Chapter 1 – Health Care Governance and Administration

1.4.3.1 For Cause Medical Peer Review

• 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.

• References

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

  • Coleman v. Newsom, et al., U.S. District Court for the Eastern District Court of California, Case No. 2:90-cv-00520-LKK-JFM

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

  • California Constitution, Article VII, Public Officers and Employees

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

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

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

  • California Code of Regulations, Title 2, Division 1, Chapter 1, Sections 1-549.74

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

  • Skelly v. State Personnel Board (1975) 15 Cal.3d 194

  • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging

  • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.2.5, Professional Practice Evaluation

  • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.3.2, Medical Peer Review Referral and Intake

  • Plata Physician Professional Clinical Practice Review, Hearing and Privileging Procedures, Pursuant to Order Approving, With Modifications, Proposed Policies Regarding Physician Clinical Competency, July 9, 2008;Plata v. Newsom, et al., Federal Court Case No. C01-1351 published September 4, 2008, Court ordered procedures
    

• Revision History

  • Effective: 12/2017

  • Reviewed: 10/17/2025