1. (a) All health care staff are responsible for referring safety concerns involving clinical performance or conduct to the attention of the institutional supervisor or regional or headquarters executive leadership.
2. (b) Requests for safety assessments shall immediately be submitted to the Professional Practice Evaluation Support Unit (PPESU) if failure to take action may result in imminent danger to the health of any patient or staff.
3. (c) When a safety assessment is requested or being conducted, the licensed medical provider's privileges shall temporarily be modified to eliminate imminent danger and ensure patient safety.

4. (d) Within two business days of receiving a referral, the Safety Assessment Panel (Panel) shall make an initial determination:

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

      1. (A) Refer the matter to the Medical Peer Review Committee (MPRC) for further review and disposition as warranted.

      2. (B) Provide the hiring/contracting authority with written notice of the following:

         1. 1. The Panel's initial determination.
         2. 2. The referral to the MPRC for further review and action, as warranted.
      3. (C) The hiring/contracting authority shall immediately terminate any privilege modifications in effect.

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

      1. (A) Schedule an emergency MPRC meeting for a second determination on the clinical performance or conduct at issue.
      2. (B) Notify the referring party of the MPRC meeting.
      3. (C) Review any privilege modification in place and if necessary, direct the hiring/contracting authority in writing to make a change and give the medical provider written notification of the change in the privilege modification.

5. (e) Within two business days of the Panel's determination, the MPRC shall meet and make the final determination regarding the clinical performance at issue.

   1. (1) 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:

      1. (A) Close the case.
      2. (B) Conduct a Professional Practice Evaluation pursuant to section 3999.135.
      3. (C) Open a Peer Review Formal Investigation pursuant to section 3999.141.

   2. (2) If the MPRC determines that the clinical performance does or is likely to pose an imminent danger to the health of patient(s) or staff, the PPESU shall serve the medical provider with a Notice of MPRC Action pursuant to section 3999.140(b) and shall conduct the Informal Hearing, if requested.

      1. (A) The MPRC may also conduct a Peer Review Formal Investigation into the licensed medical provider's clinical performance in general or the clinical performance or conduct at issue in the Notice of MPRC Action.
      2. (B) 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 the MPRC, shall commence after the Informal Hearing takes place.

      3. (C) 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 the MPRC, shall commence upon the earlier of the following:

         1. 1. The date of the licensed medical provider's written waiver of the Informal Hearing.
         2. 2. Expiration of the five business day period after service of the Notice of MPRC Action.

Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.

History

1. New section filed 7-1-2019 as an emergency; operative 7-1-2019 (Register 2019, No. 27). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 12-9-2019 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 12-5-2019 as an emergency; operative 12-10-2019 (Register 2019, No. 49). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 3-9-2020 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 3-9-2020 as an emergency; operative 3-10-2020 (Register 2020, No. 11). A Certificate of Compliance must be transmitted to OAL by 6-8-2020 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 3-9-2020 order transmitted to OAL 6-8-2020 and filed 7-20-2020 (Register 2020, No. 30).