Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 4.2 – Professional Workforce: Medical Services

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1.4.2.5 Professional Practice Evaluation

  • 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.

  • References

  • Revision History

    • Effective: 12/2017

    • Revised: 09/03/2025