Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 4.3 – Professional Workforce: Medical Peer Review Process

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1.4.3.2 Medical Peer Review Referral and Intake

  • 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.

  • References

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

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

    • California Constitution, Article VII, Public Officers and Employees

    • California Business and Professions Code, Section 800, et seq.

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

    • 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

    • Health Care Department Operations Manual, Section 1.4.3.3, Safety Assessment, Summary and Automatic Privilege Modification

  • Revision History

    • Effective: 12/2017

    • Revised: 06/16/2025