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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1.3.5 Behavioral Health Professional Peer Review Committee

  • 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.

  • References

    • 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 14, Section 4991, 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

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

  • Revision History

    • Effective: 10/23/2023