Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 3.4 – Dental Care: Dental Clinic Administrative Procedures

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3.3.4.3 Dental Peer Review

  • Policy

    • The California Department of Corrections and Rehabilitation (CDCR), California Correctional Health Care Services (CCHCS), and the Health Care Executive Committee (HCEC) shall maintain oversight and coordination of the statewide professional peer review processes to achieve the CCHCS’ strategic objectives.  The Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC) shall establish the Headquarters Dental Peer Review Committee (HDPRC) to plan, develop, manage, and improve the peer review process for CDCR dentists and assist the institution Dental Peer Review Committee (DPRC) in fostering the continuous professional development and training of the clinical workforce.  The dental peer review process shall adhere to all applicable aspects of the CCHCS/DHCS Health Care Department Operations Manual (HCDOM) on Peer Review.

  • Purpose

    • To achieve and maintain the highest possible standards of professional, ethical, dental health care through continuous quality review and/or peer review of services provided.

  • Procedure

    • Peer review is intended to ensure patient safety and the delivery of an acceptable level of care with the ultimate goal of promoting good dental practice culminating in consistently positive outcomes and continuously improving patient care through the gathering and examination of quality review data. In addition, the dental peer review process provides an appropriate, objective and systematic due process for licensed dental practitioners, in accordance with Title 22 of the California Code of Regulations, the California Business and Professions Code, bargaining unit contracts and applicable California Law governing restriction, suspension or revocation of privileges, termination of employment and reporting to appropriate professional licensing boards.

    • Confidentiality

      • The DHCS affirms the confidentiality of peer review information and the need to prevent its inappropriate use. It is essential that the analysis of and conclusions drawn from healthcare peer review data, along with the recommendations and actions developed for use by the DHCS, be kept from unauthorized persons or organizations and be protected from any use other than for internal or quality improvement purposes.  The proceedings and records of peer review bodies are protected by Section 1157 of the California Evidence Code.  All participants in the review processes referenced in this policy shall adhere to the above provisions regarding confidentiality.

    • HDPRC

      • HDPRC membership shall consist of:

        • One Supervising Dentist (SD) nominated and selected by Program Support Team (PST) and institution staff dentists to serve for two years. This individual shall not be eligible to serve consecutive terms.

        • Two institution staff dentists selected by the four Regional Dental Directors (RDD) to serve for two years. These individuals shall not be eligible to serve consecutive terms.

        • Two PST dentists selected by the four RDDs to serve for two years. These individuals shall not be eligible to serve consecutive terms. When a PST dentist member of the HDPRC is unable to attend an HDPRC meeting the RDDs may select another PST dentist to serve as the alternate.

        • One staff dentist from ACDC, Headquarters selected by the three Chief Dentists (CD) to serve for two years. This individual shall not be eligible to serve consecutive terms. Another staff dentist from Dental Program Headquarters may serve as the alternate.

        • At least one CD and/or one RDD shall attend HDPRC meetings and serve as non-voting advisors. Any CD or RDD may serve as the alternate.

        • No Region may have more than one PST or institution staff dentist serving at the same time.

        • HDPRC members shall select a chairperson and vice-chairperson from amongst themselves to serve for two years.

      • Meetings

        • HDPRC meetings shall be held at a minimum once a quarter to review routine institution peer review cases or as needed regarding routine Clinical Performance Appraisals (CPA) or to consider requests for Patterns of Practice (POP) stemming from ‘for cause’ cases sent forward by the institution SD, the RDD, or at the direction of the Deputy Statewide Dental Director (DSDD), or Statewide Dental Director (SDD).

        • A quorum consists of four HDPRC members, one of which must be the chairperson or vice-chairperson.

        • Any member of the HDPRC shall recuse themselves from an upcoming review for reasons of a potential conflict of interest.

          • Such recusals shall only be allowed prior to the beginning of the proceedings or when the member discovers the potential conflict. In either case, whichever is the earlier event.

          • The HDPRC member shall be replaced by another dentist from either Dental Program Headquarters or PST region selected by the HDPRC chairperson.

      • Responsibilities

        • The HDPRC shall evaluate patient care using generic screening criteria and methodologies such as health record reviews and patient outcome data as well as other logs and reports.  During the evaluation process a review of each procedure and service shall be performed to determine:

          • Appropriateness – Were timely dental evaluations and diagnostic tests including radiographs performed per the HCDOM, Chapter 3, Article 3, Dental Care?  Were the correct diagnoses and conclusions drawn?  Was the appropriate treatment provided consistent with the HCDOM, Chapter 3, Article 3, Dental Care? Was the documentation accurate, legible and properly organized as required by the HCDOM, Chapter 3, Article 3, Dental Care?

          • Competence – Was the care delivered in a professional, competent manner and within the guidelines of the HCDOM, Chapter 3, Article 3, Dental Care and the Standard of Care in Dentistry?  Were any changes to the diagnoses or treatment plans correctly perceived and supported by clinical data? Was appropriate documentation noted in the health record?

          • Outcome – Did the patient receive satisfactory access to care and was the treatment appropriate for the diagnosis and were unexpected outcomes documented in the health record?

        • Based on the duties assigned to a dentist by management, the HDPRC shall decide whether to conduct a Clinical Performance Appraisal, a Pattern of Practice, or to make a danger determination possibly leading to restriction or summary suspension of privileges when failure to do so may result in an imminent danger to the health of any patient, prospective patient, or other person.

        • The standard for taking action affecting a practitioner’s ability to provide health care services shall be when the practitioner’s clinical care falls below the required standard of care in that they have failed to deliver care that is consistent with the degree of care, skill and learning expected of a reasonable and prudent practitioner acting in the same or similar circumstances.

    • DPRC

      • Only licensed dentists that are employees in good standing of the CDCR DHCS Dental Department are eligible to serve on the DPRC.

      • PST dentists shall provide oversight and validation of the DPRC under the guidance of the RDD.

      • Each CDCR facility shall establish a DPRC composed of:

        • The facility SD who shall chair the DPRC.

        • A staff dentist elected for a one year period as vice-chairperson of the DPRC by the other staff dentists at the facility. This individual shall chair the committee when the SD is unavailable to preside over the committee and shall not be eligible to serve consecutive terms as vice-chairperson.

        • Two staff dentists selected as general members by the facility SD with the approval of the RDD to each serve a six month term. These members shall be replaced with other dentists from the institution on a rotating basis.

        • The Health Program Manager (HPM) III in a supporting, non-voting capacity.

      • Service term requirements

        • A dentist may serve on the DPRC as vice-chairperson, or a general member, or a combination thereof for a maximum of two consecutive terms that do not exceed 18 months. Exceptions to this rule may be granted by either the DSDD or SDD.

        • After serving up to a maximum of 18 months, a dentist shall be eligible to once again serve after a period of six months during which they do not serve on the DPRC.

        • In order to allow for stability and continuity in DPRC function, the service term requirements outlined in Section (c)(3)(D) 1. and 2. shall be waived during the period in which the DPRC is established for the first time at a facility.

        • Any member of the DPRC shall recuse themselves from an upcoming review for reasons of a potential conflict of interest.

          • Such recusals shall only be allowed prior to the beginning of the proceedings or when the member discovers the potential conflict. In either case, whichever occurs first.

          • The DPRC member shall be replaced by a staff dentist at the facility or from another facility within the same region, selected by the RDD from the region in which the review is being conducted.

          • If the replacement dentist is from a different region from the one in which the peer review is being conducted, the selection made by the RDD shall be approved by the DSDD or SDD.

        • An exception process shall be implemented when a dentist has been the subject of repeat “for cause” reviews within an 18 month period.

          • Any subsequent peer reviews of the dentist in question shall be conducted by a DPRC, at their institution, composed of two different staff dentists in the position of general members who did not participate in any of the reviews during the previous 18 month period.

          • The DPRC chairperson and vice-chairperson can be the same individuals as in the previous committee.

      • Meetings

        • DPRC meetings shall be held regularly, and with sufficient frequency, to ensure that each dentist providing treatment at the institution is the subject of a routine peer review at a minimum once every six months and shall normally consist of a minimum of ten health record review cases for each dentist being reviewed.

          • Cases reviewed shall be selected in compliance with the guidelines set forth in the Peer Review Case Selection Tool.

          • Each DPRC member shall review all of the health record review cases selected for a dentist undergoing routine peer review.

          • Peer review cases shall be selected and made available to DPRC members sufficiently in advance to allow them to access and review the health record(s) as well as all other necessary documents prior to the DPRC meeting.

          • A quorum consists of three DPRC voting members, one of which must be the chairperson or the vice-chairperson.

          • In order to establish a quorum, a DPRC member who is absent from the institution can be temporarily replaced by a staff dentist at the facility, or from another facility within the same region, selected by the RDD from the region in which the review is being conducted.

          • A Regional or Headquarters dentist may attend and participate in DPRC meetings at any time but shall not count towards the required quorum.

        • Meeting minutes shall be recorded by the HPM III or designee. The SD shall maintain DPRC minutes on file for a period of three years.

      • Responsibilities

        • In performing routine peer reviews at a facility, the DPRC shall act under the auspices and as an agent of the HDPRC in protecting the health and welfare of patients, in preserving standards of health care delivery, and in evaluating practitioner competency as outlined in Section (c)(2)(C)1.a. through c.

        • The DPRC shall implement a quality review process to exercise concurrent and direct observation through:

          • Proctoring to monitor and review a dentist’s skills during their initial probationary period to ensure they can adequately perform the minimum expected clinical skills. (Reference the HCDOM, Section 3.3.4.2(e)(2). The proctoring process shall be performed by the SD or designee with concurrence from the RDD, and shall include:

            • A review of the dentist’s clinical and patient management skills.

            • Cases sufficient in complexity and in number to demonstrate the dentist’s competency in all aspects of dental care delivered within CDCR.

            • Procedures which ensure that the proctor shall function as an observer in the case and not a consultant or assistant and that the proctor shall perform pre- and post-treatment examinations of the patients being treated.

            • Provision for dentists from outside the local facility but employed by CDCR to be utilized as proctors when needed.

            • A minimum of five health record review cases and three clinical review cases during the proctoring period. Each of the clinical review cases shall be performed by a different proctoring clinician.

            • The use of the Dental Peer Review Audit Tool during the health record case review process.

            • Provision for proctors to generate a brief narrative report of clinical review cases, to include, at a minimum:

              • Pre-clinical – Did the dentist review and complete appropriate forms records as required by the HCDOM, Chapter 3, Article 3, Dental Care?

              • Clinical-Dental Practice – Was there proficiency in using the dental equipment and materials during the procedure as well as in applying infection control procedures?

              • Clinical-Patient Care – Did the dentist effectively deliver dental care so that patient discomfort was minimized whenever possible? Was the care provided within the guidelines set forth by the HCDOM, Chapter 3, Article 3, Dental Care and the Standard of Care in Dentistry?

              • Clinical Interaction With Auxiliary Staff – Was the auxiliary dental staff effectively utilized to their level of licensure and was auxiliary staff given clinical direction in an adequate manner?

          • Mentoring to foster continuous professional development and training for dentists if they fail to demonstrate acceptable skills. Additional training may be required if this occurs. The mentoring process shall be performed by the SD.

            • In determining the level of mentoring required, consideration shall be given to the dentist’s judgment, skills, recognition and management of complications and treatment outcomes.

            • The mentoring process shall last for a minimum of six months and may include:

              • Items outlined in Section (c)(3)(F)2.a.

              • Provision for mentoring to be extended in 30 day increments up to a total of 12 months.

          • The SD who shall place reports of cases used for proctoring or mentoring in the appropriate dentist’s supervisory file for a period of one year or until the dentist in question receives their next annual performance appraisal.

        • Reference the HCDOM, Section 3.3.4.2(e)(3) and (4) for further DPRC responsibilities.

        • The DPRC may choose to utilize a non-CDCR employed, outside consultant for an independent evaluation of a case, only with the approval of the DSDD or SDD.

        • When performing peer reviews, DPRC members shall collaborate to reach a consensus and shall assign one agreed upon rating to each of the ten categories on the Dental Peer Review Audit Tool. In the event the DPRC members are unable to agree on the rating for a particular category, the chairperson or vice-chairperson shall decide the appropriate rating to be assigned.

        • The DPRC shall generate and submit the following peer review documents to the appropriate RDD for validation by PST dentists and to the HDPRC. The originals shall be kept on file by the DPRC for a period of three years and copies sent to the appropriate RDD and to the HDPRC. The RDD and PST dentists shall maintain peer review documents used for DPRC validation for a period of three years.

          • A Dental Peer Review Audit Tool Summary for each dentist who is the subject of a review.

          • A Review Summary Report consisting of a compilation of the results of each Dental Peer Review Audit Tool Summary produced subsequent to a health record case review.

        • When proctoring, mentoring, or other routine peer review results suggest questionable treatment or identify a pattern of substandard practice, the SD shall refer the findings to the RDD and/or HDPRC.

        • Any institutional dentist receiving an unacceptable score on the Dental Peer Review Audit Tool may be directed to receive one or all of the following by the DPRC under the guidance of the RDD and/or the HDPRC:

          • Appropriate counseling.

          • Appropriate remedial training or continuing education.

          • Continued mentoring and review of their work until satisfactory scores are obtained or it becomes apparent that remediation is not a viable option.

      • ‘For Cause’ Review Process

        • The ‘for cause’ review process may be initiated as a result of credible information provided by any person to institution, regional, or headquarters dental or administrative staff about the conduct, performance, or competence of dental practitioners. Anonymous referrals shall not be considered.

        • Sources of information may include, but are not limited to:

          • Staff.

          • Patients.

          • The public.

          • The credentialing process.

          • The privileging process.

          • The peer review process.

          • The death review process.

          • The quality review process.

      • Review Accountability

        • Reviews performed by HDPRC/DPRC members, PST staff, or outside consultants on clinicians employed by CDCR are to be forthright and objective in nature.

        • Performing a review that does not present an accurate assessment of a clinician’s standards of practice and clinical skills is unacceptable.

  • References

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

    • Health Care Department Operations Manual, Chapter 3, Article 3, Dental Care

    • Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.4.2, Licensure and Credentialing

  • Revision History

    • Effective: 04/2006
      Revised: 11/2017, 11/2020, 02/2022