Chapter 1 – Health Care Governance and Administration

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.

Purpose

• To maintain a comprehensive and standardized New Medical Provider Onboarding and New Physician Manager Onboarding process that:

• Supports new medical providers and new physician managers with required orientation and training facilitated by experienced subject matter experts.

• Facilitates adherence to applicable clinical guidelines and departmental standards.

• Promotes job satisfaction and retention while increasing provider effectiveness and efficiency.

Applicability

• This policy applies to all new medical providers and new physician managers with CCHCS, CDCR.

Responsibility

• The Headquarters (HQ) Deputy Director Medical Services, and Deputy Medical Executive (DME), Clinical Policy and Provider Workforce are responsible for statewide planning, implementation, and evaluation of this policy at the HQ level within their unit.

• Regional Health Care Executives and Regional DMEs are responsible for the implementation of this policy for the providers working at their designated regional office and those working at the subset of institutions within an assigned region.

• The Chief Executive Officer and Chief Medical Executive (CME) are responsible for the implementation of this policy at the assigned institution.

Procedure Overview

• The Credentialing and Privileging Support Unit shall notify the Education and Training Unit of all new civil service medical providers and new physician managers who shall then be enrolled and participate in all aspects of the standardized onboarding process, which is in addition to other standard training and orientation for new employees. New Civil Service Medical Providers shall participate in:

  • Institution orientation and training

  • Peer Mentorship

  • Shadowing and Proctoring

  • Headquarters organizational level orientation and training

  • Electronic Health Records System (EHRS) training

  • Dragon Dictation training (optional)

• New registry medical providers shall participate in onboarding necessary to perform their assigned duties.  Appropriate onboarding may include some of the following including, but not limited to:

  • Institution or Telemedicine orientation and training

  • EHRS training

  • Dragon Dictation training (optional)

• New physician managers shall participate in:

  • Headquarters New Physician Manager Onboarding orientation and training

  • New Physician Manager Peer Mentorship Program

• The following tools shall be maintained and reviewed for updates as appropriate at least annually to ensure onboarding is properly supported with current information and resources:

  • Onboarding Checklist

  • Onboarding Plan Template

  • Onboarding Agenda and Curriculum

  • Physician Resource Library (PRL) Index & User Guide

  • Peer Mentor Guidelines

Procedure for New Civil Service Medical Providers

• Onboarding shall commence after completion of the credentialing process and provisional clinical privileges have been granted.

  • Orientation and Training

    • The DME, or Assistant DME, and CME, or Chief Physician & Surgeon (CP&S), utilizing the Onboarding Checklist, the Onboarding Plan Template, and the PRL shall ensure each new civil service medical provider is properly oriented to all of the outlined areas over the course of the initial 12 weeks of onboarding.

    • It is the responsibility of the physician manager and supervisor to ensure the CDCR New Employee Orientation is completed during the same period. The Onboarding Checklist, the Onboarding Plan Template, and the Sample Schedule are located within the PRL.

  • Peer Mentorship

    • New medical providers shall be assigned a peer mentor who shall serve as a non-managerial point of contact, with whom the new provider can connect. This will help to enculture new providers into the organization’s values, assist with acclimation to their new environment, aid in preventing burnout and increase collegiality by creating a positive atmosphere that encourages growth and support during the onboarding period.

  • Shadowing and Proctoring (for new medical providers involved in direct patient care)

    • New medical providers shall, in the first three weeks of employment, be assigned to a variety of providers across clinical settings with the purpose of shadowing and observing how care is delivered in the various unique correctional settings and how the care teams interact within the Complete Care Model.

    • After the third week of employment, new medical providers may begin seeing patients while being proctored by the CP&S or CME.

  • Headquarters Onboarding

    • ETU staff shall maintain a rolling training calendar and publish a listing of upcoming HQ Onboarding and EHRS training dates for at least a six-month period. An HQ-based training program consisting of the Learning Management System (LMS), remote, and in-person didactic sessions shall be developed and maintained by ETU to include all topics designated to HQ as outlined in the Onboarding checklist.

  • Electronic Health Record Training

    • A training program consisting of approximately 16 hours of basic EHRS training via LMS shall be completed prior to the new provider participating in any direct patient care.

    • After the completion of basic EHRS training and a minimum of two to three weeks of direct patient care and EHRS utilization, the new medical provider shall attend an in-person or virtual eight-hour Optimization training to ensure familiarity and competency with the EHRS and its ancillary electronic documentation requirements.

• Direct Patient Care Responsibilities during the Onboarding Period

  • Clinical Responsibilities

    • Once the new medical provider has been successfully oriented to all clinical service areas and spent time shadowing and proctoring, they shall be allowed to practice independently with an abbreviated schedule with support from the CP&S and CME as needed. There should be a gradual increase in the number of clinical encounters assigned each day over the course of at least a four-week period before the new provider is expected to perform at full capacity consistent with their experienced peers.

  • Afterhours or Provider On-Call Responsibilities during the Onboarding period

    • On-call duties shall begin no earlier than six to eight weeks after the hire start date with backup support from the CP&S or CME for a minimum of four on-call shifts.

  • Within 90 days of the new civil service medical provider hire date, the institution CP&S or CME shall ensure completion of the Onboarding Checklist, review, sign, and submit the completed checklist to Medical Services at ETU@cdcr.ca.gov as indicated on the form.

Procedure for Registry Providers

• Institution Orientation and Training

• Registry medical providers shall obtain up to 40 hours of onboarding, typically provided within the initial 14 days of their contract assignment. The 40 hours of initial onboarding shall be paid at the adjusted contract rate. The specific number of hours of onboarding to be provided for registry providers is determined by their area of specialty.

• It is the responsibility of the physician manager and supervisor to ensure the Registry Medical Provider completes the Registry Medical Provider Onboarding Curriculum and Certification.

Procedure for New Physician Managers

• Onboarding shall commence after completion of the credentialing process.

• Orientation and Training

  • The hiring authority or physician manager shall ensure that the new physician manager completes the New Physician Manager Onboarding curriculum and the Physician Manager Mentor Program within the first 12 months of their new position.

• Peer Mentorship

  • The new physician manager shall be assigned a peer mentor who shall serve as a non-supervisory point of contact to help enculture new leaders into the organization’s values, assist with acclimation to their new environment, aid in preventing burnout and increase collegiality by creating a positive atmosphere that encourages growth and support during the onboarding period.

Policy

• California Correctional Health Care Services (CCHCS) shall recruit, train, evaluate, and integrate Advanced Practice Provider (APP) staff, specifically Nurse Practitioners (NP) and Physician Assistants (PA), as part of the CCHCS Medical Services Program.  CCHCS shall promote the use of APP staff in primary care settings and in certain specialty care settings if the APP has achieved advanced training, education, and competency as determined by the physician manager.  CCHCS recognizes that physicians and APP staff are integral and valued members of the CCHCS Medical Services primary care team. 

Purpose

• To provide standardized procedures for APP staff; to outline the functions that APP staff may perform; to assist health care providers in understanding the roles, responsibilities, scope of practice, and level of supervision for APP staff; and to ensure integration of APP staff into the primary care team.

Responsibility

• 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.

• Regional Health Care Executives are responsible for implementation of the procedure at the subset of institutions within an assigned region.  Regional executive teams shall provide training and ongoing support to the Chief Medical Executive (CME) and Chief Physician & Surgeon (CP&S).

• The Chief Executive Officer (CEO), or designee, of each institution is responsible for the local implementation, monitoring, and evaluation of this procedure.

• The CEO is responsible for hiring APP staff (civil service or contract employees).  The hiring process for APP staff shall follow established State Personnel Board rules and CCHCS procedures.

• The CME and CP&S are responsible for onboarding, training, evaluation, and clinical supervision of APP staff.

Procedure Overview

• This procedure defines the roles and responsibilities of APP staff, specifically NPs and PAs working within their scope of practice as defined by federal and state law, and in accordance with an approved Practice Agreement.

Procedure

• Education, Experience, and Certification

  • The hiring authority shall obtain verification of credentials from the headquarters Credentialing and Privileging Support Unit (CPSU) prior to making a formal job offer to an APP applicant.

  • APP staff hired by CCHCS (civil service and contract employees) shall comply with the minimum professional requirements for credentialing and privileging approval pursuant to the Health Care Department Operations Manual (HCDOM), Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

  • For PA staff only, additional qualifications include proof of completion of an approved controlled substance education course. A certificate of completion shall be retained at the hiring institution for the duration of employment.  An electronic copy of the certificate shall be submitted to the headquarters CPSU for retention in the credentialing file. PA staff must ensure that their Practice Agreement is updated to reflect completion of the education course.

    • PA staff who successfully complete a controlled substance education course are authorized to write medication orders for Schedule II through V controlled substances without prior approval from a physician.

    • PA staff who have not successfully completed a controlled substance education course are only authorized to write medication orders for Schedules III through V without prior approval from a physician. Orders for Schedule II medications must have prior approval from a physician.

• New Medical Provider Onboarding

  • All civil service APP staff shall complete the New Medical Provider Onboarding (NMPO) program at their assigned institution.  NMPO shall include pertinent information regarding the work environment, institution and headquarters resources, as well as job expectations. NMPO shall be completed pursuant to the HCDOM, Section 1.4.2.1, New Medical Provider Onboarding.

• Scope of Practice Authority

  • APP staff must request and be granted provisional privileges prior to beginning patient care duties and shall follow all CCHCS policies and procedures.  APP staff employed by CCHCS may perform the functions listed in the Practice Agreement that are within their scope of practice and for which they are deemed competent and are consistent with their credentialing, privileging, education, and experience, and that are delegated in writing by their physician manager utilizing the Practice Agreement to delineate the authorized health care services.

  • Practice Agreement

    • Within five calendar days of hire, and prior to providing health care services, all APP staff must review and sign the Practice Agreement with the physician manager at the hiring institution.

    • Signing the Practice Agreement implies:

      • The intent of all parties to comply with the Practice Agreement’s regulations.

      • The willingness of all parties to maintain a collaborative working relationship.

    • Supervising physicians and APP staff can request the Practice Agreement from the CPSU at CredentialsVerificationUnit@cdcr.ca.gov.  The Practice Agreement can also be accessed on CCHCS Lifeline under Medical Services in the Provider Resource Library (PRL) under Administrative Support/HR-Related. If staff requires access to the PRL, a request may be submitted to:  ProviderResourceLibrary@cdcr.ca.gov.

    • The Practice Agreement shall be reviewed and signed upon reappointment, relocation to a new institution, or if a new physician manager is hired at the current institution.  The signed Practice Agreement shall be maintained at the hiring institution for the duration of employment.  An electronic copy of the signed Practice Agreement shall be submitted to the headquarters CPSU for retention in the credentialing file.

      • Delegated Services Agreements signed prior to December 31, 2019, shall remain valid until the time of reappointment, relocation to a new institution, or if a new physician manager is hired at the current institution.

    • The Practice Agreement adheres to the regulations jointly promulgated by the California Board of Registered Nursing and the Medical Board of California.

  • Clinical Direction of Medical Assistants (MA)

    • The CP&S and/or the CME, or other physician manager, serving as the MA staff Physician Manager, may indicate in writing that an APP may provide clinical oversight to MAs functioning as provider support within an APP-lead care team.

• Care Setting

  • APP staff may perform medical services as specified in the Practice Agreement in Reception Centers, Primary Care Clinics, Specialty Clinics, Outpatient Housing Units, Correctional Treatment Centers, Hospice Units, Triage and Treatment Areas, Skilled Nursing Facilities, and other clinical settings as determined by the physician manager.

  • Credentialing and privileging for practice in licensed inpatient settings shall be in accordance with all applicable State regulations.

    • When providing care in an inpatient setting, the APP staff shall closely collaborate with the physician manager, who shall be the physician of record.

    • In an urgent medical situation, if the physician manager is not readily available, the APP staff may clinically consult with other attending physicians.  The physician manager shall be apprised of the situation when they are available and shall remain the physician of record.

• Physician Consultation

  • Physician consultation shall be obtained as specified in the Practice Agreement.

  • Whenever a physician is consulted, a notation including the date, time, and physician’s name shall be documented in the health record.

  • All patient consultations or treatment related to new or recurrent diagnosis of depression, anxiety, or any other mental health condition or diagnosis shall be referred to mental health services at the institution consistent with the Mental Health Program Guide.

  • Whenever an APP makes a mental health referral it shall be documented in the health record.

• Patient Health Records

  • All APP staff shall be responsible for the preparation of a complete health record for each patient encounter.  All information relevant to patient care shall be documented in the health record including, but not limited to:

  • Assessments

  • Diagnoses

  • Treatment plans

  • Consent forms

  • Procedure notes

  • Physician consultations and/or referrals (including the physician’s name)

  • Discharge notes

  • Other procedure specific information.

• Supervision of Advanced Practice Providers

  • The CME at each institution shall ensure that all APP staff receive the same oversight and supervision including adequate support.  APP staff shall generally receive day-to-day supervision by the CP&S with the CME serving as back-up.  The physician manager shall not supervise more than four NP staff and four PA staff at one time.  It is the responsibility of the physician manager to ensure physician consultation is available at all times either onsite, by telephone, or via electronic device, and that the following occur for all APP staff:

  • APP staff are properly credentialed including appropriate privileges as described in the HCDOM, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

  • APP staff receive NMPO in accordance with HCDOM.

  • APP staff comply with all departmental policies, procedures, and the Practice Agreement.

  • Health record reviews for each APP staff are completed within established timeframes as specified in Section (e)(8)(B).

  • Completion of three probationary reports and annual performance evaluations for each APP staff pursuant to State Personnel Board rules.

  • The Practice Agreement is signed by each APP staff and physician manager and is retained at the hiring institution and with the headquarters CPSU for the duration of employment.

• Evaluation of Clinical Competence

  • Initial Focused Professional Practice Evaluations (IFPPE) shall be completed for every APP staff during their probationary period.  The IFPPE shall be completed pursuant to the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

  • Health Record Reviews

    • To promote safe, effective prescribing, all patient health records for whom a Schedule II medication was ordered by any APP must be reviewed and co-signed by the physician manager within seven calendar days.

    • The physician manager is responsible for review and co-signature of a minimum of two health records per month from each APP staff.  Health records for review shall include, but not be limited to, the following types of patients and/or situations:

      • Patient cases based on predetermined clinical triggers.

      • Patients discharged from a community hospital or emergency department.

      • High risk patient encounters seen by the APP.

      • Patients not improving with current treatment (e.g., a diabetic patient with persistent A1C results≥ 9%).

      • Medium risk patients with multiple comorbidities.

      • Patients whose clinical presentation is complex.

      • Patients discussed with the physician manager.

    • Health records shall be forwarded through the Electronic Health Record System within one calendar day of the encounter.

    • It is the joint responsibility of the physician manager and the individual APP to ensure the minimum number of health records are submitted and reviewed.

    • The physician manager shall review and countersign the health records submitted by APP staff within seven calendar days of the date of the clinical encounter.

    • Documentation shall be patient-specific and reflect adequate quality of care, completeness, accuracy, and legibility (if applicable).

      • In addition, for health records with orders for Schedule II controlled substances, the physician manager shall review the health record for appropriateness of the order and ensure documentation of follow up and monitoring.

      • The physician manager shall enter a note in the health record either concurring with the APP or providing alternate orders and/or patient management direction as appropriate.

    • If quality of care issues are discovered during the review, the physician manager shall take action to correct immediate problems and communicate with the APP in a timely manner to discuss the review and provide patient management direction and/or additional training. At their discretion, the physician manager may elevate the issue for further review using the Focused Professional Practice Evaluation process as described in the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

  • Ongoing Professional Practice Evaluations (OPPE) shall be completed for every civil service APP staff for the duration of their employment with CCHCS.  The OPPE shall be completed, and APP staff shall receive an individual improvement plan pursuant to the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

• On-Call

  • APP staff may be scheduled to provide on-call services in all areas of the institutions pursuant to the HCDOM Section 5.2.1, On-Call/Standby and Callback.

  • When an APP is on-call, the assigned physician manager shall be available either onsite, by telephone, or via electronic device to provide supervision and clinical support.  In the event that the physician manager is not available, the Regional Deputy Medical Executive or other approved designee may be contacted for supervision or clinical support.

  • APP staff scheduled on-call shall be compensated in accordance with their respective Bargaining Unit Memorandum of Understanding.

Policy

• California Correctional Health Care Services (CCHCS) shall recruit, orient, train, evaluate, develop, and integrate Medical Assistant (MA) staff into the health care delivery system. CCHCS shall promote the use of MA staff in ambulatory care settings and in other settings for defined tasks.  CCHCS recognizes that MA staff are integral and valued members of the care team.

Purpose

• To outline the supervision of the MA staff and establish the functions and tasks that MA staff shall perform in support of patient care consistent with the Complete Care Model within Primary Care Clinics and Mental Health Services Delivery System clinical areas.

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.

• Regional

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

• Institutional

  • The Chief Executive Officer (CEO) is responsible for the implementation of this policy at the institution level and for ensuring successful integration of the MA classification into the medical and mental health primary care teams at their institution.  The CEO may delegate the day-to-day operations of this process to the Chief Medical Executive (CME) and/or Chief/Supervising Psychiatrist, and the Chief Nurse Executive (CNE).

  • The CNEis responsible for training and administrative supervision of MAs, providing the initial orientation, testing of proficiencies to perform technical support services prior to performing those tasks, and ongoing mentoring of MAs assigned to their institution.

  • The CME and/or Chief Physician and Surgeon (CP&S) and the Chief/Supervising Psychiatrist are responsible for the clinical supervision of MA staff.

Procedure

• Overview

  • This procedure defines the roles and responsibilities of MA staff working within their scope of practice as defined by federal and state law. CCHCS shall utilize MA staff to perform functions within their scope of practice performed under specific written orders from the licensed health care provider (Physician, Psychiatrist, Podiatrist, or Advanced Practice Provider (APP). 

• Education, Experience, and Certification

  • MA staff hired by CCHCS shall possess a valid certificate from an agency approved by the Medical Board of California to practice as an MA.

  • Prior to performing technical support services, an MA shall receive training by the Supervising Registered Nurse (RN), nursing instructor, licensed health care provider, or an instructor in an approved school program to ensure the MA’s competence in performing a technical support service at the appropriate standard of care.

• Medical Assistant Onboarding

  • Civil service MA staff shall complete position specific onboarding and proficiency testing at their assigned institution within 30 calendar days of the date of hire, in addition to New Employee Orientation and one week of nursing on-boarding training that is institution specific.  Onboarding shall include pertinent information regarding the work environment, institution and headquarters resources, as well as job expectations. Proficiency in expected tasks and procedures shall be tested using the current Medical Assistant Technical Supportive Services Proficiency Observation and shall be administered by the institution CNE, or designee.

• Evaluation of Clinical Proficiency and Duties

  • The CNE, or designee, or nursing or Mental Health (MH) designee, shall ensure that the MA is proficient in the skills necessary to perform essential job functions. During the onboarding process, the MA shall be observed by a Supervising RN, or in the case of MAs working in the MH program, a MH supervisor, demonstrating proficiency in each of the skills listed in Section (d)(4)(B). Prior to the MA independently working in the clinic, the CME or CP&S for Medical MAs or Chief/Supervising Psychiatrist for MH MAs or other Physician Manager shall review and sign the Medical Assistant Technical Supportive Services Proficiency Observation checklist confirming the MA is proficient in the expected skills and noting any exceptions. Exceptions or additions of skills for MH MAs may be noted on the checklist.

  • Expected skills include, but are not limited to:

    • Use of the Electronic Health Record System.

    • First aid.

    • Measuring:

      • Weight

      • Height

      • Oral, tympanic, axillar, and rectal temperature

      • Apical and radial pulses

      • Respiratory rate

      • Manual and automated blood pressure

      • Visual acuity (Snellen Chart)

      • Peak flow

    • Recognizing and reporting abnormal vital signs.

    • Performing 12 lead electrocardiogram.

    • Preparing patients for examinations including positioning and draping.

    • Assisting the licensed health care provider in examinations.

    • Assisting the licensed health care provider in procedures including shaving and disinfecting treatment sites.

    • As authorized by the licensed health care provider, providing the patient information and instructions.

    • Performing patient ear lavage and removing impacted cerumen.

    • Administering medications via oral, sublingual, vaginal, or rectal routes. Inhalation medication requires additional certification/training.

    • Applying topical medication.

    • Performing intramuscular, subcutaneous, and intradermal injections with additional certification/training.

    • Describing and recording skin test reactions. MAs shall not interpret test results.

    • Applying bandages (e.g., dry sterile, steri-strip, ace wrap), dressings, and orthopedic appliances (e.g., knee immobilizer, orthotics).

    • Removing bandages, dressings, orthopedic appliances, casts, splints, external devices, staples, and sutures.

    • Orthotic impression; padding and custom molded shoes.

    • Collecting nasal smears; throat cultures; and urine, stool, sputum, and semen specimens.

    • Performing glucometer calibration; point of care testing for blood glucose; point of care testing-UA Dipstick, point of care testing-Fecal Occult Blood Test.

    • Processing and examining specimens.

    • Selecting and adjusting crutches and canes for patients.

    • Instructing patients on the proper use of crutches and canes.

  • MA duties shall include, but are not limited to:

    • Attending daily huddles and Population Management Working Sessions. MAs shall actively participate in treatment team and primary care clinic huddles.

    • Conducting syringe and tool inventories for the assigned provider clinics and documenting the results of the counts on the appropriate forms.

    • Maintaining accurate logs for needles and syringes utilized.

    • Maintaining security of working areas and materials e.g., ensuring patients do not have access to contraband materials within the working areas.

    • Collecting the CDCR 7362, Health Care Services Request Form, for assigned area(s) of responsibility each day and delivering the forms to the Primary Care RN to determine disposition.

    • Checking-in/out of patients as directed (e.g., directing a patient to a room, recording vital signs, updating scheduling to indicate that the patient arrived for the appointment).

    • MAs shall assist in the management of the clinic schedule by:

      • Utilizing expected skills referenced in Section (d)(4)(B).

      • Ensuring the daily clinic starts as scheduled.

      • Reviewing and printing the Patient Summary Sheet for each patient as directed by care team members.

      • Reviewing Effective Communication (EC) needs of each patient pursuant to the Health Care Department Operations Manual (HCDOM), Section 2.1.2, Effective Communication Documentation; including ensuring paper forms contain the EC stamp/sticker; coordinating Sign Language Interpreters/Video Remote Interpretation, or other interpreters as needed; and ensuring the designated alternate means of EC are available prior to the scheduled appointment time.

      • Utilizing available resources including decision support tools (e.g., Patient Registries, Patient Summaries, Huddle Reports) to identify prescriptions expiring within seven calendar days. MAs shall review the health record and provide a Medication Reconciliation form to the provider for medication orders and appointment scheduling, if necessary, to ensure continuity of patient care.

      • Preparing the exam room and ensuring the necessary supplies and forms are available prior to each appointment.

      • Ensuring the health care and mental health provider maintains adherence to the clinic schedule.

      • Accurately charting, transcribing, and implementing provider diagnostic orders within their scope of practice.

      • Assisting the Health Care Access Unit officer in maintaining an accurate clinic log.

    • Performing routine testing per the physicians’ order (e.g., electrocardiograms, visual acuity, office pulmonary function tests such as peak flow).

    • Fitting prescription lenses or using optical devices in connection with ocular exercises, visual training, vision training, or orthoptics pursuant to Business and Professions Code, Section 2544 and 3042, if specifically trained.

    • Assisting with telehealth clinic visits including preparing patients and administrative support for clinics as needed.

    • Positioning, operating, and maintaining telehealth equipment including reporting damaged, malfunctioning, and missing equipment to the clinic supervisor.

    • Processing provider’s orders for Durable Medical Equipment (DME) including:

      • Distributing ordered DME (e.g., shoes, orthotics, insoles, glasses)

      • Completing the DME log.  Once logged, the MA shall forward the completed DME receipts to the required departments per institutional local operating procedure (e.g., the ADA Coordinator).

      • Monitoring and ordering medical supplies and DME to maintain minimum clinic levels, completing appropriate paperwork, and distributing to the appropriate departments.

    • Distributing ordered medical supplies to the patient with written instruction by the authorized provider (e.g., catheters for self-catheterization, wound care supplies, diabetic self-care supplies).

    • Providing basic patient information and reinforcing patient education provided by the RN or provider.

    • Assisting in the institution’s response to emergencies as part of the health care team including:

      • Performing basic first aid and cardiopulmonary resuscitation (CPR) in emergencies per individual certification.

      • Assisting with coordinating the transportation of patients during medical emergencies.

      • Maintaining Basic Life Support certification in accordance with the HCDOM, Chapter 3, Article 7, Emergency Medical Response.

    • Cleaning and performing operator level maintenance on assigned equipment and notifying the appropriate supervisor when equipment is not functioning per the manufacturer’s specifications.

    • Attending in-service training classes, staff or committee meetings as required, and continuing education classes.

    • Maintaining required MA certification(s) and having knowledge of current local operating procedures.

    • Assisting with Quality Management monitoring including compliance reports, medication refusals, and Penal Code 2602 data monitoring.

    • Additional duties as required for MH MAs assigned to telepsychiatry.

• Care Setting

  • MA staff may perform designated tasks in Reception Centers, Ambulatory Care Clinics, Specialty Clinics, Telehealth, and other clinical settings as determined by the Physician Manager. MAs shall not be utilized in inpatient settings; Triage and Treatment Areas; or specialized health care housing units including Correctional Treatment Centers, Skilled Nursing Facilities, Outpatient Housing Units, and Psychiatric Inpatient Program units.

  • MA staff may provide emergency medical response services in accordance with their training and experience in other areas of the institution when medically necessary for the preservation of life and limb.

• Health Record

  • Technical supportive services performed by the MA shall be documented in the health record, which shall include the name, initials, or other identifier of the MA; the date, time, and description of the service performed; and the name of the licensed health care provider) who gave the MA patient-specific authorization to perform the service, or who authorized such performance under a patient-specific standing order.

• Supervision and Clinical Oversight of Medical Assistants

  • An onsite Physician Manager, or APP designee, shall be available at all times for provider consultation while MA staff is working including in the institution or receiving clinical direction from a Telehealth provider.

  • MA staff shall not be scheduled during hours when an onsite Physician Manager, or APP designee, is not available.

  • The CP&S and/or the CME for Medical MAs or Chief/Supervising Psychiatrist for MH MAs serves as the  Physician Manager and may indicate in writing that an APP may provide clinical oversight to MAs functioning as provider support within an APP-lead care team.

  • Daily clinical oversight of the MA is completed by the licensed health care provider working with the MA, and in the care team setting an RN may also provide clinical direction for basic tasks which do not require a specific order. The clinical oversight function for the MA may be delegated to an APP.

  • A licensed health care provider may provide written instructions to be followed by an MA in the performance of tasks or supportive services. The written instructions may provide that a Supervising RN may assign a task that is authorized by a licensed health care provider.

  • The CNE, or Supervising RN designee, at each institution shall ensure that MA staff receive administrative supervision and support.

  • The CNE, or Supervising RN designee, shall complete probationary and annual performance evaluations for MA staff with input from the licensed health care provider and others who work closely with the MA.

Purpose

• To ensure that medical providers document all relevant clinical encounters in a complete and timely manner while adhering to all organizational, federal, state, regulatory, and accreditation requirements. The health record is a medical legal document and where every effort shall be made for an accurate and timely record of the patient’s condition, progress, and treatment plans.

Responsibilities

• Statewide

  • The Deputy Director, Medical Services is responsible for the oversight, implementation, monitoring and evaluation of this procedure.

• Regional

  • The Regional Deputy Medical Executive is responsible for the oversight, implementation, monitoring and evaluation of this procedure at the subset of institutions within an assigned region.

• Institutional

  • The Chief Medical Executive, or designee, is responsible for ensuring that medical physicians, Nurse Practitioners, and Physician Assistants understand and adhere to documentation expectations.

Procedure

• Medical providers shall adhere to the following documentation requirements:

  • Content and format of the health record shall be uniform, and medical providers shall use only approved California Department of Corrections and Rehabilitation (CDCR) documentation formats.

    • For patient safety reasons, abbreviations, acronyms, and symbols shall be used only when they are on the CCHCS approved list of abbreviations and symbols.

    • All documentation shall be entered electronically, except during Electronic Health Record System (EHRS) downtime procedures or when a particular process requires paper documentation. All paper documentation shall be legible so that patient safety is preserved when other health care staff are caring for the patient.

      • Documentation shall be clear, concise, objective, reflect factual information, and shall serve to identify the patient, support and justify the provider’s medical decision making regarding the patient’s diagnosis, care, treatment, and services provided, as well as document the course of treatment and results.

      • Documentation shall not be discourteous to other individuals and shall not include copies of administrative memos, administrative directives or emails, non-clinical information, or other information which is unrelated to the patient’s care.

    • When using templates, care shall be taken to ensure the information entered is accurate and consistent.

  • Frequency and Timeliness of documentation: To provide safe and efficient treatment for patients, all health care staff shall have timely access to health information.

    • Documentation shall be entered in the patient’s medical record whenever the patient is assessed, evaluated, given education, or receives orders for diagnostic testing, medications or other treatment.

      • This includes, but is not limited to, in-person and telemedicine clinic visits, inpatient admissions and rounding, Triage and Treatment Area (TTA) visits, on-call duties and in clinic co-consultations with a nurse.

      • Documentation frequency in the inpatient setting is determined by Title 22 for Correctional Treatment Center (CTC) patients, except for the exemptions CDCR has obtained, and for Psychiatric Inpatient Program (PIP), and Skilled Nursing Facilities (SNFs). Documentation frequency is and as outlined by CCHCS leadership for medical providers seeing patients in Mental Health Crisis Bed (MHCB), and  Outpatient Housing Unit (OHU) patients. Refer to Appendix 1, Documentation Frequency in Inpatient Settings.

    • Medical providers shall document in the medical record after the encounter. Specifically, documentation shall be completed, signed off, and submitted within the following timeframes:

      • For in-person or telemedicine encounters, documentation is expected to be completed the day of the appointment but no later than the next calendar day.

      • For inpatient rounding and on-site after hours encounters, documentation is expected to be completed the day of the encounter but no later than the next calendar day.

      • For on-call encounters done remotely, documentation shall be completed in the EHRS by the end of the next business day. (Health care staff shall have access to the onsite health care staff’s documentation of the TTA visit, etc. to assist with ongoing management).

      • For patients admitted to a CTC, PIP, MHCB, OHU, SNF or hospice, an admitting History and Physical (H&P) shall be performed by a medical provider within 24 hours of admission.

      • In rare circumstances where timeframe extensions are needed, written supervisor approval is required.

    • Telephone and verbal orders shall be reviewed and signed within 48 hours excluding weekends and holidays. Orders placed weekends or holidays shall be reviewed and signed off the next business day.

    • Late Entry: When a pertinent medical record entry was missed or not written in a timely matter, the provider shall follow the requirements:

      • Identify the new entry as a “late entry”

      • Identify or refer to the date and circumstance for which the late entry is written.

      • Enter the current date and time;

      • The entry shall be signed.

      • When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.

    • Addendum: An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.

      • In the EHRS the date, time, and author of the addendum is noted automatically and the addendum is flagged as part of the original note.

  • Identification of Documentation: In order to allow clinical information to be located easily within the EHRS, providers shall ensure that their documentation is made in the appropriate area of the EHRS and that entries are labeled correctly and with as much specificity as possible.

    • Medical notes in the Documentation section of the EHRS are each assigned a note “Type” and a “Title”.

      • The note “Type” is selected using a drop-down menu and includes choices “History and Physical”,” “Outpatient Progress Note”, “Inpatient Progress Note”, “Phone Message/Call” and “Procedure Note”.

      • The note “Title” is populated by choosing a “Note Template” from the selections offered. There are several choices of note templates that can be used including “Admission H&P”, “Office Visit Note”, “Progress/SOAP note”, “Procedure Note”, and “Free Text Note”. The note “Title” can also be entered as free text and customized.

      • Refer to Appendix 2, Examples of Encounter/Note Types, Titles and Templates for examples.

    • Ensuring, at minimum, that the note “Type” is correct shall assist other health care providers as they review the chart. For example:

      • Note type “Outpatient Progress Note” would be used for Chronic Care and Episodic Care, while note type “Procedure Note” would be used when documenting a medical procedure. Refer to Appendix 2 for examples.

    • On – Call Documentation: On – call duties are done “on-site” at some institutions and by phone.

      • The “on-site” call duties shall be documented utilizing note types “TTA Progress Note” or “Inpatient Progress Note” for rounding in inpatient areas.

      • Phone on-call duties shall be documented using the “Phone Message/Call” note type.

      • The medical provider shall record the assessment (or verbal assessment received), the actions taken, and the medical rationale for the actions taken. The on-call provider ensures any necessary follow up is ordered with the primary care provider (PCP).

  • Other Documentation Expectations:

    • Voice-activated documentation systems (e.g., Dragon): Providers using these systems shall review the note, correct errors and omissions and sign the note to authenticate its accuracy. A blanket disclaimer regarding possible dictation errors does not absolve a provider from needing to proofread their dictated notes for accuracy and completeness.

    • Copy and paste guidelines: The “copy and paste” functionality available in the health record has the potential to eliminate duplication of effort and save time, however it is also easily abused and “Legacy charting” that is not carefully edited is a risk to patient safety.

      • Carefully review and “copy and paste” information: Any “copy and paste” functionality should be kept to a minimum and when used, the pasted information shall be carefully reviewed and edited to ensure up-to-date and accurate documentation. Ensure that the information pasted belongs to the correct patient.

      • Copy and paste from the provider’s previous encounter: A provider may copy and paste entries made into the patient’s record during a previous encounter into a current record as long as care is taken to ensure that the information actually applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded.

      • Copying from another provider’s entry: If a provider copies all or part of an entry made by another provider’s source documentation, the provider using the copied entry becomes responsible for the accuracy of the other provider’s source document. The source author’s name should be included.

      • Copying test results and data: If a provider copies and pastes test results into an encounter note, the provider is responsible for ensuring the copied data is relevant and accurate.

    • Review of Diagnostic Tests and Labs: Providers shall indicate that they have reviewed and addressed diagnostic reports by initialing and dating each report (when presented with a hard copy) or by electronically endorsing each report through the approved EHRS workflows. Refer to the Health Care Department Operations Manual (HCDOM), Sections 3.1.13, Medical Imaging Services, and 3.1.14, Laboratory Services.

      • Per policy, the provider creates a patient letter, which is sent to the patient.

      • If clinically indicated the provider shall create a plan of care that addresses any abnormal test results and document this plan in the health record.

    • Effective Communication: Providers shall document validation that effective communication was provided when required by policy. Refer to the HCDOM, Section 2.1.2, Effective Communication Documentation.

Policy

• The California Correctional Health Care Services (CCHCS) Professional Practice Evaluation (PPE) program shall ensure that patients receive health care services from competent and qualified licensed medical providers. The CCHCS PPE program is designed to follow a set of core competency standards.

• The PPE program shall include structured Initial Focused Professional Practice Evaluations (IFPPE), Ongoing Professional Practice Evaluations (OPPE), Exploratory Focused Professional Practice Evaluation (EFPPE), and For Cause Medical Peer Review processes to assess the licensed medical provider’s general clinical knowledge, skills, and professional judgment. The PPE processes allow the physician managers and medical executives to provide objective, actionable, and clinically relevant feedback to the licensed medical provider during performance evaluations including suggested opportunities for improvement. These processes support ongoing professional development and improve the quality of professional practice and clinical care.

• The PPE program shall ensure the timely evaluation of licensed medical providers.

• The PPE measures and standards shall be reviewed by the Deputy Director, Medical Services, and the Medical Peer Review Committee (MPRC) at a minimum of every two years to ensure continued relevance and alignment with statewide goals and objectives.

Purpose

• To establish a structured clinical PPE program to:

  • Preserve standards of medical practice by providing a mechanism by which licensed medical providers are systematically evaluated for professional competency.

  • Improve patient care through training and development of licensed medical providers to ensure adherence to the highest applicable clinical standards.

  • Ensure patient safety and optimal clinical outcomes.

• To outline the PPE process and demonstrate how it complements the state-required civil service employee evaluations including the annual STD 638, Performance Appraisal Summary, STD 636, Report of Performance for Probationary Employee, and the optional STD 637, Individual Development Plan.

Applicability

• This policy applies to all civil service licensed medical providers including Physicians and Surgeons, Physician Assistants, and Nurse Practitioners. 

Confidentiality

• In accordance with applicable laws governing confidentiality of peer review documents, it is essential that PPE documentation be maintained as confidential and not be available to unauthorized persons. All persons participating in the PPE process shall maintain PPE documentation in strict confidence. 

Procedure Overview

• This procedure outlines the CCHCS PPE program which utilizes a suite of professional practice evaluation tools. The required evaluations outlined in this procedure are in addition to, and do not replace the required Civil Service STD 636, STD 638, and the optional STD 637. At the institutions, these evaluations shall be conducted as a shared responsibility between the Chief Medical Executives and the Chief Physician and Surgeons. 

• The OPPE is a process whereby physician managers and medical executives identify strengths and opportunities to improve the quality of care and patient safety. When conducting the professional practice evaluation, the physician managers or medical executives shall consider health record clinical documentation, patient clinical outcome data, as well as utilization trends and other markers of clinical management.

• The Focused PPE is a process whereby the physician manager evaluates the clinical competence and professional performance of a licensed medical provider. The various types of Focused PPEs are:

  • Initial Focused Professional Practice Evaluation

    • The IFPPE shall be conducted for all newly hired licensed medical providers involved in direct patient care including those who are not subject to a probationary period. 

  • Exploratory Focused Professional Practice Evaluation

    • An EFPPE shall be conducted when an OPPE evaluation identifies significant concerns with either clinical competency or professional practice patterns.

  • For Cause Medical Peer Review

    • A For Cause Medical Peer Review shall be conducted when the licensed medical provider’s ability to deliver patient care in a safe manner is called into question. Reviews may focus on a specific area of the licensed medical provider’s practice or a broader range of areas, and may utilize any source of information likely to assist in a thorough evaluation of the patient care in question.

    • All For Cause Medical Peer Review requests shall be referred to and conducted by the MPRC pursuant to the Health Care Department Operations Manual (HCDOM), Sections 1.4.3.1, For Cause Medical Peer Review and 1.4.3.5, Peer Review Formal Investigation.

Procedure

• Initial Focused Professional Practice Evaluation

  • The IFPPE is designed to assess the licensed medical provider’s competence to perform the job duties as outlined in the duty statement, identify opportunities for improvement, and assist the physician manager and medical executive with determining whether the provisional privileges of a provider on probation should be advanced to active privileges.

  • The physician manager shall complete the IFPPE at least seven days prior to the due date to allow the supervising medical executive sufficient time to review and endorse by the due date.

    • The IFPPE conducted for licensed medical providers shall occur at 10 weeks and 16 weeks from the start date.

    • The timing of the first and second IFPPE conducted for licensed medical providers whose employment is less than full time shall be calculated according to their fractional time base.

    • The PPE Select Patient List Power BI tool shall be used to generate clinical encounters likely to yield the most meaningful opportunities for improved patient outcomes.

    • The physician managers shall review the clinical care of 12 distinct patients over the course of the evaluation period. Each patient’s care shall be reviewed in a longitudinal manner rather than focus on one specific clinical encounter.

    • Upon completion of the IFPPE, the supervising medical executive shall review the IFPPE either endorsing the findings and recommendations or documenting findings and recommendations of their own.  The supervising medical executive shall return the endorsed IFPPE to the physician manager by the due date.

    • Once endorsed, the physician manager or medical executive shall discuss the IFPPE findings and recommendations with the licensed medical provider including areas where performance is at or above that which is expected as well as any noted opportunities for improvement.

    • The licensed medical provider shall sign the IFPPE.  If the provider refuses to sign, the physician manager or medical executive shall document the refusal.  A copy of the completed IFPPE shall be provided to the licensed medical provider.  One copy of the completed IFPPE shall be filed in the supervisory file, a copy shall be sent to the personnel specialist, and another copy to the PPE Support Unit no later than 14 days after the due date.

• Ongoing Professional Practice Evaluation and Individual Improvement Plan

  • The physician manager or medical executive shall develop a recommendation based on the review of the licensed medical provider’s performance to include areas of strength and opportunities with a specific plan for improvement. If a follow-up review is needed, the time frame for that follow-up review shall be outlined in the recommendation.

  • The physician manager shall complete the OPPE at least seven days prior to the due date to allow the supervising medical executive sufficient time to review and endorse by the due date.

    • The PPE Select Patient List Power BI tool shall be used to generate clinical encounters likely to yield the most meaningful opportunities for improved patient outcomes.

    • The physician manager shall review the clinical care of six distinct patients over the course of the evaluation period.  Each patient’s care shall be reviewed in a longitudinal manner rather than focus on one specific encounter.

    • Upon completion of the OPPE, the supervising medical executive shall review the OPPE either endorsing the physician manager’s findings and recommendations or documenting findings and recommendations of their own. The supervising medical executive shall return the endorsed OPPE to the physician manager by the due date.

    • Once endorsed, the physician manager or medical executive shall discuss the OPPE findings and recommendations with the licensed medical provider including areas where performance is at or above that which is expected as well as any noted opportunities for improvement.

    •  The licensed medical provider shall sign the OPPE.  If the licensed medical provider refuses to sign the OPPE, the physician manager or medical executive shall document the refusal.  A copy of the completed OPPE shall be provided to the licensed medical provider. One copy of the completed OPPE shall be filed in the supervisory file, a copy shall be sent to the personnel specialist, and another copy to the PPE Support Unit no later than 14 days after the due date.

• Exploratory Focused Professional Practice Evaluation

  • When the need for an EFPPE is identified, the physician manager or medical executive shall notify the Professional Practice Evaluation Support Unit of the basis for the EFPPE. The request shall include a clear written explanation of the nature of the patterns or trends of practice and performance that are in question.

    • Upon receipt of the request, the physician manager or medical executive shall utilize the PPE Select Patient List Power BI tool to select a minimum of six patient encounters that span the designated time frame to complete the EFPPE. Based on the evaluation findings and nature of the practice concerns, the physician manager or medical executive shall discuss the case with the supervising medical executive as appropriate and formulate recommendations for a specific plan for improvement which may range from additional education and training to a referral to the MPRC for consideration of clinical privilege modification due to significant patient safety concerns.

    • Upon completion of the EFPPE, the supervising medical executive shall review the EFPPE either endorsing the physician manager or medical executive’s findings and recommendations or documenting findings and recommendations of their own.

    • Once completed, the physician manager shall discuss the findings and recommendations with the licensed medical provider including areas where performance is at or above that which is expected as well as any noted opportunities for improvement.

• For Cause Medical Peer Review

  • The For Cause Medical Peer Review shall be conducted when a PPE or other circumstance brings the licensed medical provider’s ability to provide direct patient care, supervise licensed providers, or manage a clinical program in a safe manner into question. The physician manager and medical executive shall review the PPE and the circumstance(s) to focus on a specific area of the licensed medical provider’s practice. All review requests shall be referred to and conducted by the MPRC pursuant to the HCDOM, Sections 1.4.3.1, For Cause Medical Peer Review and 1.4.3.5, Peer Review Formal Investigation.

  • If there is a risk of imminent danger to patients or a clinical program, the medical executive shall immediately submit a Safety Assessment referral to MPRC pursuant to the HCDOM, Section 1.4.3.3, Safety Assessment, Summary and Automatic Privilege Modification.