Chapter 1 – Health Care Governance and Administration

Policy

• California Correctional Health Care Services (CCHCS) and California Department of Corrections and Rehabilitation (CDCR) shall conduct peer review in a fair and consistent manner and in accordance with community standards for licensed medical providers with known or suspected substandard clinical practices and/or clinical misconduct which includes acts, demeanor, or conduct reasonably likely to be detrimental to patient safety or the delivery of medical care.  The policies and procedures set forth in this chapter shall be utilized to conduct non-routine, for cause peer review evaluations in order to determine when privileges should be suspended, revoked, or otherwise restricted or modified.  These are known as Focused Professional Practice Evaluations (FPPE).

• Generally, these policies and procedures do not apply to matters that are subject to routine peer review (i.e., matters within the scope of the Health Care Department Operations Manual, Section 1.4.2.5, Professional Practice Evaluation) unless routine peer review reveals a concern for a provider’s ongoing ability to safely provide patient care.

• These policies and procedures do not substitute a supervisor’s ordinary duty to monitor, train, evaluate and respond to all performance issues. However, any doubt should be resolved in favor of referring matters for handling under these policies and procedures.

• Privileges are a condition of employment for all physicians and surgeons and, as such, final actions modifying privileges may simultaneously impact employment.

• All aspects of proceedings conducted under this chapter are deemed to be confidential and legally privileged peer review proceedings.  All persons participating in these processes shall adhere to expectations and legal requirements by maintaining all records, files, and documents pertaining to peer review proceedings in strict confidence.

Overview

• Based upon referrals which may be made pursuant to the Health Care Department Operations Manual, Section 1.4.3.2, Medical Peer Review Referral and Intake, or the outcome of Safety Assessments, the Medical Peer Review Committee (MPRC) shall provide centralized, standardized, and autonomous non-routine or for cause peer review for licensed medical providers.  The MPRC shall make determinations which it deems necessary and appropriate to remediate deficiencies in clinical practices and/or professional misconduct.  The MPRC shall refer all Final Proposed Actions involving privileging modifications to the Health Care Executive Committee (HCEC) for approval and action. Other actions taken by MPRC may be reported to the HCEC on a consent calendar.

• Informal hearings shall be offered to all licensed medical providers prior to the MPRC taking any action that would result in a privilege modification.

• All appeals of Final Proposed Actions shall be heard by a Judicial Review Committee (“JRC”) at an evidentiary hearing.  The JRC consists of a panel of three independent and impartial peers who shall hear and determine the disposition of a Final Proposed Action brought before them.

• The Governing Body oversees and directs the actions of the HCEC as needed and at its discretion.

Purpose

• Ensure that patients receive medical care from competent medical providers.

• Improve the quality of medical care.

• Reduce morbidity and mortality.

• Further the goal of providing appropriate, objective, and systematic due process for licensed medical providers before privileges are impacted and which may have an impact on the licensed medical provider’s employment.

• Immediately address clinical performance or conduct issues which are below the applicable legal standard of care and/or may result in imminent danger to the health and/or safety of patient(s) and/or staff.

• Satisfy legally required reporting obligations to the licensed medical provider’s licensing board and the National Practitioner Data Bank.

Responsibility

• CDCR and CCHCS departmental leadership are responsible for the implementation, monitoring, and evaluation of this policy and associated procedures.

Procedure Overview

• This procedure describes how instances of actual or suspected substandard clinical performance are referred for non-routine or for cause peer review so that appropriate action can be taken to ensure patient safety.

Responsibility

• California Department of Corrections and Rehabilitation and California Correctional Health Care Services staff are encouraged to refer to the Professional Practice Evaluation Support Unit (PPESU) any provider whose conduct, performance, or competence is identified as concerning for patient safety. Identified referral sources shall refer known or suspected instances of substandard clinical performance as soon as possible.  All referrals involving any potential or perceived imminent danger to the health of patients or staff shall be made within one business day of discovery.

• The following referral sources are required to timely forward all suspected instances of substandard clinical practices and professional misconduct to the PPESU:

  • Safety Assessment Panel pursuant to Health Care Department Operations Manual (HCDOM), Section 1.4.3.3, Safety Assessment, Summary and Automatic Privilege Modification.

  • Institutional health care leadership.

  • Regional health care leadership.

  • Headquarters health care leadership.

  • Nursing Professional Practice Council.

  • Mental Health Peer Review Committee.

  • Dental Peer Review Committee.

  • Statewide Health Care Incident Review Committee.

  • Office of Internal Affairs.

  • Federal Receiver or designee(s).

Procedure

• Written Referrals

  • A referral for non-routine peer review shall be in writing.

  • A referral shall include:

    • A concise statement about the incident, allegation, or reasonable suspicion pertaining to the medical provider(s).

    • The referrer is encouraged to provide as much specificity as possible supporting the suspicion to the extent that the evidence is known or presently available. Referrals should include at a minimum the following details:

      • Date of the alleged incident.

      • Date of discovery of the alleged incident.

      • Names of witnesses, including contact information. A summary of a statement may be appropriate.

      • Type of conduct, practice, or failure to act that caused the concern.

      • Proper practice and why the practice from this professional deviated from the acceptable practice, including medical records.

      • At risk or reckless behavior, if any.

      • Any complaints (staff or patient) associated with the allege incident or incidents.

      • Any past problems of which the referrer is aware.

      • Describe any feedback or training provided.

      • Any other documentation which is available or may be made available.

• Where to Submit Referrals

  • Referrals shall be emailed to: mprcsupport@cdcr.ca.gov

  • In the absence of email availability, the referrals shall be sent to:
    CCHCS
    P.O. Box 588500
    Elk Grove, CA 95758
    Attn: Professional Practice Evaluation Support Unit, Bldg. E

• Referral Intake Package

  • The PPESU support staff shall compile a Referral Intake Package consisting of the information from the referral, a summary of prior peer review activity if applicable, and all relevant documentation pertinent to determining the issue.

  • The PPESU support staff shall forward the Referral Intake Package to the Peer Review Intake Screener (PRIS), with the following exceptions:

    • Referrals from the Health Care Executive Committee (HCEC) shall be scheduled directly to the Medical Peer Review Committee (MPRC) calendar without prior review from the PRIS.

    • If the licensed medical provider referred to the PPESU support staff is already under peer review at the MPRC level (i.e., non-routine or routine peer review which has been elevated to MPRC review), the case shall automatically be added to next MPRC calendar for review and incorporation into the existing peer review matter.

  • Referrals that do not result in a referral for non-routine peer review or are not part of an open case shall be included on the MPRC consent calendar and provided to the HCEC.

• Peer Review Intake Screener

  • The PRIS shall be a member of the MPRC, as determined by the Deputy Director, Medical Services. For referrals involving a Physician Assistant or a Nurse Practitioner, the PRIS may be a physician or a provider of the same discipline as the subject provider.  The PRIS shall be assigned by the MPRC committee chair in collaboration with the assigned Regional Deputy Medical Executive.

  • The PRIS shall review all Referral Intake Packages within five business days after receipt from the MPRC support staff, or sooner, as warranted by circumstances surrounding the referral to determine whether the referral meets Intake Referral Criteria.

  • If the PRIS determines that the clinical issues identified pose potential or actual imminent danger to the health of patient(s) or staff, the PRIS shall immediately transmit a Request for Safety Assessment to the MPRC Chairperson pursuant to HCDOM, Section 1.4.3.3, Safety Assessment, Summary and Automatic Privilege Modification.

  • If the PRIS determines the referral does not meet Intake Referral Criteria:

    • The PRIS shall provide a written summary explaining why the case does not meet Intake Referral Criteria and provide the summary and the referral package to the PPESU support staff.

    • The PPESU support staff shall place the matter on the MPRC consent calendar.

      • If the consent calendar item is accepted by the MPRC, the case shall be closed.

      • If the consent calendar item is not approved by the MPRC, the committee shall discuss the case(s) at the time of the disapproval or schedule the matter for the next meeting, depending on time and/or urgency.

  • If the Peer Review Referral meets Intake Referral Criteria, the PRIS shall summarize the case and return it to the PPESU support staff which shall schedule the matter for review by the MPRC.

• Intake Referral Criteria

  • Evaluation of whether a non-routine peer review referral meets Intake Referral Criteria consists of an evaluation of whether the licensed medical provider’s clinical performance or conduct has or is likely to have a negative impact on or pose a risk to patient safety or the clinical environment including whether the licensed medical provider’s professional performance or conduct falls below the applicable standard of care.

Procedure Overview

• This procedure shall be utilized to immediately address all safety concerns arising out of or related to clinical performance or conduct issues to protect the due process rights of the subject provider and satisfy any reporting obligations to the subject licensed medical provider’s licensing board and the National Practitioner Data Bank.

Responsibility

• All health care staff including, but not limited to, medical executives, physician managers, the Peer Review Intake Screener, and the Statewide Health Care Incident Review Committee are responsible for referring safety concerns involving clinical performance or conduct to the attention of the institutional supervisor or regional or headquarters executive leadership.

• The medical executive is responsible for informing the Medical Peer Review Committee (MPRC) Chairperson and the Deputy Director, Medical Services, of the referred safety concerns.

• The MPRC Chairperson, the Deputy Director, Medical Services, or designee, and the medical executive (collectively referred to as the “Panel”) are responsible for reviewing the facts to arrive at an initial determination regarding a Request for Safety Assessment and otherwise ensuring timely and efficient compliance with this procedure.

Procedure

• Initial Determination

  • If the medical executive determines that a licensed medical provider’s clinical performance or conduct poses an imminent danger to the health of any patient or staff, the medical executive shall promptly make a referral by submitting a Request for Safety Assessment (RSA).

  • RSAs shall be submitted to the Professional Practice Evaluation Support Unit (PPESU) support staff.  The PPESU staff shall forward the RSA and all supporting documentation to the Panel within one business day.

  • The RSA shall include:

    • A completed RSA form.

    • All available supporting documents relevant to the underlying issues related to clinical practice and professional conduct.

    • A description of the potential danger to the health of any patients or staff as a result of the identified clinical performance or conduct.

  • When a Safety Assessment is requested or is being conducted, the licensed medical provider’s managers and supervisors shall redirect the licensed medical provider’s duties in the least restrictive manner to perform duties that eliminate the prospect of imminent danger and ensure patient safety until the Safety Assessment is completed, and the modification of privileges reviewed to determine ongoing necessity.

    • Administrative Time Off shall only be utilized in conjunction with a suspension of privileges with written approval from the Panel.

  • Within two business days of receiving the referral from the PPESU support staff, the Panel shall review the RSA and all additional facts and documents supporting the allegation in order to arrive at an initial determination regarding whether the clinical performance at issue does or is likely to cause imminent danger to the health of patient(s) or staff.

    • The Panel may consult with the referral source and California Correctional Health Care Services (CCHCS) legal counsel to MPRC in the course of making its initial determination.

    • If the Panel finds that additional information is needed to make its determination, the Panel shall return the RSA to the physician manager or medical executive with a request for additional information necessary to make a determination. To the best of its ability, the Panel shall specify which items are needed in order to make a determination.

  • If the Panel finds that the clinical performance or conduct in question does not or is not likely to pose an imminent danger to the health of patient(s) or staff, the Panel shall:

    • Refer the matter to the MPRC for further review and disposition as warranted.

    • Provide the hiring or contracting authority with written notice of the following:

      • The Panel’s initial determination.

      • The referral to the MPRC for further review and action, as warranted.

    • The hiring or contracting authority shall immediately terminate any redirection that may be in effect.

  • If the Panel finds that the clinical performance or conduct in question does or is likely to pose an imminent danger to the health of patient(s) or staff, the Panel shall:

    • Schedule an emergency MPRC meeting for a determination of the clinical performance or conduct at issue.

    • Notify the referring medical executive of the MPRC meeting.

    • Review potential actions such as modification of duties or redirection, considering the least restrictive action necessary to ensure patient and staff safety. If the least restrictive action is available, the Panel shall direct the hiring or contracting authority in writing to take such action. The licensed medical provider shall be given written notification of the change in duties or redirection.

• Medical Peer Review Committee Determination

  • The MPRC shall meet and make a final determination regarding the clinical performance and/or conduct at issue based on a de novo review of all available information bearing on the matter at that time.

  • The MPRC determination of the Safety Assessment shall occur within two business days following the Panel’s initial determination.  Any voting member of the MPRC who has a conflict of interest with the subject licensed medical provider or the subject incident shall not attend.

  • The MPRC shall give great weight to the decision of the Panel in its initial determination, but the MPRC is not bound by the Panel’s determination.

  • A quorum is not needed, a simple majority of those present is sufficient to evaluate and make a determination regarding the findings of the Panel.

  • If the MPRC determines that the clinical performance does not or is not likely to pose an imminent danger to the health of patient(s) or staff, the MPRC shall do one or more of the following:

    • Close the case.

    • Conduct a Professional Practice Evaluation pursuant to the Health Care Department Operations Manual (HCDOM), Section 1.4.2.5, Professional Practice Evaluation.

    • Open a Peer Review Formal Investigation into the matter.

      • If MPRC conducts a Peer Review Formal Investigation into the matter, the PPESU shall give the licensed medical provider and the hiring or contracting authority written notification of the following:

        • The MPRC determination to open a Peer Review Formal Investigation.

        • The basis for the investigation, including the clinical performance at issue and the right to expand the investigation to review any additional clinical performance issues.

        • The status of any privilege modifications or other restrictive actions that may be in effect.

  • If the MPRC determines that the clinical performance or conduct does or is likely to pose an imminent danger to the health of patient(s) or staff, the PPESU shall serve the licensed medical provider with a Notice of MPRC Action and shall conduct the Informal Hearing, if requested, pursuant to HCDOM, Section 1.4.3.4, Informal Hearings.

    • A copy of the Notice of MPRC Action shall be provided to the licensed medical provider’s hiring or contracting authority who is encouraged to attempt to contact the licensed medical provider in person or by telephone to ensure that the licensed medical provider received the notice.

    • The MPRC may also conduct a Peer Review Formal Investigation into the licensed medical provider’s clinical performance in general and/or the clinical performance or conduct at issue in the Notice of MPRC Action.

    • If the licensed medical provider participates in an Informal Hearing regarding the Notice of MPRC Action, the Peer Review Formal Investigation, if determined to be necessary by MPRC, shall commence after the Informal Hearing takes place.

    • If the licensed medical provider does not request or waives their right to an Informal Hearing, the Peer Review Formal Investigation, if determined to be necessary by MPRC, shall commence upon the earlier of the following:

      • The date of the licensed medical provider’s written waiver of the Informal Hearing.

      • Expiration of the five business day period after service of the Notice of MPRC Action.

• Summary Redirection

  • When necessary to protect the health of patients and staff, or when a Safety Assessment is requested, physician managers or medical executives shall redirect licensed medical providers in the least restrictive manner necessary to eliminate the prospect of imminent danger to the health of patient(s) or staff. Redirection prior to an RSA determination is not considered by CCHCS to constitute a modification of privileges as it is not the action of a peer review body. The licensed medical provider shall remain redirected for as long as is determined to be necessary to protect the health of patients and staff, or until such time as the RSA is resolved.

  • The MPRC shall determine as part of its evaluation of the RSA whether to impose any privilege modifications.

  • If the Safety Assessment results in a finding that an imminent danger to the health or safety of patient(s) or staff exists or is likely to occur because of the licensed medical provider’s clinical performance or conduct, all modifications of job duties shall remain in place while the Peer Review Formal Investigation is pending.

• Automatic Privilege Modification and Non-Punitive Termination

  • A summary suspension of privileges may occur as a result of either of the following:

    • A licensed medical provider’s failure to comply with HCDOM, Section, 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

    • As a result of a disciplinary action against the licensed medical provider’s license or Drug Enforcement Administration (DEA) registration.

  • Licensed medical providers shall immediately notify the Credentialing and Privileging Support Unit (CPSU) support staff of any disciplinary action against their license or DEA registration.

  • The CPSU support staff shall forward information regarding any failure to comply with the HCDOM, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging to the PPESU who shall:

    • Schedule the matter on the next MPRC agenda for automatic and immediate suspension or restriction of the licensed medical provider’s privileges as warranted by the circumstances.

    • Notify the licensed medical provider and the hiring/contracting authority of the actions taken and the right to an Informal Hearing on the matter.  The notice shall contain the same or similar information as stated in Section (c)(2)(E).  The Informal Hearing shall be limited to the question of whether the provider has failed to comply with credentialing and privileging policies and procedures.

  • Revocation or suspension of license to practice 

    • Whenever a licensed medical provider’s license or other legal credential authorizing practice in the State of California is revoked or suspended by the licensed medical provider’s licensing board, the MPRC shall immediately refer the matter to the licensed medical provider’s Regional Personnel Administrator or Headquarters Section Chief, Classification & Pay/Transaction & Benefits, Human Resources, to initiate a non-punitive termination pursuant to Government Code Section 19585.

  • Restriction or probation of license to practice or prescribe medication 

    • If a licensed medical provider is placed on probation by their licensing or certifying authority or the licensed medical provider’s license or other legal credential authorizing practice in California is limited or restricted by the applicable licensing authority, including the DEA, the licensed medical provider may no longer be able to perform all of their job duties.

    • Upon receipt of notice that a licensed medical provider’s license to practice in California or DEA registration has been restricted or put on probation, the MPRC shall immediately refer the matter to the licensed medical provider’s Regional Personnel Administrator or Headquarters Section Chief, Classification & Pay/Transaction & Benefits, Human Resources, for an evaluation of whether a non-punitive termination under Government Code Section 19585 is appropriate prior to imposing an automatic suspension or restriction of privileges.

    • If the Regional Personnel Administrator or Headquarters Section Chief, Classification & Pay/Transaction & Benefits, Human Resources, determines that a non-punitive termination is not appropriate pursuant to Government Code Section 19585, the PPESU shall refer the matter to the MPRC for handling in the manner set forth in Section (c)(4)(C) above for an automatic restriction of privileges which comports with the licensing board’s disciplinary order. 

      • If the matter involves the licensed medical provider’s DEA registration, the PPESU shall immediately notify the Statewide Chief of Pharmacy Services and the Pharmacist-in-Charge at the location at which the licensed medical provider practices of the change in status of the licensed medical provider’s DEA registration.

Procedure Overview

• This procedure sets forth the process for providing a licensed medical provider with an opportunity to respond to allegations that provide the basis for a modification of privileges.  Privilege modifications may include, but are not limited to, restrictions, suspensions, or revocations of some or all of a licensed medical provider’s privileges. 

• In cases involving a summary modification of privileges, the Informal Hearing shall occur after the subject medical provider is notified of the summary modification of privileges, but prior to the time that reports of the action are legally required by the subject medical provider’s licensing board and the National Practitioner Data Bank (NPDB).

• In all other cases, the Informal Hearing shall be offered after the completion of a Peer Review Formal Investigation and prior to the Medical Peer Review Committee (MPRC) making any recommendation to the Health Care Executive Committee (HCEC) that may result in a modification of privileges.  The MPRC shall have the right to impose such privilege modifications as they deem necessary and appropriate to protect patient safety during the time of the privilege modification.

Procedure

• Within three business days after the MPRC votes to modify a licensed medical provider’s privileges in any manner, the Professional Practice Evaluation Support Unit (PPESU) shall notify the subject medical provider in writing of MPRC’s determination.  The Notice of MPRC Action shall be personally served or served by overnight mail to the last known address of the medical provider with a Proof of Service and return receipt requested.

• The notification shall contain the following:

  • The MPRC determination.

  • Identification of any privilege modifications imposed to mitigate or eliminate any actual or perceived risk to patient safety created by the clinical performance or conduct.

  • A statement that a Peer Review Formal Investigation shall be conducted into the matter.

  • A statement of the facts relied upon by the MPRC to support its determination that some level of privilege modification is necessary to ensure the safety of staff and patients until the matter is closed.  The statement of facts shall include a summary of one or more specific cases or incidents giving rise to the determination of imminent danger.

  • A clear, bolded description of the Informal Hearing procedure to rebut the Notice of MPRC Action, to include how to request an Informal Hearing and the licensed medical provider’s right to have a representative at the Informal Hearing.  The licensed medical provider may rebut a privileging action by informing the PPESU by telephone, electronic mail, in person, or by U.S. Mail.

  • Copies of the documents relied upon by the MPRC to make its decision to modify privileges.

  • Information about how to make an appointment to examine additional relevant documents that are in the possession or under the control of California Correctional Health Care Services (CCHCS) within five calendar days from service of the Notice of MPRC Action.

  • A clear, bolded notification that any request for an Informal Hearing regarding the privilege modification must be made within five business days of service of the Notice of MPRC Action.

  • Notification that, if the licensed medical provider participates in an Informal Hearing, MPRC shall record the Informal Hearing and that the licensed medical provider may make their own recording of the Informal Hearing.

  • A clear, bolded notification that pursuant to 42 United States Code, Section 11101, and Business and Professions Code, Section 805, certain specified summary suspensions must be filed with the licensed medical provider’s licensing board or the NPDB.

• Within two business days of receiving a timely request for an Informal Hearing, the PPESU shall schedule the hearing to occur no later than ten calendar days after the effective date of a summary privilege suspension or modification by the MPRC. Failing to request a hearing shall not be deemed an admission of the charges leading to the privilege modification and shall not prejudice the licensed medical provider’s right to participate in any Peer Review Formal Investigation pertaining to the same matter or the licensed medical provider’s right to appeal any Final Proposed Action of the HCEC.

• The MPRC Chairperson, or designee, shall conduct the Informal Hearing and at least one other MPRC member of the medical provider’s discipline, or designee, shall be present. Voting members of the MPRC may also attend and, absent a conflict of interest, may participate in the hearing and vote on the decision.

  • During the hearing:

    • The licensed medical provider may be accompanied by a representative of their choice.

    • The Informal Hearing shall be recorded by the MPRC.  The licensed medical provider may also record the hearing.

    • The licensed medical provider may make a statement concerning the clinical performance at issue on such terms and conditions as MPRC may impose.

    • No witness shall present evidence and no witness testimony shall be taken.  However, when necessary, the referring party/institution may be consulted by MPRC during deliberations to clarify facts or other ambiguities raised by the subject medical provider during their testimony.

    • The licensed medical provider may provide the MPRC Chairperson with any relevant documents in their possession at the Informal Hearing.

  • A written Informal Hearing decision shall be rendered no more than 14 calendar days after the effective date of the summary privileging action.  The written decision shall be included in the licensed medical provider’s peer review file, and a copy of the decision shall be sent to the licensed medical provider and the hiring/contracting authority.

  • If after deliberations the MPRC votes to rescind an existing privileging modification but, due to ongoing concern, votes to replace it with a different privilege modification or corrective measure, the MPRC shall refer the matter for Peer Review Formal Investigation into the clinical performance of the subject medical provider.

  • If after deliberations the MPRC votes to rescind the existing privileging modification and not replace it with a different privilege modification, the MPRC may still refer the matter for a Peer Review Formal Investigation and reinstate the medical provider’s privileges, or refer the matter back to the institution for a Professional Practice Evaluation pursuant to Health Care Department Operations Manual, Section 1.4.2.5, Professional Practice Evaluation, with a reinstatement of privileges.

  • If after deliberations the MPRC votes to uphold and retain the initial privileging modifications, the MPRC shall refer the matter for Peer Review Formal Investigation.  All of the records and proceedings of the Informal Hearing shall become part of the record for consideration within the Peer Review Formal Investigation.

  • When a privilege suspension or modification is recommended as a Final Proposed Action, the PPESU support staff shall schedule the hearing to occur no later than the next MPRC meeting and prior to the MPRC making its recommendation of Final Proposed Action to the HCEC.

  • When required by law, a notice of the privilege modification or suspension shall be reported to the licensed medical provider’s licensing board and the NPDB.

Procedure Overview

• This procedure sets forth the process for conducting Peer Review Formal Investigations into the clinical performance and/or conduct of a medical provider pursuant to allegations that the medical provider’s clinical performance or conduct falls below the applicable standard of care.  Peer Review Formal Investigations are impartial fact-finding reviews.

• Peer Review Formal Investigations into clinical practice concerns involving quality of care issues including, but not limited to, patient care and/or decision-making shall be conducted by a provider of the same discipline and to the extent possible the same licensure as the subject medical provider.

• Peer Review Formal Investigations into professional misconduct concerns including, but not limited to, disruptive conduct, behavior, or ethical issues may be conducted by a clinical provider of the same discipline and licensure as the subject medical provider or by a non-clinical investigator.  A non-clinical investigator shall not reach any conclusions or make any findings regarding issues involving clinical decision-making, patient care decision-making, and/or direct patient care issues which involve clinical decision-making.

• Peer Review Formal Investigations require written notification to the subject medical provider.

Responsibility

• The Medical Peer Review Committee (MPRC) is responsible for requesting a Peer Review Formal Investigation, overseeing the progress of the investigation, analyzing the information provided in the investigation report, and preparing a Final Proposed Action.

Procedure

• Basis for Peer Review Formal Investigation

  • A Peer Review Formal Investigation shall be initiated when suspected substandard clinical practices and/or professional misconduct occurs which is reasonably likely to be detrimental to patient safety or the delivery of health care including, but not limited to, the following:

    • Failure to Perform Required Standards of Care.  Failure to deliver care that is consistent with the degree of care, skill, and learning expected of a reasonable and prudent licensed medical provider acting in the same or similar circumstances (e.g., accuracy of diagnosis, appropriateness of therapy, timely and appropriate consultation, resource management and length of stay, timely transfer as needed for severity and acuity of illness, or medical decision-making).

    • Disruptive Conduct.  Failure to work in harmony with others or evidence of disruptive behavior or conduct of such serious nature as to be detrimental to or pose a threat to patient care.

    • Unethical Conduct.  Unethical behavior that is detrimental to patient care and/or undermines a culture of safety.

    • Failure to Practice within Known Competencies.  Electing to engage in care practices requiring skills or knowledge beyond those possessed by the medical provider in willful disregard of the limits of the licensed medical provider’s competencies.

    • Failure to Notify.  Failing to notify appropriate authorities (e.g., management or MPRC) that substandard care is being provided by another individual or that circumstances exist in particular instances that may result in preventing access to care or the delivery of appropriate levels of care by any individual.

  • Pursuant to Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.3.3, Safety Assessment, Summary and Automatic Privilege Modification, all Safety Assessment MPRC determinations resulting in a finding that a licensed medical provider poses an immediate risk or threat to patient safety shall trigger a Peer Review Formal Investigation into the underlying basis of the Safety Assessment as well as the overall clinical performance of the subject medical provider.

• Peer Review Formal Investigation Process

  • Within five business days of the MPRC decision to initiate a Peer Review Formal Investigation, the following shall occur:

    • The MPRC Chairperson shall assign an investigator depending upon the type of performance or conduct at issue.  The Professional Practice Evaluation Support Unit (PPESU) shall inform the investigator of the nature of the case and the type of investigation to be conducted.

    • A Notice of Pending Peer Review Formal Investigation notification letter shall be personally served or served by overnight mail to the last known address of the licensed medical provider with a Proof of Service and return receipt requested.  The notification shall include copies of all documents relied upon by the MPRC in making the determination that triggered the Peer Review Formal Investigation.

    • A copy of the Notice of Pending Peer Review Formal Investigation shall be sent to the institutional Chief Executive Officer (CEO), Chief Medical Executive (CME), Chief Physician and Surgeon (CP&S), and Regional Deputy Medical Executive (RDME).

  • The Peer Review Formal Investigation may consist of one or more of, but is not limited to, the following:

    • An examination of documents relating to the event in question.

    • A review of the licensed medical provider’s patient charts to assess either overall quality of clinical care, a more focused aspect of the quality of clinical care, or a combination of both as deemed appropriate based on the clinical practice issue(s).

    • An interview with the subject medical provider.

    • Interviews with staff possessing knowledge about the licensed medical provider’s clinical performance or conduct issues in question.

  • The subject medical provider shall be offered an opportunity to provide a response to the allegations outlined in the investigative report through a scheduled interview with the reviewer(s).

    • The licensed medical provider may be accompanied by a representative of his/her own choosing who shall not disrupt or interfere with the interview.  The licensed medical provider or the investigator may end the interview at any time.

    • Both the investigator and the licensed medical provider may record the interview.

  • The investigator shall analyze all reported incidents or cases for the following factors if relevant and as appropriate for the investigator’s background:

    • Clinical management.

    • Timeliness of clinical interventions.

    • Adherence to the department’s critical pathways and/or other established guidelines, or clinically appropriate care and evaluation of any variations.

    • Interviews with staff possessing knowledge about the licensed medical provider’s clinical practices.

    • Health record documentation.

    • Follow-up case management.

    • Professional conduct.

    • Other alleged disruptive conduct.

    • Allegations of ethical violations.

    • Patterns of practice.

    • Skills, knowledge, training, and experience.

    • Any impediments (e.g., inability to get test results back or lack of access to patient) to the delivery of appropriate types and levels of care.

    • Possible physical or mental impairment of the licensed medical provider.

    • Other factors as requested by the MPRC or which appear relevant to the investigator.

  • The investigator shall complete the Peer Review Formal Investigation and issue a report within the timeframe ordered by MPRC.  The investigation report shall contain the investigator’s factual findings and shall include the following:

    • All documents and other evidence to support the findings.

    • In cases involving clinical judgment and direct patient care, clear explanations as to why the clinical performance deviates from or adheres to the applicable standard of care.

  • A copy of the investigation report shall be sent to the licensed medical provider at his/her last known home address by overnight mail with a return receipt requested, and one copy shall be sent to the institution’s CEO, CME, CP&S, and RDME.

  • The licensed medical provider shall have ten calendar days from service of the investigation report to submit a written rebuttal to the MPRC via the PPESU via email to: mprcsupport@cdcr.ca.gov. In the absence of email availability, the written rebuttal shall be sent to:
    CCHCS
    P.O. Box 588500
    Elk Grove, CA 95758
    Attn: Professional Practice Evaluation Support Unit, Bldg. B

  • Upon expiration of the licensed medical provider’s time to submit a rebuttal to the investigation report, the matter shall be calendared for MPRC review and discussion at the next regularly scheduled MPRC meeting.  The MPRC shall review the investigator’s report and any rebuttal submitted by the licensed medical provider.

  • The MPRC may take any of the following actions in response to the investigative report and the licensed medical provider’s rebuttal, if any:

    • Request additional information by a specified date.

    • Take remedial action including, but not limited to:

      • Education.

      • Proctoring.

      • Performance monitoring.

      • Referral for physical or mental evaluation and/or treatment.

    • Modify or restrict clinical privileges including, but not limited to, restricting privileges to prescribe particular medications and/or to perform particular procedures.

    • Issue letters of admonition, censure, reprimand, or warning; although nothing herein shall be deemed to preclude the licensed medical provider’s direct supervisor from issuing informal written or oral warnings outside of the mechanism for corrective action, nor shall it preclude the hiring/contracting authority from taking adverse action.

    • Take no action against the medical provider.

    • Suspend privileges.

    • Revoke privileges.

  • Upon voting to conclude a Peer Review Formal Investigation, the MPRC shall send its recommendation(s) to the HCEC.  The recommendation shall include a chronology of the major events in the peer review process and all supporting documents considered when choosing the recommendation.  If the recommendation is for a privilege modification of any kind, such as a suspension or a revocation of privileges, the recommendation shall be in the form of a Final Proposed Action.

  • The MPRC shall maintain all materials regarding the matter including copies of all materials provided to the HCEC.
    

Procedure Overview

• This procedure sets forth the process for appealing a Final Proposed Action pertaining to privileges and/or employment to the Judicial Review Committee (JRC).

Procedure

• Appealing the Final Proposed Action

  • Final Proposed Actions pertaining to privileges and/or employment must be appealed in writing and filed with the State Personnel Board (SPB) within 30 calendar days of service of the Notice of Final Proposed Action.

    • An appeal of a Final Proposed Action is an appeal of the privileging action.  It is not an appeal of the employment action since the employment action is automatically determined by the disposition of the privileging action.

    • Appeals shall be made in writing and must be delivered or sent to:
      Appeals Division
      State Personnel Board
      801 Capitol Mall
      Sacramento, CA 95814

    • The licensed medical provider shall also serve a copy of the appeal to the following address:
      California Correctional Health Care Services
      P.O. Box 588500
      Elk Grove, CA 95758
      Attn: Professional Practice Evaluation Support Unit, Bldg. E

  • Failing to timely appeal shall be deemed to be a failure to exhaust administrative remedies and a waiver of all rights to challenge the Final Proposed Action before an administrative or judicial tribunal including, but not limited to, the Judicial Review Committee (JRC), the SPB, or a court of law.

  • The parties shall, notwithstanding Business and Professions Code, Section 809.3(c), be represented by the person(s) of their own choosing including, but not limited to, an attorney.

• Time and Place for Hearing before the Judicial Review Committee

  • The SPB shall schedule (or cause to be scheduled) a hearing before an Administrative Law Judge (ALJ) and the JRC within 30 calendar days of the SPB’s receipt of the notice of appeal.  The SPB shall serve notice to the parties of the time, place, and date of the hearing as required by Business and Professions Code, Section 809.1(c)(2).

    • State-employed ALJs shall preside over the hearings only after receiving special training in medical hearings.

    • Scheduling a hearing date shall be as set forth in Business and Professions Code, Section 809.2(h), which generally states, unless extended for good cause, the date for commencement of the hearing shall not be more than 60 calendar days after SPB’s receipt of the appeal.

• Conduct of Proceedings – Generally

  • An ALJ shall administer pre-hearing and hearing processes under terms and conditions ordinarily applicable to SPB disciplinary action hearings to ensure constitutionally appropriate due process.  Hearing rights include, but are not limited to:

    • Being provided with all information made available to the finder of fact.

    • Having a record made of the proceedings (excluding deliberations) made available to both parties at their own expense.

    • Calling, examining, and cross-examining witnesses.

    • Presenting and rebutting relevant evidence.

    • Submitting an oral or written statement at the close of the hearing.

• Confidentiality

  • To the extent Evidence Code, Section 1157 is applicable on its own terms, confidentiality shall apply to SPB and JRC proceedings and records.

• Role of Administrative Law Judge

  • The ALJ shall endeavor to ensure all participants have a reasonable opportunity to be heard and to present relevant oral and documentary evidence in an efficient and expeditious manner and that proper decorum is maintained.

  • The ALJ shall have the authority and discretion to make all rulings on questions pertaining to matters of procedural law (e.g., the admissibility of evidence).

  • The ALJ shall prepare a proposed decision concerning affirmative defenses (i.e., unlawful retaliation, unlawful bias, unlawful discrimination, or conflict of interest).

  • The ALJ may also submit his/her own recommendations to the SPB regarding whether there is substantial evidence to support the JRC’s decision.

  • If the ALJ determines that either side at the hearing is not proceeding in an efficient and expeditious manner, the ALJ may take such discretionary action as warranted by the circumstances.

  • The ALJ may participate in the JRC deliberations when requested to do so by the JRC. However, clinical competency and privileging determinations as well as employment decisions based on such determinations shall be made exclusively by the JRC.

  • The ALJ shall not be entitled to vote, comment, or otherwise advise any person or entity regarding such matters as the merits of the case and remedy pertaining to privileges and employment decisions based on privileging conclusions and finding of facts relating to the standard of care.  This prohibition does not preclude the ALJ from submitting his/her written recommendations to the SPB regarding whether there is substantial evidence to support the JRC’s decision.

• Role of Judicial Review Committee

  • The scope of the JRC’s authority is by majority vote to determine by a preponderance of the evidence whether the nature of the action pertaining to privileges as set forth in the Notice of Final Proposed Action is reasonable and warranted (Business and Professions Code, Section 809.3(b)(3)) and whether the action pertaining to employment is therefore just and proper based on privileging conclusions and findings of fact relating to the standard of care.

  • All factual issues including determining the sufficiency of evidence, which pertain to privileging and, therefore, employment determinations based on privileging conclusions and findings of fact relating to the standard of care, shall be decided by a JRC consisting of three physicians.

  • The ALJ may assist the panel of physicians in writing a decision that is grounded in the evidentiary record as described above.

  • The JRC decision shall be based on the evidence introduced at the hearing including logical and reasonable inferences from the evidence and the testimony.

  • The JRC may sustain, modify, or reject the privileging and employment actions based on privileging conclusions and findings of fact relating to the standard of care.

• Time and Content of Decisions

  • The JRC shall render a written decision within 30 calendar days after submission of the case.

    • The JRC decision shall contain a concise statement of the reasons in support of the decision, including findings of fact and conclusions articulating the connection between the evidence produced at the hearing and the conclusion reached (Business and Professions Code, Section 809.4(a)(1)).

    • JRC decisions concerning privileges and employment shall be based on whether the appellant medical provider’s acts and/or omissions constitute a failure to meet the standard of care as defined in this procedure.

  • In matters adversely impacting employment status, grade levels, benefits, and/or wages, the written JRC decision shall be available to the ALJ within 30 calendar days.

  • The ALJ shall complete preparation of his/her written proposed decision regarding any affirmative defenses raised at hearing and recommendations to the SPB regarding whether there is substantial evidence to support the JRC’s decision.

  • The JRC’s decision, the ALJ’s proposed decision, and the ALJ’s substantial evidence recommendation shall be delivered to the SPB and simultaneously served on the parties within 60 calendar days after submission of the case.

  • In matters that do not adversely impact employment status, grade levels, benefits, and/or wages, the SPB shall serve the parties with the JRC’s decision within 30 calendar days after submission of the case.

• Judicial Review Committee Selection for Hearing

  • The SPB shall request a JRC pool of at least five primary care physicians through the California Medical Association Institute of Medical Quality (Institute).  The Institute shall be asked to provide the names of physicians familiar with correctional medicine to the extent reasonably possible.

    • In any matter concerning a non-primary care specialist, the Institute shall provide the names of three licensed practitioners in that area of specialty so that one may be selected as the third JRC member instead of a primary care physician.

    • In the event that the Institute is unwilling or unable to provide this pool of independent physicians, the Health Care Executive Committee (HCEC) and the Union of American Physicians and Dentists will work together to establish an alternative method of selecting a physician pool from which the JRC will be selected.

    • In matters not involving specialty care medical providers, the appellant medical provider shall select one JRC member from the primary care physician pool and the HCEC shall select one JRC member from the primary care physician pool.  The HCEC and the appellant medical provider shall then each alternately strike one name from the five remaining primary care JRC nominees until only one is left, with the first strike determined by coin toss.

    • In matters involving specialty care medical providers, the subject medical provider shall select one JRC member from the pool and the HCEC shall select one JRC member from the primary care physician pool.  The HCEC and the appellant medical provider shall then each alternately strike one name from the list of specialty physicians and the last remaining specialist shall serve as the third JRC member.  The first to strike shall be determined by coin toss.

  • JRC members shall be subject to voir dire pursuant to Business and Professions Code, Section 809.2(c), except that it shall apply to both parties rather than just the appellant medical provider.

• State Personnel Board Scope and Standard of Review

  • The JRC decision shall be final and binding upon the parties and not subject to SPB review if the matter only concerns privileges (e.g., corrective measures including, but not limited to, privilege restrictions and measures that do not adversely impact employment status, grade level, benefits, and/or wages.)

  • The SPB shall only review JRC decisions adversely impacting employment status, grade levels, benefits, and/or wages.  This review shall be limited to whether there is substantial evidence to support the JRC decision.

  • The SPB shall make its decision based on the record and will not conduct a new trial.

    • The SPB shall apply the substantial evidence standard when reviewing JRC decisions.  If the SPB concludes there is substantial evidence that the appellant medical provider’s performance or conduct falls below the applicable standard of care, the JRC’s privileging and employment decisions shall be affirmed.

    • If the SPB concludes there is not substantial evidence, it shall remand the matter to the JRC for reconsideration along with a statement of the reasons.  A copy of the SPB’s remand decision shall be served upon the parties within three business days after the SPB makes its remand decision.

  • The SPB shall complete its review and render a final decision within 45 days of receiving the JRC decisions.  A copy of the SPB’s final decision shall be served upon the parties within three business days after the SPB makes its final decision.

• Licensing Actions

  • In those cases where privileges have been automatically suspended or revoked due to a disciplinary action against the medical provider’s license by the Medical Board of California where there has been a corresponding non-punitive termination, SPB review, if requested, shall be limited to the question of whether the action against the license occurred.