Chapter 1 – Health Care Governance and Administration

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.