Documentation and Decision Support Committee

  • Two Headquarters (HQ) Physician Managers

  • One Regional Physician Manager

  • Three Institution Physician Managers

  • One CNE or Nurse Consultant Program Review

  • One Chief or Senior Psychologist

  • One Chief or Senior Psychiatrist

  • One Chief or Supervising Dentist

  • One Quality Management Representative

  • One Pharmacy Services Representative

• Committee members may choose a designee to serve in their stead. Designees must be approved by the Chair or the Chair’s designee.

• Non-voting participants shall include:

  • The author of the activity application.

  • Presenter(s).

  • Subject matter expert(s).

• A quorum for purposes of voting shall include at least six committee members. In the event that six voting committee members are not present or if a tie occurs, agenda items and applicable materials shall be sent to committee members to vote via electronic vote (e-vote).

• All voting members (including when there are more than required for a quorum) present at the committee meeting shall be eligible to vote to approve or reject an activity application.

• Committee meetings shall be scheduled monthly but may be cancelled if there are no items for review.

Continuing Medical Education Requests

• Continuing Medical Education Category 1 Credit Application

  • A CME Category 1 Credit Application is required by the committee and shall be submitted for approval. All sections of the form must be filled out prior to submission. A copy of the CME Category 1 Credit Application can be found on the Education and Training Unit SharePoint site on Lifeline under Medical Services: CME Application form.doc (sharepoint.com).

  • The CME Category 1 Credit Application includes extensive planning to outline the Continuing Medical Education description, support, and implementation to ensure education provided is thorough, complete, and appropriate to receive Continuing Medical Education credit.

  • If the application is approved, the committee shall contact the author and determine a mutually acceptable timeframe to present the activity.

  • In preparation for the committee meeting, the author shall create a presentation or visual to share. The presentation shall be sent to the CHCE Planning Committee support staff prior to the presentation date to ensure appropriate visibility and functionality.

• CHCE Planning Committee Scope of Review

  • Submissions for Continuing Medical Education credits shall be considered by the committee in the order in which they are received, absent extenuating circumstances approved by the Chair.

  • The committee shall review, evaluate, and discuss the information provided by the author of the CME Category 1 Credit Application and obtain additional information as deemed necessary.

  • The committee shall consider the following criteria when evaluating a CME activity:

    • Activity description that includes location, anticipated dates, and type of activity (e.g., internet or webinar, live course, enduring material, other).

    • Professional practice gaps to be addressed and learning objectives to be achieved through activity (e.g., data, sources, physician attributes or core competencies, alignment with CHCE and CCHCS missions).

    • Educational design/methodology and educational strategies to achieve objectives.

    • Cultural and linguistic competency implemented to address competency as required by California Business and Professions Code, Section 2190.1.

    • Addressing biases in health care.

    • Evaluation and outcome measurements based on knowledge, performance, and patient outcomes.

• Continuing Health Care Education Committee Decisions

  • After reviewing each Category 1 Credit Application, the committee shall take one of the following actions:

    • Approve the application. If the committee approves the activity, the committee support staff shall promptly notify the author in writing of the approval following the meeting.

    • Return the application to the author for revisions. Once the author has made the recommended revisions, the author shall submit the revised application for further evaluation by the committee. The committee shall determine whether an additional meeting is required to further discuss the application, or the committee may determine that no further discussion is required and may vote on the application electronically. The committee support staff shall promptly notify the author in writing of the approval following the meeting.

    • Deny the application. The committee may determine in its discretion that a proposed activity should not be implemented. The committee support staff shall promptly notify the author in writing of the approval following the meeting.

  • When an application is approved, the author shall then proceed to work with the ETU to implement their activity.

• Live Continuing Medical Education Activities

  • To enroll for an upcoming CME course, clinical staff shall review the corresponding Activity Announcement emails sent from the ETU mailbox, and save the corresponding appointment invite to their Outlook calendar.

  • Attendance for live activities delivered via webinar is captured electronically via the designated platform when attendees sign in from their CDCR account.  Attendance for live in-person activities may be captured via a sign-in sheet.

  • CME credit for in-person activities shall be obtained by submitting sign-in sheets to ETU@cdcr.ca.gov.

• Enduring Material Continuing Medical Education Activities

  • An enduring material is an on-demand activity that does not have a specific time or location designated for participation; rather, the participant determines whether and when to complete the activity. Enduring material can be found on the ETU SharePoint site under ‘Continuing Medical Education Activities – Enduring Material.’

  • CME credit for enduring materials shall be obtained by completing the post-activity assessment associated with the activity. Credit for completing CME enduring material is given commensurate with the approved AMA PRA Category 1 Credit™ hours.

• Reporting AMA PRA Category 1 Credit™ hours

  • For staff other than Medical Doctors (MDs) and Doctors of Osteopathic Medicine (DOs), attendance for each activity is tracked by CHCE Planning Committee support staff, and annual transcripts are provided to the field.

  • Attendance for MDs and DOs is reported directly to the Accreditation Council for Continuing Medical Education’s (ACCME) Program and Activity Reporting System and these MDs and DOs may access their CME activity transcript at any time via ACCME’s https://www.cmepassport.org/.

Record Retention

• Documentation of committee recommendations and resulting decisions shall be retained for three years.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain an Ethics Committee at headquarters to support clinicians and improve patient care by:

• Consulting on and reviewing cases where ethical dilemmas have been identified and staff, patients, or surrogates have questions or are in conflict.

• Educating health care staff and patients using the wide body of literature in bioethics and published legal decisions related to clinical ethics.

Purpose

• The CCHCS Ethics Committee shall provide multidisciplinary consultation, guidance, and education about the ethical aspects of providing health care within the California prison system.

• The Ethics Committee supports ethical reflection, respectful dialogue, and critical analysis based on standard practices from the ethics literature to facilitate resolution of bioethical dilemmas.

• Organizational benefits from the Ethics Committee include:

  • Enhancing patient care

  • Conserving resources/avoiding unnecessary costs

  • Improving accreditation review

  • Reducing risk of lawsuits

  • Sustaining organizational integrity

  • Encouraging professionalism of all staff within the organization

Applicability

• The Ethics Committee is accountable to and reports to the Governing Body or a subcommittee which reports to the Governing Body.

Procedure

• Ethics Committee Membership

  • Chairperson and Vice-chairperson

    • Chairperson shall be a clinician or nurse from headquarters or the field appointed by the Director, Health Care Operations or designee.

    • Vice-chairperson shall be a clinician or nurse administrator from headquarters appointed by the Director, Health Care Operations or designee.

  • General Membership

    • Members will be nominated by leaders of disciplines which support the Ethics Committee. Individuals nominated should have an interest in the area of health care ethics, be willing to serve a minimum of one year on the Ethics Committee, and attend monthly meetings on a regular basis. Membership is composed of approximately 20 members of a multidisciplinary group of CCHCS and California Department of Corrections and Rehabilitation (CDCR) representatives. Each of the following disciplines/groups shall be invited/encouraged to appoint a member to the Ethics Committee:

      • Medical Services

      • Nursing Services

      • Mental Health Services

      • Dental Services

      • Custody

      • CCHCS Office of Legal Affairs

      • CDCR Office of Legal Affairs

      • Chaplaincy

      • CDCR Division of Adult Institutions

      • Community members

    • Ethics Committee members shall be geographically designated throughout the state.

    • Members with expertise in issues relevant to a referred case will be specifically invited to attend meetings where these issues will be discussed (i.e., a mental health representative for a mental health issue, a dental representative for a dental case, etc.).

  • Consult Team

    • As time and support permit, a subset of committee members shall be trained to serve as clinical ethics consultants.

    • Selected individuals shall be among those who have expressed interest and possess the clinical knowledge necessary to triage consult requests.

    • These identified individuals shall receive additional training and mentoring including attending a comprehensive ethics course, if possible, at least once during their first year of service.

    • Attempts shall be made to designate Consult Team members geographically.

    • Designated trained and qualified Consult Team members shall triage Ethics Committee consultation requests from institutions and obtain additional information on each case as needed. In addition, these members may provide ethics education to the referring institution and further guidance if/when an Ethics Committee consultation is deemed not appropriate. Pending the formation of a Consult Team, the Ethics Committee Chairperson, Vice-chairperson, or designee, shall perform these functions.

    • Consultations provided by Consult Team members shall be reviewed at scheduled Ethics Committee meetings.

• Meetings

  • The Ethics Committee shall meet no less than quarterly.

  • A quorum shall exist when at least six members are present. Each member shall have one vote.

  • Members of the Ethics Committee in any discipline may vote on Ethics Committee recommendations.

  • Ethics Committee action is approved with a majority vote. A record of Ethics Committee proceedings shall be kept in a secure location, in which all Ethics Committee actions and recommendations are described.

• Ethics Committee Meeting Activities

  • The Ethics Committee consults on and reviews institutional cases referred by individuals from throughout the organization to the Ethics Committee wherein staff has identified ethical dilemmas and when staff, patients, or surrogates have questions or are in conflict.

  • Participation of referring individuals is encouraged when discussing referred, institutional cases.

  • The Ethics Committee also reviews and discusses cases reviewed by Consult Team members.

  • Meeting agenda includes:

    • New active case consultations, presentations, and discussions.

    • Consults managed in the past month by a committee member.

    • Review of recommendations and topics of interest.

    • Journal club, ethics related topics.

  • The Ethics Committee may use the four-box method of ethics consultation for all recommendations. (Refer to Appendix 1).

  • The Ethics Committee does not make health care treatment decisions as these are between providers and their patients. The suggestions presented by the Ethics Committee to the referring institution are not institutionally binding, nor are they legally binding. The Ethics Committee shall make recommendations in specific cases in a prospective manner, but shall not judge the ‘ethics’ of past events or decisions.

  • The Ethics Committee provides relevant education and training on ethics topics to Ethics Committee members and to staff via webinar or other appropriate distribution methods.

• Confidentiality

  • The proceedings and records of the CCHCS Ethics Committee shall be confidential and protected from discovery to the extent permitted by law.

Policy

Responsibility

• Statewide

  • CCHCS and CDCR departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place, and appropriate tools, training, technical assistance, and levels of resources are available so that care teams can successfully implement the HDMEC policy.

  • The Deputy Director (DD) of Medical Services and the Deputy Medical Executive of Utilization Management are responsible for the statewide planning, implementation, and evaluation of the HDMEC policy.

• Regional

  • Regional leadership is responsible for this policy at the subset of institutions within an assigned region.

• Institutional

  • The Chief Executive Officer, or designee, has overall responsibility for adherence to this policy at the institution.

Procedure

• HDMEC

  • Membership

    • The Chair shall be a Deputy Medical Executive or Assistant Deputy Medical Executive appointed by the DD, Medical Services. The Chair shall assist the DD, Medical Services, in the selection of other members of the HDMEC.

    • Voting Members (and alternate designees) are appointed by the DD, Medical Services, from among CCHCS and CDCR staff nominated by relevant leaders for each discipline:

      • Two or more physician executives or managers, or their designees, from Medical Services.

      • Two or more institution or regional physician executives or managers.

      • Two or more executives or managers, or their designees, from Nursing Services.

      • Two or more institution or regional nursing executives or managers.

      • The Chair may designate any voting member to chair the HDMEC in their absence.

    • Non-Voting Members

      • Members may include one executive or managerial representation from:

        • Dental Services.

        • Psychiatry Services.

        • Procurement Services.

        • Direct Care Contracts.

        • Health Care Correspondence and Appeals Branch.

        • Corrections Services.

        • Division of Adult Institutions.

        • CCHCS Office of Legal Affairs

        • Fiscal Management Section

      • The Chair is a non-voting member unless needed to reach a quorum, as noted below.

  • Meetings

    • The HDMEC shall meet as often as necessary but not less frequently than annually.

    • A quorum shall consist of at least 50% of voting members in attendance. In reaching the quorum requirement, alternate designees of the same clinical discipline may be counted toward a quorum, and the Chair may serve as a member for their clinical discipline, if necessary, to reach a quorum.

      • In the event of a tie amongst voting members, the Chair has the option to serve as the tiebreaker, if not acting as a voting member to reach a quorum, or request additional information and review the case a second time at a future HDMEC meeting with the same voting members present.

    • A record of the proceedings shall be kept and shall record activities, recommendations of the committee, and attendance.

    • The proceedings and records of the HDMEC shall be confidential and protected from discovery to the extent permitted by law.

  • Scope of Review

    • The HDMEC shall report to the Headquarters Utilization Management Committee.

    • The HDMEC is responsible for the following:

      • Review all approved requests for nonformulary DME from institutions.

      • Review and resolve provider appeals of denied nonformulary DME requests.

      • Review and resolve issues pertaining to security concerns versus health care needs.

      • Provide a written response to the requestor, if applicable.

      • Determine the necessity of DMEs and maintain the Durable Medical Equipment and Medical Supply Formulary.

  • Requests to HDMEC

    • To request an addition, change, or deletion of item(s) on the DME and Medical Supply Formulary, institutional staff shall submit a Form OBS 5002.

    • If a request for non-formulary DME or medical supply is denied at the institutional level the primary care provider may request a higher-level review by the HDMEC. The Chief Medical Executive, or designee, shall then forward the denied request for service through the “HQ DME Committee” message pool for further review.

• Medical Equipment and Supply Interdisciplinary Team

  • Membership

    • The members shall be selected so as to represent the functional areas of the institution that are necessary for the appropriate and coordinated delivery of DMEs and medical supplies, including a minimum of two physicians and two nurses.

  • Meetings

    • The Medical Equipment and Supply (MES) Interdisciplinary Team shall meet at least monthly.

    • A record of the proceedings shall be kept and shall record activities, recommendations of the MES Interdisciplinary Team, and attendance.

  • Scope of Review

    • The MES Interdisciplinary Team shall:

    • Report to the HDMEC.

    • Utilize the Health Care Services Dashboard to monitor and review the timely distribution of DME.

    • Review and address out-of-compliance orders.

    • Review and address discrepancies of DME orders in the Electronic Health Records System and Strategic Offenders Management System.

    • Review and disseminate new statewide guidelines, policies, procedures, and recommendations.

    • Provide oversight and management of institutional practices and processes of DME and medical supplies that is consistent with CCHCS and CDCR standards.

Procedure Overview

• This procedure sets forth the composition and general operational rules of the Medical Peer Review Committee (MPRC), as well as the procedures under which it conducts non-routine or for cause peer reviews of the clinical practice and professional conduct of licensed medical providers within the California Department of Corrections and Rehabilitation (CDCR) adult institutions and the regional and headquarters offices of the California Correctional Health Care Services (CCHCS).  All MPRC recommendations shall ensure the safety of patients and staff and shall be commensurate with the identified deficiencies in clinical practice and professional conduct.

Responsibility

• The Deputy Director, Medical Services, has overall responsibility for ensuring this procedure is applied to all cases where there are allegations of substandard clinical practice or professional misconduct.  The Deputy Director, Medical Services, shall designate the MPRC Chairperson.

• The Regional Deputy Medical Executives (RDME) are each responsible for the implementation of and compliance with this procedure as it relates to clinical practice and professional conduct for the licensed medical providers who work within their designated institutions.

• The MPRC Chairperson is responsible for presiding at all meetings, facilitating the clinical discussion, and ensuring actions are taken in accordance with current, accepted meeting procedures and applicable CCHCS policies and procedures.

• An assigned non-clinical manager and support staff shall attend the meetings to ensure administrative and procedural requirements are met.

Procedure

• Membership

  • The Deputy Director, Medical Services, shall appoint the MPRC voting members to include the following:

    • All RDMEs.

    • Four physician managers, at least two of which are institution based.

    • Two line staff physicians nominated by the Union of American Physicians and Dentists.

  • A Nurse Practitioner or Physician Assistant shall be nominated by the MPRC Chairperson to serve when a matter pending before the MPRC involves a Nurse Practitioner or Physician Assistant.  This member shall only serve on the MPRC for the purpose of reviewing the case involving the Nurse Practitioner or Physician Assistant but shall not continue to serve beyond the time needed to bring the case to resolution.

  • Potential nominees shall submit their Curriculum Vitae to the MPRC for review and recommendation.  The approved membership shall review the candidate(s) and make their recommendations to the Deputy Director, Medical Services, for consideration. The Deputy Director, Medical Services, shall consider but is not bound by their recommendations in making or approving the selection of any nominee to become a member.

  • Term limits for committee membership:

    • Except for the RDMEs who shall serve as voting members throughout their assignment as RDME, the maximum term for voting members of the MPRC shall not exceed 24 months.  Exceptions to this rule may be granted by the Deputy Director, Medical Services, for good cause.

    • After serving a maximum of 24 months, a period of six months must pass during which they do not serve on the MPRC before the member is eligible to return as a voting member of the MPRC. 

    • In order to allow for the creation of staggered terms for the MPRC membership, the term limits outlined above may be waived during the initial establishment of the MPRC by the Deputy Director, Medical Services. The date of initial establishment is the effective date of this procedure.  The Deputy Director, Medical Services, in their sole discretion, may set term limits of up to 36 months for up to half of the voting members.

  • An attorney from the CCHCS Office of Legal Affairs shall be assigned to attend MPRC meetings and provide the MPRC with legal advice regarding any matters pending before the MPRC or any other legal issues which may impact the MPRC. The inability for an attorney to attend will not affect the commencement of the meeting to occur.

• Conflict of Interest

  • Regular voting members of the MPRC, as CCHCS employees, shall comply with applicable laws and regulations regarding disclosure of outside employment, enterprises or activities, and prohibitions against engaging in conflicts of interest.  These include the California Code of Regulations, Title 15, Sections 3409 and 3413, as well as pertinent provisions of the Government Code, Public Contracts Code, and the Fair Political Practices Act (FPPA).  Among other things, these requirements prohibit CDCR and CCHCS employees from deriving any compensation from any entity doing or seeking to do business with the State of California.

  • If any matter of business before the MPRC represents an actual or potential conflict of interest for any member, they shall disclose the conflict or potential conflict to the MPRC and recuse themself from participating in any discussion or voting on the matter creating the conflict or potential conflict.  They shall provide relevant knowledge of the conflict of interest to the committee.

  • Final decisions regarding conflict of interest questions shall be decided by the MPRC Chairperson.  In the event that the MPRC Chairperson has an actual or perceived conflict of interest, final decisions regarding the conflict of interest shall be decided by the Deputy Director, Medical Services.

• Meetings

  • The MPRC shall meet no less than two times per month, unless there are no pending matters. Meetings may be conducted in person, or via telephone or video conference. The MPRC shall convene to hear referrals on an emergency basis (Refer to the Health Care Department Operations Manual, Section 1.4.3.3, Safety Assessment Summary and Automatic Privilege Modification).

  • MPRC support staff shall distribute the meeting materials to the MPRC members a minimum of seven calendar days in advance of regularly scheduled meetings; in cases of emergency meetings, distribution of meeting materials shall be sent within two business days. Exceptions to this timeline shall be approved by the MPRC Chairperson for good cause.

  • The proceedings and records of the MPRC shall be confidential and protected from discovery to the extent permitted by law including, but not limited to, California Evidence Code Section 1157.

• Voting

  • MPRC voting members shall include a minimum of 10 physicians and may also include one Nurse Practitioner or one Physician Assistant, if available, and if warranted by the case(s) under review.  Actions taken regarding a Nurse Practitioner or Physician Assistant shall not be invalidated by the absence of a Nurse Practitioner or Physician Assistant during the deliberative process.

  • A quorum shall be defined as 5 committee members in attendance, excluding Nurse Practitioners and Physician Assistants.  MPRC members may select standing alternates to act as their proxy, subject to the consent of the Deputy Director, Medical Services.  MPRC members not able to attend a regularly scheduled meeting shall inform the MPRC Chairperson and MPRC support staff, when feasible, at least three calendar days in advance of the meeting.  The MPRC Chairperson may waive the notification requirement in order to establish a quorum. 

  • Each MPRC voting member, or designee, shall have one vote on any matter that comes before the MPRC.  Only duly appointed members, or their designee, shall vote on MPRC matters.  A motion carries when it receives a simple majority vote.  The MPRC Chairperson may vote in order to reach a quorum or when necessary to break a tie vote.   The MPRC may use electronic voting to address issues when necessary to take immediate action.  

  • The MPRC Chairperson may schedule additional meetings of the MPRC at their discretion.

• Medical Peer Review Committee Process

  • In reviewing cases before them, the MPRC shall consider all available relevant information including, but not limited to, such matters as:

    • The nature of the licensed medical provider’s actions, conduct, or decision(s) which form the basis of the event(s) under consideration and the extent to which they did or could have affected patient care, patient safety, or the delivery of safe and effective medical care in the facility.

    • The licensed medical provider’s prior history of similar conduct in the past.

    • The licensed medical provider’s prior peer review history, whether routine or non-routine, or relevant prior history with administrative discipline.

    • Any physical, medical, or mental health condition suffered by the licensed medical provider that affects the licensed medical provider’s ability to provide safe, effective, and competent care.

    • The licensed medical provider’s willingness to accept and incorporate corrective measures to prevent future occurrences of similar conduct, actions, or decision-making of the type under review.

  • The MPRC may take one or more of the following actions:

    • Request additional information from the institution, the Clinical Peer Reviewer, or other parties prior to any further consideration of the case. 

    • Refer the matter back to the institution to provide monitoring.

    • Training, education, proctoring, or referral for physical or mental health evaluation for the subject medical provider. 

    • Refer the matter back to the institution for a case conference or education to be provided to all licensed medical providers. 

    • Open a Peer Review Formal Investigation into the matter.  A Peer Review Formal Investigation may include an FPPE.

    • Conduct a Safety Assessment into the matter, which may result in a summary suspension of privileges.

    • Prepare a Final Proposed Action.

    • Close the matter.

  • The MPRC is responsible for ensuring that all reports required by law, based on the interim action taken, are timely filed with the medical provider’s licensing board and the National Practitioner Data Bank.  In cases involving Nurse Practitioners, the MPRC shall report the action taken to the Board of Nursing.

• Referrals to the Health Care Executive Committee

  • The MPRC shall refer the following matters and actions to the HCEC for review and further action as the HCEC deems appropriate:

    • Final Proposed Actions

      • The MPRC may recommend that the HCEC take any one of the following final actions:

      • Modify, restrict, suspend, deny, or revoke the clinical privileges of the licensed medical provider.

      • Issue a letter of admonition, censure, reprimand, or warning.

    • Consent Calendar Items

      • Consent calendars shall include summaries of all matters discussed and all actions taken at the MPRC meetings.  The consent calendar shall include, but not be limited to, case summaries and recommendations regarding one or more of the following:

      • Opening a Peer Review Formal Investigation.

      • Monitoring of some or all of a licensed medical provider’s clinical encounters.

      • Recommending additional education or training for a licensed medical provider.

      • Safety Assessment determinations including any interim, provisional modifications to the licensed medical provider’s privileges pending a Final Proposed Action. 

      • Recommendations for the Credentialing and Privileging Unit to place a credential alert or a credential bar in a licensed medical provider’s file.

Procedure Overview

• The Health Care Executive Committee (HCEC) oversees and reviews all peer review matters brought before it by the Medical Peer Review Committee (MPRC).  As part of its duties, the HCEC shall perform the following:

• Receive, review, and make final decisions on licensed medical provider credentialing, privileging and reappointment in accordance with the Health Care Department Operations Manual, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

• Act on all recommendations and Final Proposed Actions submitted by the MPRC which may include accepting findings and recommendations, accepting findings but determining a different Final Proposed Action, remanding matters for additional investigation or deliberation, and rejecting Final Proposed Actions thus terminating peer review or privileging proceedings.

• Ensure that licensed medical providers subject to HCEC clinical review have been provided due process during that review and that HCEC recommendations are supported by “substantial evidence.”

• Review and take action as necessary on all consent calendar items.

• Meet as required to review all matters brought before the HCEC.

• Appoint the Hearing Officer in Pre-Deprivation Hearings and take action on post-hearing recommendations which may include modifying or affirming a Final Proposed Action.

Responsibility

• The Undersecretary, Health Care Services, shall appoint a member of the HCEC to act as the HCEC Chairperson.

• The HCEC Chairperson shall preside at all meetings.

• The Chief Counsel of the California Correctional Health Care Services (CCHCS) Office of Legal Affairs (COLA) shall appoint an attorney from COLA to provide legal counsel to the HCEC.  That attorney shall provide advice to members of the HCEC on procedural and substantive matters, on resolution of appeals taken from actions of the HCEC, and shall coordinate representation on appeals.  Legal counsel shall provide a regular report to the HCEC on legal matters, including the status of appeal cases and changes in legislation or court orders affecting the HCEC.

Procedure

• Membership

  • The HCEC is comprised of the following voting members:

    • Deputy Director, Human Resources

    • Deputy Director, Medical Services

    • Deputy Director, Mental Health Services

    • Deputy Director, Dental Services

    • Deputy Director, Nursing Services

  • Any changes or additions to the membership shall be approved by the Undersecretary, Health Care Services.

• Meetings

  • The HCEC shall meet monthly or as often as necessary at the request of the HCEC Chairperson to consider MPRC recommendations regarding Final Proposed Actions.  The HCEC may meet in person or via teleconference, as necessary.

  • The HCEC Chairperson shall approve each agenda and direct the HCEC support staff to distribute the agenda to all HCEC members and legal counsel one week before the scheduled meeting.

  • A quorum is necessary to conduct the business of the HCEC and exists when a majority of the voting membership is present.

• Confidentiality

  • The proceedings and records of the HCEC shall be confidential and protected from discovery to the extent permitted by law.

  • Only the members of HCEC and members of the HCEC support staff and legal counsel are permitted to attend meetings of the HCEC.  However, the HCEC Chairperson may permit a guest to attend on a case-by-case basis.

• Conflict of Interest

  • Regular voting members of the HCEC, as California Department of Corrections and Rehabilitation (CDCR) and CCHCS employees, shall comply with applicable laws and regulations regarding disclosure of outside employment, enterprises or activities, and prohibitions against engaging in conflicts of interest.  These include the California Code of Regulations, Title 15, Sections 3409 and 3413, as well as pertinent provisions of the Government Code, Public Contracts Code, and the Fair Political Practices Act (FPPA).  Among other things, these requirements prohibit CDCR and CCHCS employees from deriving any compensation from any entity doing or seeking to do business with the State of California.

  • Concurrently with their annual completion and submission of the Statement of Economic Interests (Form 700) pursuant to the FPPA, members of the HCEC shall provide a copy of their submitted Form 700 to the HCEC Chairperson to be kept on file for reference in the event that a member’s ability to participate in a HCEC decision may be impacted by an actual or potential conflict of interest.

  • If any matter of business before the HCEC represents an actual or potential conflict of interest for any member, he or she shall disclose the conflict or potential conflict to the HCEC and recuse himself or herself from participating in any discussion or voting on the matter creating the conflict or potential conflict.

  • Final decisions regarding conflict of interest questions shall be decided by the HCEC Chairperson.  In the event that the HCEC Chairperson has an actual or perceived conflict of interest, final decisions regarding the conflict of interest shall be decided by the Undersecretary, Health Care Services.

• Voting

  • Each HCEC voting member shall have one vote on any matter that comes before the HCEC and shall have no vote if he or she has previously voted on the matter at any other proceeding.  Only duly appointed members shall vote on HCEC matters.  A motion carries when it receives a simple majority of the voting members participating in the meeting.

  • All voting members may vote on matters involving medical, dental, or mental health providers, amendments to policies and procedures, bylaws, resolution of appeals, and any other matters coming before the HCEC.

  • The current edition of Parliamentary Law and Rules of Order for the 21st Century shall govern parliamentary procedures.

  • The HCEC Chairperson may schedule special meetings of the HCEC at his/her discretion.

  • A record shall be kept of the HCEC proceedings in the form of meeting minutes.

• HCEC Review of MPRC Action

  • The HCEC shall review all MPRC recommendations and Final Proposed Actions and may take one of the following actions:

    • Accept the factual findings and recommendations of MPRC.

    • Accept the factual findings of the MPRC but reject the Final Proposed Action as being inappropriate based on the factual findings and prepare a new Final Proposed Action.

    • Remand the matter to the MPRC for additional investigation or deliberation.  The MPRC shall be provided a date by which the HCEC expects the matter to be returned.

  • Interim privilege modifications such as summary suspensions and provisional privilege restrictions do not require HCEC action until a Final Proposed Action is submitted to the HCEC.

  • The HCEC shall ensure that medical providers subject to MPRC clinical review have been provided due process during that review and the MPRC’s recommendations are supported by substantial evidence.

  • The HCEC shall give great weight to the recommendations of the MPRC.  In carrying out its review, the HCEC may request any additional information from the MPRC that it requires to complete its review of any case before it.

  • In performing its functions, the HCEC may not act in an arbitrary or capricious manner.

  • In instances in which MPRC’s failure to investigate or initiate a privileging action is contrary to the weight of the evidence, the HCEC shall have the authority to direct MPRC to initiate an investigation or a privileging action.

  • If the MPRC fails or refuses to take action in response to a direction from the HCEC, the HCEC shall have the authority to independently take action with respect to a medical provider’s privileges in accordance with the policies and procedures set forth in this chapter.  Prior to taking independent action, the HCEC shall provide notice in writing to the MPRC that it intends to take independent action.

• Notice of Final Proposed Action

  • The Notice of Final Proposed Action is a notice to the licensed medical provider informing him or her of the HCEC’s decision to take an action pertaining to privileges and possibly employment.  Once the HCEC decides upon a Final Proposed Action, it must serve the action on the licensed medical provider within five business days of the vote to serve the Final Proposed Action.

  • Notice of Final Proposed Action shall contain all of the following information:

    • The nature of the Final Proposed Action (e.g., privileges revoked and employment terminated; privileges suspended and licensed medical provider placed on Administrative Time Off).

    • The consequences of the action with regard to privileges, employment, and reporting required by the licensed medical provider’s licensing board and/or to the National Practitioner Data Bank (NPDB).

    • The effective date of the action.  Insofar as the action pertains to employment, the effective date shall be no fewer than five business days after service of the Notice of Final Proposed Action.

    • The reasons for the action including the acts and/or omissions with which the medical provider is charged.

    • A copy of all material relied upon by the HCEC in making the decision.

    • Notice of the right to respond and request a Pre-Deprivation Hearing before the effective date of the action.

    • Instructions regarding when and how to appeal the HCEC decision.

    • Notice that failing to appeal the HCEC decision shall result in the action taking effect and any corresponding actions such as legally required notifications to the medical provider’s licensing board and/or the NPDB.

  • A copy of the Notice of Final Proposed Action served on the licensed medical provider shall be filed with the State Personnel Board when it impacts any of the terms or conditions of employment, including employment status, grade level, benefits and/or wages.

• Pre-Deprivation Hearing Process

  • A Pre-Deprivation Hearing shall be offered and, if requested within the time specified in the Final Proposed Action, shall be held before the effective date of the Final Proposed Action.

  • The HCEC shall select the Hearing Officer when the Notice of Final Proposed Action also impacts terms of conditions of employment.  The Hearing Officer shall be a licensed physician.

  • The Hearing Officer shall provide a recommendation to the HCEC following the hearing.

• When Final Proposed Action Becomes Effective

  • After considering the Hearing Officer’s recommendation, the HCEC shall either modify the Final Proposed Action or affirm it, as noticed.  The Final Proposed Action, insofar as it concerns the employment, shall be considered final and take effect on the date specified in the Final Proposed Action.  In addition, where applicable, employment shall be terminated on the effective date of the action if privileges were revoked.

• Rescission of Final Proposed Action

  • In the event the HCEC determines that rescission of the Final Proposed Action is warranted, any summary suspension in effect shall be immediately terminated and a written notice shall be sent to the subject medical provider as well as, if necessary, a supplemental report to the applicable licensing board, and the peer review proceedings shall end.

Policy

• This procedure sets forth the composition and general operational rules of the Behavioral Health Professional Peer Review Committee (BHPPRC), as well as the procedures under which it conducts non-routine or for cause peer reviews of the clinical practice and professional conduct of Clinical Social Workers within Medical Services, California Department of Corrections and Rehabilitation (CDCR) adult institutions and headquarters offices of the California Correctional Health Care Services (CCHCS). This policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers, when employed under Medical Services. All BHPPRC recommendations shall ensure the safety of patients and staff and shall be commensurate with the identified deficiencies in clinical practice and professional conduct.

Responsibility

• The Chief Psychologist in the Integrated Substance Use Disorder Treatment (ISUDT) Program in collaboration with the Deputy Medical Executive (DME) for Integrated Care and Complex Patient Populations (ICCPP) Director, Medical Services, has overall responsibility for ensuring this procedure is applied to all cases where there are allegations of substandard clinical practice or professional misconduct. The Deputy Director, Medical Services shall designate the BHPPRC Chairperson.

• The Supervising Psychiatric Social Workers within Medical Services are each responsible for the implementation of and compliance with this procedure as it relates to clinical practice and professional conduct for the behavioral health professionals (BHP) who work within Division of Adult Institutions and provide telehealth at headquarters.

• The BHPPRC Chairperson is responsible for presiding at all meetings, facilitating the clinical discussion, and ensuring consequential actions are in accordance with current, accepted meeting procedures and applicable CCHCS policies and procedures.

• An assigned non-clinical manager or support staff shall attend the meetings to ensure administrative and procedural requirements are met.

Procedure

• Membership

  • Membership appointed by the DME of ICCPP shall include the following (this policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers, when employed under Medical Services):

    • Chief Psychologist, ICCPP.

    • At least two Supervising Psychiatric Social Workers working within the Medical Services Division.

    • At least one headquarters based physician manager.

    • At least one headquarters Chief Nurse Executive (CNE).

    • At least two line staff BHPs.

  • Term limits for committee membership:

    • The maximum term for voting members of BHPPRC shall not exceed 24 months.

    • After serving a maximum of 24 months, a period of six months must pass during which he or she does not serve on the BHPPRC before the member is eligible to return as a voting member of the BHPPRC.

    • In order to allow for the creation of staggered terms for the BHPPRC membership, the term limits outlined above may be waived during the initial establishment of the BHPPRC by the Deputy Director, Medical Services. Initial establishment runs for a period of 36 months from the effective date of this procedure. The Deputy Director, Medical Services, in their sole discretion, may set term limits of up to 36 months for up to half of the voting members.

  • An attorney from the CCHCS Office of Legal Affairs shall attend BHPPRC meetings and provide the BHPPRC with legal advice regarding any matters pending before the BHPPRC or any other legal issues which may impact the BHPPRC.

• Conflict of Interest

  • Regular voting members of the BHPPRC, as CCHCS employees, shall comply with applicable laws and regulations regarding disclosure of outside employment, enterprises or activities, and prohibitions against engaging in conflicts of interest. These include the California Code of Regulations, title 15, Sections 3409 and 3413, as well as pertinent provisions of the Government Code, Public Contracts Code, and the Fair Political Practices Act (FPPA). Among other things, these requirements prohibit CDCR and CCHCS employees from deriving any compensation from any entity doing or seeking to do business with the State of California.

  • Concurrently with their annual completion and submission of the California Fair Political Practices Commission (FPPC) Form 700, Statement of Economic Interests pursuant to the FPPA, members of the BHPPRC shall provide a copy of their submitted FPPC Form 700 to the BHPPRC Chairperson to be kept on file for reference in the event that a member’s ability to participate in a BHPPRC decision may be impacted by an actual or potential conflict of interest.

  • If any matter of business before the BHPPRC represents an actual or potential conflict of interest for any member, he or she shall disclose the conflict or potential conflict to the BHPPRC and recuse himself or herself from participating in any discussion or voting on the matter creating the conflict or potential conflict.

  • Final decisions regarding conflict of interest questions shall be decided by the BHPPRC Chairperson. In the event that the BHPPRC Chairperson has an actual or perceived conflict of interest, final decisions regarding the conflict of interest shall be decided by the Deputy Director, Medical Services.

• Meetings

  • The BHPPRC shall meet no less than two times per month, unless there are no pending matters.

  • BHPPRC support staff shall distribute the meeting materials to the BHPPRC members a minimum of ten calendar days in advance of regularly scheduled meetings. Exceptions to this timeline may be approved by the BHPPRC Chairperson for good cause.

  • The proceedings and records of the BHPPRC shall be confidential and protected from discovery to the extent permitted by law.

• Voting

  • BHPPRC voting committee members shall include a minimum of five BHPs.

  • A quorum shall be defined as five of the seven committee members in attendance. BHPPRC members may select standing alternates to act as their proxy, subject to the consent of the Deputy Director, Medical Services. BHPPRC members not able to attend a regularly scheduled meeting shall inform the BHPPRC Chairperson and BHPPRC support staff, when feasible, at least three calendar days in advance of the meeting. The BHPPRC Chairperson may waive the notification requirement in order to establish a quorum.

  • Participation by telephone or video conference shall be permissible.

  • Each BHPPRC voting member or designee shall have one vote on any matter that comes before the BHPPRC.  Only duly appointed members shall vote on BHPPRC matters. A motion carries when it receives a simple majority vote. The BHPPRC Chairperson may not vote unless it becomes necessary to break a tie vote. The BHPPRC may use electronic voting to address issues when necessary to take immediate action.

  • The BHPPRC Chairperson may schedule additional meetings of the BHPPRC at their discretion.

• BHP Peer Review Committee Process

  • In reviewing cases before them, the BHPPRC shall consider all available relevant information including, but not limited to, such matters as:

    • The nature of the BHP’s, conduct, or decision(s) which form the basis of the event(s) under consideration and the extent to which they did or could have affected patient care, patient safety, or the delivery of safe and effective medical care in the facility.

    • The BHP’s prior history of similar conduct in the past.

    • The BHP’s prior peer review history, whether routine or non-routine, or relevant prior history with administrative discipline.

    • Any physical, medical, or mental health condition suffered by the BHP that affects the BHP’s ability to provide safe, effective, and competent care.

    • The BHP’s willingness to accept and incorporate corrective measures to prevent future occurrences of similar conduct, actions, or decision-making of the type under review.

  • BHPPRC may take one or more of the following actions:

    • Request additional information from the institution, the Clinical Peer Reviewer, or other parties prior to any further consideration of the case.

    • Refer the matter back to the supervisor to provide training, education, proctoring, performance monitoring, or referral for physical or mental health evaluation for the subject medical provider.

    • Refer the matter back to the supervisor for a case conference or education to be provided to all BHPs.

    • Open a Peer Review Formal Investigation into the matter. A Peer Review Formal Investigation may include an FPPE.

    • Send a Letter of Concern when the clinical issues involve a BHP providing registry or contract services.

    • Conduct a Safety Assessment into the matter, which may result in a summary suspension of privileges.

    • Prepare a Final Proposed Action.

    • Close the matter if the BHPPRC determines there are no concerns with clinical care.

  • The BHPPRC is responsible for ensuring that all reports required by law, based on the interim action taken, are timely filed with the Board of Behavioral Sciences and the National Practitioner Data Bank.

• Referrals to the Health Care Executive Committee

  • The BHPPRC shall refer the following matters and actions to the Health Care Executive Committee (HCEC) for review and further action as the HCEC deems appropriate:

    • Final Proposed Actions

      • The BHPPRC may recommend that the HCEC take any one of the following final actions:

        • Modify, restrict, suspend, deny, or revoke the clinical privileges of the BHP.

        • Issue a letter of admonition, censure, reprimand, or warning.

      • Consent Calendar Items

        • Consent calendars shall include summaries of all matters discussed and all actions taken at BHPPRC meetings. The consent calendar shall include, but not be limited to, case summaries and recommendations regarding one or more of the following:

          • Opening a Peer Review Formal Investigation.

          • Monitoring of some or all of a BHP’s clinical encounters.

          • Recommending additional education or training for a BHP.

          • Safety Assessment determinations including any interim, provisional modifications to the BHP’s privileges pending a Final Proposed Action.

          • Recommendations for the Credentialing and Privileging Unit to place a credential alert or a credential bar in a BHP’s file.

Policy

• The Division of Health Care Services (DHCS) and California Correctional Health Care Services (CCHCS) shall ensure patients receive health care services from properly licensed and/or credentialed health care providers. Health care providers whose positions or job descriptions by law or regulation require current licensure, certification, and credentialing shall be in compliance with all applicable federal and state requirements. DHCS/CCHCS shall verify all required health care provider licenses, certificates, and credentials with the primary source and document this verification upon hire and when credentials are renewed.

Purpose

• To ensure compliance with all federal and state requirements regarding the credentialing of health care providers within DHCS/CCHCS.

Scope

• Credentials for civil service and contract providers shall be approved on a statewide basis. Reappointment shall occur every three years.

Responsibility

• The Deputy Directors of DHCS and Directors of CCHCS are responsible for the statewide planning, implementation, and evaluation of credentialing processes.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a process to credential and privilege all licensed medical providers who provide patient care services at California Department of Corrections and Rehabilitation (CDCR) institutions to ensure that they meet minimum credentials, privileging, and performance standards. Licensed medical providers shall not perform any job duties prior to having their credentials approved nor provide direct patient care until privileges have been granted. CCHCS considers credentialing and privileging activities to be peer review activities within the meaning of Business and Professions Code, Section 805 and Evidence Code, Section 1157.

Purpose

• To ensure that all licensed medical providers subject to this policy and who provide patient care services at CDCR institutions meet minimum credentials, privileging, and performance standards.

Applicability

• This policy and procedure applies to all licensed medical providers.

Responsibility

• Hiring or Contracting Authority

  • The Hiring or Contracting Authority (HCA) is responsible for ensuring that licensed medical providers are appropriately credentialed and operate within the scope of their clinical privileges. Prior to submitting a request for credentialing and privileging, the HCA shall ensure that all pre-appointment human resources requirements have been met including, but not limited to, completing Live Scan reviews.

• Medical Reviewer

  • The Medical Reviewer (MR) shall review and make a determination regarding all credential and core privileging applications referring to the Medical Peer Review Committee for a recommendation as specified in Referral Criteria (Appendix 4).

• Physician Manager

  • The physician manager is responsible for reviewing requested additional clinical privileges and for making a determination regarding privileging actions and for monitoring and surveillance of the professional competency and clinical performance of those who provide patient care services with delineated clinical privileges.

• Medical Executive

  • The medical executive is responsible for coordinating and facilitating the Performance Evaluation Meeting (PEM) where a recommendation regarding advancing provisional privileges to active privileges for newly hired civil service licensed medical providers, including those who are not subject to a probationary period, is made.

• Local Governing Body

  • The Local Governing Body (LGB) for each institution or facility where direct patient care services are provided within a licensed unit is responsible for reviewing requested clinical privileges and for making a determination regarding privileging actions.

• Credentialing and Privileging Support Unit

  • The Credentialing and Privileging Support Unit (CPSU) shall review and process all applications for credentials and privileges in accordance with this policy and procedure.

• Medical Peer Review Committee

  • The Medical Peer Review Committee (MPRC) shall review and act on credentialing and privileging application referrals received from the MR.  The committee shall monitor credentialing and privileging activities within CCHCS and ensure that program-specific standards for credentials and clinical privileges remain current and up-to-date under applicable legal, accreditation, and community standards.

  • The MPRC shall refer all proposed actions that will impact the privileges of a licensed medical provider to the Health Care Executive Committee (HCEC) for approval and further action. All other actions taken by the MPRC shall be reported to the HCEC on an informational consent item report. This includes placement of credential alerts and credential bars as well as privilege modifications which are not taken for medical disciplinary cause or reason (i.e., lapse or expiration of credentials or privileges or a failure to secure required certifications or licenses).

• Health Care Executive Committee

  • The HCEC shall oversee the MPRC’s credentialing and privileging activities and shall review all privileging actions taken by the MPRC.  The HCEC may act independently as necessary to ensure that patient health care at CCHCS meets the standard of care.

• Licensed Medical Providers

  • Licensed medical providers are responsible for the following items:

    • Providing evidence of licensure, registration, certification and other relevant credentials as set forth in this section for verification prior to appointment and throughout the appointment process as requested.

    • Notifying CCHCS of information or actions that would adversely affect or otherwise limit their privileges at the earliest date after information is received by the licensed medical provider but no later than 15 calendar days. This includes not only final actions but also pending and proposed actions.

    • Maintaining licenses, registrations, and certifications in good standing and informing the HCA of any changes in these statuses, including but not limited to, any pending or proposed actions, at the earliest date after notification is received by the licensed medical provider but no later than 15 calendar days.

    • Obtaining and producing all required information for a proper evaluation of professional competence, character, ethics, and other qualifications. The information shall be complete and verifiable. The licensed medical provider has the responsibility for furnishing information that will help resolve any questions concerning these qualifications.

  • Failure to keep CCHCS fully informed on these matters may result in administrative or disciplinary action.

Procedure Overview

• The credentialing and privileging process includes primary source verifications for credentialing determinations for licensed medical providers.  The minimum qualifications reviewed for all providers shall include, but not be limited to, licensure, certification, education, training and experience, competence, and physical and mental ability to discharge patient care responsibilities appropriately in a correctional setting.  This includes any information which impacts a provider’s:

  • Clinical skills, competency, and judgment necessary to perform the health care services provided to patients.

  • Judgement and ability to perform procedures required of any specialty for which credentials are reviewed.

  • Consistent observance of professional and ethical standards including a history of acting in a professional and collegial manner.

  • Written and verbal communication skills.

• The CPSU shall work collaboratively with appropriate stakeholders in collecting, reviewing, tracking, and evaluating licensures, relevant training, experience, and competencies of each licensed medical provider.

• Credential decisions for licensed medical providers shall be made on a statewide basis. If credentials are approved, core privileges shall be granted on a statewide basis.

• Additional privileges (not included in the core privilege or procedure list) shall be evaluated by the physician manager at the institution where such additional privileges are requested once credentials have been approved and core privileges have been granted.

• Reappointment shall occur every three years.

Procedure

• Initial Appointment

  • During initial appointment credentialing and privileging, the type of privileges that may be granted will depend on employment status.  Initial privileges may be provisional, active or contract, depending upon whether the applicant is required to serve a civil service probationary period or is providing services pursuant to a contract.

  • The applicant shall submit a completed CCHCS credential and privilege application package as outlined in the Licensed Medical Provider Credentialing and Privileging Documentation Requirements (Appendix 1) within 30 calendar days of receipt of the application. In addition, the applicant shall:

    • Attest that all information submitted for the credentialing and privileging process is accurate.

    • Agree to immediately report any change in the status of the information in the application or maintained in the credentials file.

    • Agree to abide by the CDCR Code of Conduct, CDCR Department Operations Manual, Section 33030.3.1, and the Licensed Medical Provider Code of Professional Conduct.

    • Agree to renew credentials and active privileges at least every three years.

  • The CPSU shall review the application and supporting documentation, which shall include the documents listed in the Primary Source Verification Documents (Appendix 2), to determine whether the applicant meets credentialing and privileging standards as listed in the Minimum Professional Requirements for Credentialing and Privileging Approval (Appendix 3).

    • If the application is incomplete, the CPSU shall actively work with the applicant and physician manager or HCA to gather missing information until the necessary information is obtained.

    • If unable to gather information within 30 days of receipt of the credential request, the CPSU shall inform the HCA and the medical executive or physician manager who will make a determination on whether to close the request or continue with the credentialing and privileging process.

  • When the application is determined to be complete, the CPSU shall forward the credentialing and privileging application and supporting documentation to the MR for review and a determination within seven calendar days of the review being assigned.

  • For institutions with a licensed unit, the Chief Medical Executive (CME) shall make a privilege recommendation to the LGB for determination.  The CME shall report the LGB’s privilege determination to the CPSU.

  • Upon receipt of the credentialing and privileging determination, the CPSU shall do the following:

    • Civil service applicants subject to a probation period: If credentials were approved, and provisional privileges granted, the CPSU shall inform the HCA, physician manager, medical executive, and applicant of the determination.  The length of time for provisional privileges shall be equivalent to the probationary period not to exceed 365 calendar days.

    • Civil service applicants not subject to a probationary period: If credentials were approved, and active privileges granted, the CPSU shall inform the HCA, physician manager, medical executive, and applicant of the decision.  The length of time for active privileges shall not exceed three years.

    • Contract Applicants: If credentials are approved and contract privileges granted, the CPSU shall inform the Contracting Authority of the decision.

  • For primary care advanced practice providers (APP), the CPSU shall request that the physician manager or medical executive complete and submit a signed APP Practice Agreement within five calendar days from the applicant’s start date.

  • If credentials are not approved, the CPSU shall notify the HCA, medical executive or DD, Medical Services or designee, and the Contracting Authority (for licensed contract providers) of the decision.

  • Additional Privileges

    • A licensed medical provider may request additional privileges based on their training, experience, and the institution’s needs. The licensed medical provider shall “self-report” competency which means they are attesting that they are proficient in the procedure and have successfully completed at least three cases within the past 24 months without complications.

    • If the licensed medical provider has requested additional privileges, the CPSU shall forward the application for additional privileges and supporting documentation to the physician manager for review and determination. For CMEs who have requested additional privileges, upon credential approval, the CPSU shall forward the privileging application and supporting documentation to the Regional Deputy Medical Executive (RDME) for review and determination.

    • When privileges for additional procedure(s) are requested, the physician manager or peers competent in the requested procedure(s) shall proctor a minimum of three cases. If the licensed medical provider requesting privileges has demonstrated competency in performing the procedure(s), this shall be noted in the privileging record and no further evaluation is needed.

    • If additional oversight is needed in the performance of a procedure, the physician manager shall make the determination regarding how many more cases need to be proctored. If the physician manager or peers at the institution are unable to provide proctoring, the institution may reach out to the RDME for assistance. If proctoring is unavailable, the request for additional privileges shall not be granted.

• Provisional to Active Privileges

  • No less than 60 calendar days prior to expiration of provisional privileges, the CPSU shall:

    • Inform the medical executive that the licensed medical provider’s provisional privileges will be expiring, the date of expiration, and the PEM due date.

    • If applicable, the CPSU shall also identify any referral criteria items which are listed in Referral Criteria (Appendix 4) and:

      • Inform the physician manager of any referral criteria items.

      • Request that the physician manager provide additional information regarding any referral criteria items.

  • Once all necessary materials are gathered and no less than 30 calendar days prior to expiration of provisional privileges, the medical executive shall facilitate a PEM to review the Initial Focused Professional Practice Evaluation (IFPPEs), available peer review documentation, and referral criteria items to make a determination regarding active privileges for the licensed medical provider. The following individuals may participate in the PEM:

    • DD, Medical Services or designee

    • Assistant Deputy Medical Executive (optional)

    • Deputy Medical Executive

    • MR

    • Both the CME and Chief Physician and Surgeon

    • Institution Hiring Authority

    • Health Care Employee Relations Officer (HCERO) (if there are significant concerns regarding the licensed medical provider’s performance which may warrant progressive discipline or rejection during probation)

  • Once the PEM has been completed, the physician manager or medical executive shall inform CPSU of the outcome and provide a signed Attestation of Clinical Competence (ACC).  If the physician manager or medical executive is unable to attest to the medical provider’s clinical competency, an explanation of the reasons they are unable to do so shall be provided to the CPSU.

  • If active privileges are granted, the CPSU shall notify the licensed medical provider.

  • For licensed medical providers subject to a probationary period: If, after the PEM, the determination is that active privileges shall not be granted, the CPSU shall inform the MPRC of their recommendation, and the HCA shall work with the HCERO to prepare a Rejection During Probation (RDP). A copy of the RDP shall be provided to the MPRC.  The MPRC shall determine whether or not the RDP was for medical disciplinary cause or reason and thus needs to be reported to the licensed medical provider’s licensing board or the National Practitioner Data Bank.

• Reappointment

  • No less than 60 calendar days prior to expiration of active credentials or privileges, the CPSU shall:

    • Inform the HCA, physician manager, medical executive, and licensed medical provider of the pending credentials or privileges expiration date.

    • Identify and gather available peer review documentation and professional practice evaluations from the MPRC.

    • Identify any referral criteria items which are listed in the Referral Criteria (Appendix 4).

    • Request that the physician manager or medical executive submit an ACC based on the clinical performance over the preceding three years for licensed medical providers.

    • For primary care APPs, request that the physician manager or medical executive review and submit an APP Practice Agreement.

    • Inform and request from the physician manager any referral criteria items.

  • The licensed medical provider shall submit the reappointment application no less than 30 calendar days prior to expiration of active credentials or privileges.

  • When all required elements of the application have been received, the CPSU shall forward the credentialing and privileging application and supporting documentation to the MR for review and determination within seven calendar days of the review being assigned.

  • Upon approval of credentials and granting of statewide core privileges, the CPSU shall notify the HCA, physician manager, medical executive, and the licensed medical provider of the decision.

  • If the licensed medical provider has requested additional privileges, upon approval of credentials and granting of statewide core privileges, the CPSU shall forward any application for additional privileges and supporting documentation to the physician manager. For CMEs who have requested additional privileges, upon credential approval, the CPSU shall forward the privileging application and supporting documentation to the RDME for review and determination.

  • If a licensed medical provider will be providing patient care services within a licensed unit, the CPSU shall forward the approved credentialing and privileging application and supporting documentation to the HCA and their designee.  Upon completion of the review and determination, the HCA, or designee, shall forward the LGB determination to CPSU.

  • If reappointment is not approved, the CPSU shall notify the HCA of the decision and shall concurrently refer the file to the MPRC to determine whether any reports are required by law to be filed with the licensed medical provider’s licensing board, the National Practitioner Data Bank, or both, and whether a referral to the HCA is necessary for further disciplinary action as a result of privileges not being granted.

• Changes to Privileging Status

  • Privileging status changes may be initiated by the MPRC, HCEC, HCA, physician manager, medical executive, DD, Medical Services or designee, or licensed medical provider. Changes to privileging status include, but are not limited to, expiration, resignation, rejection, denial, termination, revocation, suspension, restriction, withdrawal, or abandonment of a request for credentials or privileges.

  • Expiration of Privileges

    • Licensed medical providers shall not be allowed to continue providing patient care if the licensed medical provider’s privileges expire.

    • If a civil service licensed medical provider’s privileges have expired for any reason (including the licensed medical provider’s failure or refusal to complete the reappointment process), the CPSU shall notify the HCA, physician manager, medical executive, or DD, Medical Services or designee of the expiration of privileges.  The HCA shall ensure that the licensed medical provider is removed from providing patient care and shall initiate any further action which may be warranted, including progressive discipline.  The CPSU shall concurrently refer the file to the MPRC which shall take further action pursuant to Section (d)(7).

    • Contracted licensed medical providers shall be subject to termination of contract services upon the expiration of privileges.

  • Automatic Termination of Privileges

    • Privileges shall automatically be terminated under the following circumstances:

      • Upon permanent separation from civil service employment.

      • Upon the passage of 180 consecutive calendar days without providing contract services as a licensed medical provider, for any reason.

      • Upon termination or expiration of the contract pursuant to which the licensed medical provider is providing services

    • A licensed medical provider whose privileges were automatically terminated shall be required to reapply for credentials and privileges prior to resuming clinical care.

  • Voluntary Termination of Privileges

    • A licensed medical provider who currently possesses any type or set of privileges and no longer wishes to exercise such privileges may voluntarily terminate their privileges by providing written notice to their HCA or physician manager, or medical executive, which shall include the effective date of the termination. The HCA, physician manager, or medical executive shall forward the notice of voluntary termination of privileges to the CPSU within five calendar days of the licensed medical provider’s written notice.

    • Voluntary changes to any privileging status initiated by a licensed medical provider shall not automatically be deemed to be an unfavorable action for medical disciplinary cause or reason, triggering any form of peer review.  However, the MPRC and HCEC retain the discretion to review all voluntary changes to a licensed medical provider’s privileging status and to make an independent determination as to whether the change in privileging status warrants further reporting or action as required by law.

  • Leaves of Absence

    • In the event that a licensed medical provider’s active statewide privileges expire during a leave of absence, temporary privileges may be granted without the need for a new application, not to exceed 60 calendar days from the date the licensed medical provider returns to work.

    • The CPSU shall forward the most recent privileging application and supporting documentation to the MR to determine if temporary privileges should be granted.

    • The licensed medical provider shall submit a current reappointment application within ten calendar days of returning to work.

• Disaster Privileges

  • Disaster privileges may be granted to administer care, treatment, and services to patients when a disaster has been declared by the individual or agency with authority to declare a disaster or state of emergency (such as the Governor). The institution’s local emergency operations plan must be activated to authorize disaster privileges. At a minimum, the process for granting disaster privileges shall include:

  • A completed Disaster Privileging Form.

  • A valid, government-issued photo ID (i.e., driver’s license or passport) and at least one the following:

    • Current picture identification card from a health care organization that clearly identifies professional designation.

    • Current license, certification, or registration to practice.

    • Identification indicating that the practitioner is a member of a Disaster Medical Assistance Team, the Medical Reserve Corps, the Emergency System for Advance Registration of Volunteer Health Professional, or other recognized federal or state response organization or group.

    • Identification indicating that the practitioner has been granted authority by a government entity to provide patient care, treatment, or services in a disaster circumstance.

    • Confirmation by a licensed medical provider currently privileged by the hospital or by a staff member with personal knowledge of the practitioner’s ability to act as a licensed independent practitioner during a disaster.

    • The CPSU shall confirm and verify the information above and Disaster Privileges shall be reviewed and granted by the MR. The physician manager or medical executive shall document their review of the licensed medical provider’s clinical performance within 72 hours of granting disaster privileges to determine whether the privileges shall be continued.

• Emergency Privileges

  • For the purpose of this section, an “emergency” is defined as an unexpected or sudden event that significantly disrupts the ability to provide care or that results in a sudden, significant change or increase in the demand for the services, or a condition in which serious or permanent harm would result to a patient or in which the life of the patient is in immediate danger and any delay in administering treatment would add to that danger.

  • In the case of an emergency, any licensed medical provider, to the degree permitted by their license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the institution necessary, including the calling for any consultation necessary or desirable.

  • When an emergency situation no longer exists, such licensed medical provider shall request the privileges to continue to treat the patient. In the event such privileges are denied, or they do not desire to request privileges, the patient shall be assigned to health care staff as appropriate.

• File Closure

  • The CPSU shall close the credentialing and privileging file when any of the following conditions are met:

  • The licensed medical provider withdraws the credentialing or privileging application.

  • The HCA, physician manager, medical executive, or MR withdraws the credentialing or privileging request.

  • The CPSU is notified of a licensed medical provider’s resignation, retirement, or death.

  • The MR determines that an application will no longer be pursued.

• Privileging Actions

  • One of the following actions may occur upon request for approval of credentials and granting of privileges:

    • Credentials approval: The MR determines the licensed medical provider meets the standards for credentialing and core privileging.

    • Credential alert: If the MPRC determines that certain facts should be considered as part of the current or any subsequent request to approve credentials or grant privileges to the licensed medical provider, then a credential alert shall be placed in the credentials file and the MPRC, HCA, physician manager, medical executive, DD, Medical Services or designee, and MR shall consider the facts before acting on any subsequent application for credentials or privileges.

    • Credential bar: The MPRC shall place a credential bar in the credentials file if the MPRC determines that the licensed medical provider’s unsatisfactory service has resulted in any one or more of the following:

      • Suspension or revocation of the licensed medical provider’s privileges by the HCEC.

      • Separation for cause from civil service employment with the CCHCS.

      • Termination for cause of the licensed medical provider’s services as a contract licensed medical provider with the CCHCS.

      • Any legally enforceable agreement including, but not limited to, a settlement agreement prohibiting the licensed medical provider from practicing as an employee or contract licensed medical provider with the CCHCS.

      • The placement of a credential bar by the MPRC shall be forwarded to the HCEC as a consent calendar item. After placement of a credential bar in the credentials file, any subsequent application for credentials or privileges shall be reviewed by the HCEC.

    • Referral to the MPRC: The MR shall refer the credentials and privilege application to the MPRC for a determination in the event that the MR determines there is a need for further review of the application by the committee due to concerns as outlined in categories I & II of the Referral Criteria (Appendix 4).  The MR is not required to refer the file to the MPRC for matters that occurred more than five years prior to the date of application submission.

  • Denial of Privileges: If the MPRC determines that the privileges of the licensed medical provider shall be denied, the MPRC shall prepare a recommendation and referral to the HCEC.  The MPRC shall also determine whether the denial is for a medical disciplinary cause or reason, and whether the denial shall be reported to the licensed medical provider’s licensing board or the National Practitioner Data Bank, or the HCA for potential disciplinary action.

• Consideration of Requests for Credentials or Privileges

  • Before making a determination on a credential and privilege request, the MR shall:

    • Consider all credentialing and peer review information including credential alerts or bars, in the credentials file.

    • Confirm that the HCA who requested the credentialing is informed of and has considered all facts relevant to the employment or contracting decision including facts that resulted in the placement of a credential alert or bar.

  • If the credentials file contains a credential bar, the MR shall refer the request to the MPRC with a recommendation for approval or disapproval. The MR is not required to refer files containing a credential alert to the MPRC if they have previously reviewed the information on which the alert is based and are satisfied that the information will not negatively reflect on the competence of the licensed medical provider.

  • The MR shall approve credentials and core privileges only if they determine that the licensed medical provider:

    • Meets all credentialing and privileging requirements as delineated in this section.

    • Possesses the current competence and mental and physical ability to adequately discharge patient care responsibilities in a correctional setting.

• Referring Actions for Medical Disciplinary Reasons

  • The MR is not authorized to deny any application for credentials or privileges based on a medical disciplinary cause or reason within the meaning of the California Business and Professions Code, Section 805, et seq.

  • Where the MR recommends denial of the credentials and privilege request based on a medical disciplinary cause or reason, the MR shall refer the case to the MPRC which shall take further action pursuant to Section (d)(6).

• Civil Service Licensed Medical Provider Transfers and Promotions

  • Regardless of whether statewide privileges have expired, upon appointment to a new classification, licensed medical providers shall submit a new credentialing and privileging application pursuant to Section (f)(1) prior to starting the new position.

  • If a licensed medical provider laterally transfers to a different institution or facility and stays in the same job classification, full reappointment is not required prior to the expiration of the licensed medical provider’s current credentials and statewide privileges, but the licensed medical provider may apply for additional privileges at the new facility or institution.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a process to credential and privilege all behavioral health professionals within Medical Services who are subject to this policy and provide patient care services at California Department of Corrections and Rehabilitation (CDCR) institutions and from the regional and headquarters offices of CCHCS to ensure that they meet minimum credentials, privileging, and performance standards. Behavioral health professionals, to include Clinical Social Workers and psychologists, shall not provide any direct patient care services to CDCR patients prior to having their credentials approved and privileges granted.  This policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services. CCHCS considers credentialing and privileging activities to be peer review activities within the meaning of California Business and Professions Code, Section 805 and Evidence Code, Section 1157. (NOTE: Unlicensed clinical social workers are not subject to Business and Professions Code, Section 805(c)).

• Credentials Review

  • The credentials reviewed for all providers shall include, but not be limited to, licensure, certification, education, training and experience, current competence, and physical and mental ability to discharge patient care responsibilities appropriately in a correctional setting. This includes any information which impacts a provider’s:

  • Clinical skills and competency necessary to perform the health care services provided to patients.

  • Judgment and ability to perform techniques in any specialty for which credentials are reviewed.

  • Consistent observance of professional and ethical standards including a history of acting in a professional and collegial manner.

  • Written and verbal communication skills.

• Scope

  • Credentials for civil service and contract providers shall be approved on a statewide basis.

  • Privileges shall only be granted for the specific location where a behavioral health professional intends to provide services. If a behavioral health professional intends to provide in-person services at more than one CDCR facility, the behavioral health professional shall apply for privileges specific to each physical location.  Privileges shall only be granted once credentials have been approved.

• Reappointment, Expiration of Privileges, and Termination

  • Reappointment shall occur every three years and at other times during a behavioral health professional’s reappointment cycle as set forth in this section. If a behavioral health professional fails to complete the reappointment process, they shall not continue providing patient care services, and their privileges shall expire, resulting in an automatic revocation of privileges. The failure of any civil service employee to participate in or complete reappointment shall be subject to progressive discipline, up to and including termination. Contract  providers shall be subject to termination of contract services upon the expiration of privileges.

  • Privileges shall automatically be terminated at the time of separation under the following circumstances. The provider’s credentials and privileges shall be renewed and approved prior to the resumption of clinical care.

    • Any permanent separation from civil service employment.

    • Any separation of 180 calendar days or greater from contract employment as a behavioral health professional.

    • Any contract termination or expiration as a contract behavioral health professional.

Purpose

• To ensure that all behavioral health professionals who are subject to this policy and provide patient care services within the CCHCS Medical Services at CDCR institutions meet minimum credentials, privileging, and performance standards.

Applicability

• This policy and procedure applies to civil service and contract behavioral health professionals used by Medical Services as follows (this policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services):

• Chief Psychologist

• Senior Psychologist, Specialist

• Psychologist

• Supervising Psychiatric Social Worker (SPSW)

• Licensed Clinical Social Worker (LCSW)

• Unlicensed Clinical Social Worker

Responsibility

• Hiring or Contracting Authority

  • The Hiring or Contracting Authority (HCA) for each CDCR institution or facility where providers provide direct patient care services is responsible for ensuring that health care providers are appropriately credentialed and practice within the scope of their clinical privileges. Prior to submitting a request for credentialing and privileging, the HCA shall ensure that all pre-appointment human resources requirements have been met including but not limited to, checking references and completing Live Scan reviews.

• Deputy Medical Executive

  • The Deputy Medical Executive (DME) is responsible for reviewing requested clinical privileges for Chief Psychologists.

• Credentialing Reviewer

  • The Credentialing Reviewer (CR) is responsible for reviewing credentials applications and making a determination as to whether credentials can be approved or whether the application requires additional evaluation.

• Chief Psychologist

  • The Chief Psychologist is responsible for reviewing requested clinical privileges for SPSWs, Psychologists, and Senior Psychologist, Specialists.

• Supervising Psychiatric Social Worker

  • The SPSW is responsible for reviewing requested clinical privileges for Clinical Social Workers.

• Credentialing and Privileging Support Unit

  • The Credentialing and Privileging Support Unit (CPSU) shall review and process all applications for credentials and privileges in accordance with this policy and procedure.

• Behavioral Health Professional Peer Review Committee (BHPPRC)

  • The Behavioral Health Professional Peer Review Committee (BHPPRC) shall review and act on credentialing and privileging applications that are referred to it, monitor credentialing and privileging activities within  CCHCS and CDCR for Clinical Social Workers and psychologists, and ensure that program-specific standards for credentials and clinical privileges remain current and up-to-date under applicate legal, accreditation, and community standards.

  • The BHPPRC shall refer all proposed actions that will impact the privileges of a social worker or psychologist to the Health Care Executive Committee (HCEC) for approval and further action. All other actions taken by the BHPPRC shall be reported to the HCEC on an informational consent item report. This includes placement of credential alerts and credential bars as well as privilege modifications which are not taken for disciplinary cause or reason (i.e., lapse or expiration of credentials or privileges or a failure to secure required certifications or licenses).

• Health Care Executive Committee

  • The HCEC shall ensure that providers who provide services to CCHCS and CDCR patients provide clinical services that consistently meet the standard of care. This includes oversight of the BHPPRC’s credentialing and privileging activities.

  • The HCEC shall review all privileging actions taken by the BHPPRC and may act independently as necessary to ensure that patient health care at CCHCS and CDCR meets the standard of care.

• Applicants and Behavioral Health Professionals

  • Applicants and behavioral health professionals are responsible for the following items:

    • Providing evidence of licensure, registration, certification and other relevant credentials as set forth in this section for verification prior to appointment and throughout the appointment process as requested.

    • Notifying CCHCS and CDCR of information or actions that would adversely affect or otherwise limit their privileges at the earliest date after notification is received by the behavioral health professional but no later than 15 calendar days. This includes not only final actions but also pending and proposed actions.

    • Maintaining licenses, registrations, and certification in good standing and informing the HCA of any changes in the status of these credentials at the earliest date after notification is received by the behavioral health professional but no later than 15 calendar days including, but not limited to, any pending or proposed actions.

    • Obtaining and producing all needed information for a proper evaluation of professional competence, character, ethics, and other qualifications. The information shall be complete and verifiable. The applicant and behavioral health professional has the responsibility for furnishing information that will help resolve any questions concerning these qualifications.

  • Failure to keep CDCR, CCHCS fully informed on these matters may result in administrative or disciplinary action.

Procedure Overview

• The credentialing and privileging process includes primary source verifications and privileging determinations for behavioral health professionals listed in Section (c) who perform services and are requesting privileges related to clinical performance in CCHCS and CDCR.

• The HCA, CPSU, Headquarters and Regional Medical Executives, CR, DME, Chief Psychologist, SPSW, BHPPRC, and HCEC work collaboratively in collecting, reviewing, tracking, and evaluating licensures, relevant training, experience, and current competencies of each behavioral health professional.

Procedure

• Initial Appointment

  • The applicant shall submit a completed CCHCS credential and privilege application package as outlined in the New Behavioral Health Professional Credentialing and Privileging Documentation Requirements (Appendix 1) within 30 calendar days of receipt of the application. In addition, the applicant shall:

    • Attest that all information submitted for the credentialing and privileging process is accurate.

    • Agree to immediately report any change in the status of the information in the application or maintained in the credentials file.

    • Agree to abide by the CDCR Code of Conduct, CDCR Department Operations Manual, Section 33030.3.1, and the Behavioral Health Professional Code of Professional Conduct (Appendix 2).

    • Agree to renew credentials and active privileges at least every three years.

  • The CPSU shall review the application and supporting documentation, which shall include the documents listed in the Mandatory Primary Source Verification Documents (Appendix 3), to determine whether the applicant meets credentialing and privileging standards as listed in the Minimum Professional Requirements for Credentialing and Privileging Approval (Appendix 4).

    • If the application is incomplete, the CPSU shall actively work with the applicant and DME, Chief Psychologist or SPSW or contract vendor to gather missing information until the necessary information is obtained or until the Chief Psychologist or SPSW makes a determination regarding a final disposition for the application.

    • If the CPSU is unable to gather and/or verify all documents in a timely manner due to circumstances beyond either their control, or the behavioral health professional’s control, after the making a good faith and reasonable effort to do so, the CPSU may, in consultation with the Chief Psychologist or SPSW, move the application forward to the next step in the process.

  • When the CPSU determines the application is ready for review, the CPSU shall forward the credentialing application and supporting documentation to the CR for review and determination within seven calendar days.

  • Upon credentials approval, the CPSU shall forward the privileging application and supporting documentation to the DME, Chief Psychologist or SPSW, for review and determination.

    • For institutions with a Correctional Treatment Center (CTC), the SPSW shall make a privilege recommendation to the Local Governing Body (LGB) for determination. The SPSW shall report the LGB’s privilege determination to the CPSU. For institutions without a CTC, the SPSW shall make a privilege determination to the CPSU.

    • If mentoring or proctoring is requested, proctoring shall be done at the institution by behavioral health leadership or other peers who are experienced with performing the procedures. If there are no peers at the institution who can provide the mentoring, the institution may reach out to the Chief Psychologist for assistance.

    • A provider may request any additional procedures based on their expertise and the institution needs. The provider shall “self-report” competency which means they are proficient in the procedure and have successfully completed at least three cases within the past 24 months without complications.

    • When privileges for an additional procedure or procedures are requested, institution leadership or peers competent in the requested procedure(s) shall proctor a minimum of three cases. If the provider requesting privileges has demonstrated competency in performing the procedure(s), this shall be noted in the privileging record and no further evaluation is needed.

    • If additional oversight is needed, the institution leadership shall make the determination regarding how many more cases need to be proctored. If institution leadership or peers cannot provide proctoring for certain procedures, they shall reach out the Chief Psychologist for assistance.

  • Upon receipt of the credentialing and privileging determination, the CPSU shall do the following:

    • Civil Service Full-Time Applicants with six-month probation period: If credentials are approved and provisional privileges granted for up to 180 calendar days (from the behavioral health professional’s date of appointment), the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

    • Civil Service Full-Time Applicants with one-year probation period: If credentials are approved and provisional privileges are granted for up to 365 calendar days (from the behavioral health professional’s date of appointment) the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

      • Inform the HCA and designated supervisor of the four-month Initial Focused Professional Practice Evaluations (IFPPE) due date.

    • Civil Service Part-Time Applicants: If credentials are approved and provisional privileges granted for a period proportional to the length of the probation period not to exceed 365 calendar days (from the behavioral health professional’s date of appointment, the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

    • Contract Applicants: If credentials are approved and active privileges granted, the CPSU shall:

      • Inform the Contracting Authority of the decision.

  • If credentials are not approved, the CPSU shall notify the HCA and Chief Psychologist of the decision.

• Provisional to Active Privileges

  • No less than 60 calendar days prior to expiration of provisional privileges, the CPSU shall:

    • Inform the HCA, DME, Chief Psychologist or SPSW, that the behavioral health professional’s provisional privileges will be expiring and of the date of the expiration.

    • Inform the HCA, DME, Chief Psychologist or SPSW, of the Performance Evaluation Meeting (PEM) due date.

    • Request that the DME, Chief Psychologist or SPSW, submit an Attestation of Clinical Competency.

    • If applicable, the CPSU shall identify any referral criteria items which are listed in Referral Criteria (Appendix 5) and:

      • Inform the DME, Chief Psychologist or SPSW of any referral criteria items.

      • Request the DME, Chief Psychologist or SPSW to provide additional information regarding any referral criteria items.

  • Once all necessary materials are gathered and no less than 30 calendar days prior to expiration of provisional privileges, the DME, Chief Psychologist or SPSW shall facilitate a PEM to review the IFPPEs, results from IIPs, available peer review documentation, and referral criteria items to make a determination regarding active privileges for the behavioral health professional. The PEM shall be facilitated with the following (this policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services):

    • Headquarters Medical Executive (optional).

    • DME (required).

    • Chief Psychologist (required).

    • CR (optional).

    • SPSW (required).

    • Institution HCA (required).

    • Health Care Employee Relations Officer (HCERO) (if there are significant concerns regarding the behavioral health professional’s performance which may warrant progressive discipline).

  • If active privileges are granted, the CPSU shall notify the behavioral health professional.

  • If after the PEM, the determination is that active privileges shall not be granted, the HCA shall work with the HCERO to prepare a Rejection During Probation (RDP). A copy of the RDP shall be provided to the BHPPRC.  The BHPPRC shall determine whether or not the RDP was for disciplinary cause or reason and thus needs to be reported to the provider’s licensing board, the National Practitioner Data Bank, or both.

• Reappointment

  • No less than 60 calendar days prior to expiration of active credentials or privileges, the CPSU shall:

    • Inform the HCA, as well as the DME, Chief Psychologist or SPSW, and behavioral health professional that the behavioral health professional’s active credentials or privileges will be expiring and the date of the expiration.

    • Identify and gather available Peer Review documentation, including the Ongoing Professional Practice Evaluations (OPPE), any Focused Professional Practice Evaluations (FPPE), and the results from IIPs.

    • Identify any referral criteria items which are listed in the Referral Criteria (Appendix 5).

    • Request that the DME, Chief Psychologist or SPSW submit an Attestation of Clinical Competence based on the performance results obtained from the behavioral health professional’s OPPEs and IIPs completed over the preceding three years.

    • If applicable:

      • Inform the DME, Chief Psychologist or SPSW of any referral criteria items.

      • Request additional information from the DME, Chief Psychologist or SPSW regarding referral criteria items.

  • The behavioral health professional shall submit the reappointment application no less than 30 calendar days prior to expiration of active credentials or privileges.

  • When the CPSU determines the reappointment application is complete, the CPSU shall forward the reappointment application and supporting documentation to the CR for review and credentialing determination.

  • Upon approval of the provider’s reappointment credentials, the CPSU shall forward the reappointment application with requested privileges and supporting documentation to the DME, Chief Psychologist or SPSW for review. The DME, Chief Psychologist or SPSW shall also review the FPPEs, results from IIPs, available Peer Review documentation, and referral criteria items prior to making a determination regarding the reappointment for the behavioral health professional.

  • Behavioral health professionals shall not be allowed to continue providing patient care if the provider’s privileges expire.

  • The CPSU shall refer providers whose privileges have expired to the HCA for further action including, but not limited to, progressive discipline, or an FPPE.

  • If the behavioral health professional fails to complete the reappointment process before their privileges expire, privileges shall not be granted. The CPSU shall notify the HCA, DME, Chief Psychologist or SPSW of the expiration of privileges and shall concurrently refer the file to the BHPPRC which shall take further action in pursuant to Section (d)(7).

  • If reappointment is approved, the CPSU shall notify the HCA, as well as the DME, Chief Psychologist or SPSW, and behavioral health professional of the decision.

  • If reappointment is not approved, privileges shall not be granted. The CPSU shall notify the HCA of the decision and shall concurrently refer the file to the BHPPRC to determine whether any reports are required by law to be filed with the provider’s licensing board, the National Practitioner Data Bank, or both, and whether a referral to the HCA is necessary for further disciplinary action as a result of privileges not being granted.

• Changes to Privileging Status

  • Privileging status changes may be initiated by the BHPPRC, HCEC, HCA, DME, Chief Psychologist, SPSW, or behavioral health professional. Changes to privileging status include, but are not limited to, resignation, rejection, denial, termination, revocation, suspension, restriction, withdrawal, or abandonment of a request for credentials or privileges.

  • A behavioral health professional who currently possesses any type or set of privileges and no longer wishes to exercise such privileges may voluntarily terminate their privileges by providing written notice to their HCA, as well as the DME, Chief Psychologist or SPSW, which shall include the effective date of the termination. The HCA or DME, Chief Psychologist or SPSW shall forward the notice of voluntary termination of privileges to the CPSU within five calendar days of the behavioral health professional’s written notice.

  • Voluntary changes to any privileging status initiated by a behavioral health professional shall not automatically be deemed to be an unfavorable action for disciplinary cause or reason, triggering any form of peer review.  However, the BHPPRC and HCEC retain the discretion to review all voluntary changes to a behavioral health professional’s privileging status and to make an independent determination as to whether the change in privileging status warrants further reporting or action as required by law.

• Temporary Privileges

  • In the event that a provider’s active privileges at the current institution expired during a temporary separation or approved leave of absence, temporary privileges may be granted without the need for a new application, not to exceed 60 calendar days from the date the provider returns to work.

    • The CPSU shall forward the most recent privileging application and supporting documentation to the DME, Chief Psychologist or SPSW to determine if temporary privileges should be granted.

    • The behavioral health provider shall submit a current privileging application within ten calendar days of returning to work.

• Disaster Privileges

  • Disaster privileges may be granted to administer care, treatment, and services to patients when a disaster has been declared by the individual or agency with authority to declare a disaster or state of emergency (such as the Governor). The institution’s local emergency operations plan must be activated in order to authorize disaster privileges. Privileges that are exercised should be equivalent to those exercised at the practitioner’s primary hospital or within the statutory-defined scope of practice for those without primary hospital affiliations. At a minimum, the process for granting disaster privileges shall include:

    • A completed Disaster Privileging Form.

    • A valid, government-issued photo ID (i.e., driver’s license or passport) and at least one the following:

      • Current picture identification card from a health care organization that clearly identifies professional designation.

      • Current license, certification, or registration to practice.

      • Identification indicating that the practitioner is a member of a Disaster Medical Assistance Team, the Medical Reserve Corps, the Emergency System for Advance Registration of Volunteer Health Professional, or other recognized federal or state response organization or group.

      • Identification indicating that the practitioner has been granted authority by a government entity to provide patient care, treatment, or services in a disaster circumstance.

      • Confirmation by a licensed independent practitioner (LIP) currently privileged by the hospital or by a staff member with personal knowledge of the practitioner’s ability to act as an LIP during a disaster.

      • The CPSU shall confirm and verify the information above and Disaster Privileges shall be reviewed and granted by the designee. The designee shall document their review of the practitioner’s performance within 72 hours of granting disaster privileges to determine whether the privileges shall be continued.

• Emergency Privileges

  • For the purpose of this section, an “emergency” is defined as an unexpected or sudden event that significantly disrupts the institution’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the institution’s services, or a condition in which serious or permanent harm would result to a patient or in which the life of the patient is in immediate danger and any delay in administering treatment would add to that danger.

  • In the case of emergency, any practitioner, to the degree permitted by their license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the institution necessary, including the calling for any consultation necessary or desirable.

  • When an emergency situation no longer exists, such practitioner shall request the privileges to continue to treat the patient. In the event such privileges are denied or they do not desire to request privileges, the patient shall be assigned to health care staff as appropriate.

• File Closure

  • The CPSU shall close the credentialing and privileging file if any of the following conditions are met:

    • The behavioral health professional withdraws the credentialing or privileging application.

    • The HCA, DME, Chief Psychologist, SPSW or CR withdraws the credentialing or privileging request.

    • The behavioral health professional fails to submit all required information to constitute a completed application within 30 calendar days of the initial request.

    • The CPSU is notified of a behavioral health professional’s resignation, retirement, or death.

• Credentialing Actions

  • One of the following actions shall occur upon each review of a request for approval of credentials and granting of privileges:

    • Credentials approved: The CR determines that the credentials of the behavioral health professional have been verified to meet the minimum standards for credentialing. The DME, Chief Psychologist, or SPSW shall then proceed with making a privileging determination.

    • Credential file to be closed: The request to credential a behavioral health professional has been withdrawn or the HCA and DME, as well as the Chief Psychologist, SPSW or CR determines that an application shall no longer be pursued.

    • Credential alert: If the BHPPRC determines that certain facts should be considered as part of the current or any subsequent request to approve credentials or grant privileges to the behavioral health professional, then a credential alert shall be placed in the credentials file and the BHPPRC, HCA, DME, Chief Psychologist, SPSW, and CR shall consider the facts before acting on any subsequent application for credentials or privileges.

    • Credential bar: The BHPPRC shall place a credential bar in the credentials file if the BHPPRC determines that the behavioral health professional’s unsatisfactory service has resulted in any one or more of the following:

      • Suspension or revocation of the behavioral health professional’s privileges by the HCEC.

      • Separation for cause from civil service employment with the CCHCS and CDCR.

      • Termination for cause of the behavioral health professional’s services as a contract behavioral health professional with the CCHCS and CDCR.

      • Any legally enforceable agreement including, but not limited to, a settlement agreement prohibiting the behavioral health professional from practicing as an employee or contract behavioral health professional with the CCHCS and CDCR.

      • The placement of a credential bar by the BHPPRC shall be forwarded to the HCEC as a consent calendar item. After placement of a credential bar in the credentials file, any subsequent application for credentials or privileges shall be reviewed by the HCEC.

  • Referral to BHPPRC: The CR shall defer a recommendation on an application for credential approval and refer the case to the BHPPRC in the event that the CR determines there is a need for additional evaluation of a behavioral health professional’s credentials information due to the presence of referral criteria items or issues in the file; refer to the Referral Criteria (Appendix 5).

  • Credential disapproval: If the BHPPRC determines that the credentials of the behavioral health professional shall not be approved, the BHPPRC shall determine whether the disapproval is for a medical disciplinary cause or reason, and whether the disapproval shall be reported to the provider’s licensing board and the National Practitioner Data Bank, or the HCA for potential action. The BHPPRC shall also prepare a recommendation and referral to the HCEC.

• Consideration of Requests for Credentials or Privileges

  • Before taking any action on a request to approve credentials or grant privileges, the DME, Chief Psychologist or SPSW and CR shall:

    • Consider all credentialing and peer review information including credential alerts or bars, in the credentials file.

    • Confirm that the HCA who requested the credentialing is informed of and has considered all facts relevant to the employment or contracting decision including facts that resulted in the placement of a credential alert or bar.

  • If the credential file contains a credential bar, the CR shall refer the request to the BHPPRC with a recommendation for approval or disapproval. The CR is not required to refer files containing a credential alert to BHPPRC if they have previously reviewed the information on which the alert is based, and are satisfied that the information will not negatively reflect on the competence of the provider.

  • The CR shall approve credentials only if they determine that the behavioral health professional:

    • Meets all credentialing requirements as delineated in this section.

    • Possesses the current competence and mental and physical ability to adequately discharge patient care responsibilities in a correctional setting.

  • Where the DME, Chief Psychologist or SPSW and CR lack sufficient information to make a finding regarding current competence and mental and physical ability, the DME, Chief Psychologist or SPSW and CR shall refer the request to the BHPPRC for a determination.

• Referring Actions for Disciplinary Reasons to the BHPPRC

  • The DME, Chief Psychologist or SPSW and CR are not authorized to deny any application for credentials or privileges based on a disciplinary cause or reason within the meaning of the California Business and Professions Code, Section 805, et seq. (NOTE: Unlicensed clinical social workers are not subject to Business and Professions Code, Section 805(c)).

  • Where the DME, Chief Psychologist or SPSW and CR determine that they cannot make a recommendation to approve credentials or grant privileges they shall refer their recommendation to the BHPPRC which shall take further action pursuant to Section (d)(7).

• Civil Service Behavioral Health Professional Transfers and Promotions

  • In addition to reappointment every three years, all civil service behavioral health professionals who are selected for promotional appointments shall be required to undergo initial appointment pursuant to Section (f)(1) prior to beginning job duties for the promotional position. Appointment for a promotion shall be based on available documentation pertaining to the evaluation of the behavioral health professional’s performance.

  • If a behavioral health professional laterally transfers to a different institution or facility and stays in the same job classification, full reappointment is not required prior to the expiration of the behavioral health professional’s current credentialing cycle, but the behavioral health professional shall apply for privileges at the new facility or institution.

  • If a behavioral health professional transfers or promotes while providing services based on provisional privileges, the behavioral health professional shall still be required to complete all aspects of their provisional privileges and probationary period including probationary evaluations, IFPPEs, and IIPs before active privileges may be granted.

Policy

• All new civil service medical providers, including Physician and Surgeons, Physician Assistants (PA), and Nurse Practitioners (NP) who work in the California Department of Corrections and Rehabilitation (CDCR) shall be provided standardized onboarding which includes general and job-specific orientation and training.

• California Correctional Health Care Services (CCHCS), CDCR shall provide standardized onboarding, which includes general and job-specific orientation and training, for all new physician managers.

• All new registry medical providers, including Physician and Surgeons, PAs, and NPs, shall be provided standardized onboarding within the initial 14 days of their job start date not to exceed 40 hours.  This policy and procedure shall not be interpreted as altering or modifying existing laws and regulations governing civil service probationary periods or the provisions of any applicable bargaining unit contract.