Planning for Correctional Healthcare Oversight in California: Recommendations from a Modified Delphi Process

Healthcare Oversight Body: Scope of Work and Methods (1-12), Structure, Members, and Funding (13-17), and Reports, Follow-Up, and Enforcement (18-24)

1. The healthcare oversight body should evaluate the full continuum of care (medical, dental, and mental health). While a healthcare oversight body would ideally have a unified mandate across adult and juvenile facilities, California’s governance structures make this infeasible.
2. Healthcare oversight should promote and positively incentivize quality and quality improvement, rather than solely identifying deficiencies.
3. The healthcare oversight body should review the state budget for prison healthcare expenditures prior to its finalization. Review may include non-binding feedback, but the healthcare oversight body should not have approval authority over the budget.
4. The healthcare oversight body should review CCHCS strategic planning documents prior to their finalization. Review may include providing non-binding feedback, but the healthcare oversight body should not have approval authority over CCHCS’s strategic plans.
5. The healthcare oversight body should be able to access individual patient records — with identifying information — in order to evaluate care quality.
6. The healthcare oversight body should have the authority to make unannounced inspections/visits to prisons and be able to visit any part of a prison and talk to any patient or staff member.
7. The healthcare oversight body should have the authority to review any relevant documents held by the state prison system.
8. The healthcare oversight body should oversee health-related programming, nutrition, and exercise as it relates to the physical and mental health of patients.
9. An assessment of population level health should be a primary focus for evaluating the quality of healthcare in the prison system. In addition, the healthcare oversight body should evaluate quality through a random sampling of individual medical records among complex and medically vulnerable patients, a review of healthcare appeals data, and the administration of confidential surveys to individual patients and staff members. The healthcare oversight body should also review internal policies/procedures related to healthcare, perform on-site inspections, and evaluate incident report data in its assessment of health system performance.
10. The healthcare oversight body should create a mechanism to allow both staff and patients to anonymously share concerns about healthcare delivery in the prison system. Other parties should be able to share concerns confidentially.
11. Data from complaints or concerns regarding healthcare delivery shared with the healthcare oversight body may be used to 1) identify trends and assess performance from aggregate data and 2) evaluate urgent and serious threats to the health of the prison population or the health of an individual. The healthcare oversight body should not be tasked with evaluating or responding to every complaint.
12. The healthcare oversight body should (whenever possible) align quality standards in the prison system with standards used in evaluations of community healthcare systems.
13. The healthcare oversight body should be positioned within state government in a manner that insulates it from external political pressures. To the extent that the healthcare oversight body needs to be positioned within state government, housing it within the Health and Human Services Agency (HHS) is preferable.
14. The healthcare oversight body should receive a mandated amount of funding that is independent of the CDCR population and not renegotiated yearly in the state budgeting process. The amount of funding should be adjusted for inflation on a regular basis.
15. The leader of the healthcare oversight body should be a full-time employee who is appointed by the Governor’s office with the advice and consent of the legislature.
16. The healthcare oversight body leader should be subject to term limits of approximately 5 years, although reappointment should be permitted. The leader may be removed by the appointing authority prior to the conclusion of their term due to undisclosed conflicts of interest, unethical behavior, and/or failure to perform the duties of their job.
17. The healthcare oversight body should consider assembling a volunteer advisory board made up of diverse stakeholders.
18. The healthcare oversight body should issue reports on healthcare delivery across the entire state prison system at least annually. Additional reports on healthcare delivery at individual prisons or on topics selected by the healthcare oversight body should be issued at intervals determined by need and the levels of staffing and funding provided to the healthcare oversight body.
19. Reports issued by the healthcare oversight body should avoid pass/fail scoring or the reliance on graded or scaled scoring of healthcare quality. Instead, reports should highlight successes and identify problems that need to be fixed and a timeline for corrective action.
20. CDCR/CCHCS and the Governor’s office should be able to comment on reports before they are released to the public, but neither should have editorial control over the report.
21. The healthcare oversight body’s methodology must be clearly described and publicly available.
22. Healthcare oversight body reports may both identify deficiencies in care and also suggest corrective actions to address these deficiencies. Reports should aim to disseminate best practices by highlighting successes across institutions.
23. When the healthcare oversight body identifies significant deficiencies in care, the enforcement of corrective actions should not fall to the healthcare oversight body itself. Instead, CCHCS/CDCR should develop a corrective action plan, and a separate government entity (e.g. the Governor’s office or legislature) should be authorized to enforce the satisfactory implementation of the corrective action plan and to deploy additional resources (such as funding) or punitive measures, if needed, in consultation with the healthcare oversight body.
24. Corrective measures — whether enforced by the Governor’s office or another entity — may be enacted if the prison healthcare system (as a whole or individual prisons) fails to adequately address significant deficiencies in care. Corrective measures may include appointment of new healthcare leadership, mandated population reduction, or a loss of local control over prison healthcare delivery. If a prison is eventually stripped of its authority to deliver healthcare services, it must either close or be subject to the appointment of a temporary healthcare overseer with broad powers to implement change.