Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 3 – Health Care Workforce Governance

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1.3.2 Medical Peer Review Committee

  • 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.

  • References

    • Federal Health Care Quality Improvement Act of 1986, United States Code, Title 42,  Chapter 117, Section 11101, Findings

    • Plata v. Newsom, et al., U.S. District Court of the Eastern District of California, Case No. C01-1351-JST

    • Plata Physician Professional Clinical Practice Review, Hearing and Privileging Procedures

    • California Constitution, Article VII, Public Officers and Employees

    • California Business and Professions Code, Division 2, Chapter 1, Article 11, Section 800, et seq.

    • California Business and Professions Code, Division 2, Chapter 5, Article 12, Section 2220, et seq.

    • California Evidence Code, Division 9, Chapter 3, Section 1157

    • California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 5, Article 2, Sections 3409 and 3413

    • California Code of Regulations, Title 22, Division 5, Chapter 1, Article 7, Section 70703, Organized Medical Staff

    • Health Care Department Operations Manual, Section 1.4.3.3, Safety Assessment Summary and Automatic Privilege Modification

    • Meeting Procedures: Parliamentary Law and Rules of Order for the 21st Century, James Lochrie, 2003

  • Revision History

    • Effective: 12/2017
      Revised: 06/16/2025