Welcome to the State of California

Risk Management and Health Care

Operating an adult and youth prison system exposes the state to many risks. It must protect the safety of its employees – most of whom work in high-risk and often dangerous environments where inmates and wards may attack. Simultaneously, it must provide humane housing and care for tens of thousands of inmates and wards. When poorly managed or ignored, the risks translate into injured employees, inmates, or wards and sometimes result in costly lawsuits or court settlements. Effectively managing risk requires a risk management system that identifies, controls, and lessens the impact of potential events. It requires a decision-making structure that constantly assesses safety, resources, services, legal responsibilities, and policies, and it requires vigilant planning, checking, and adjustment of business practices to address and reduce risk. To assess the effectiveness of risk management in the state correctional system, the Corrections Independent Review Panel reviewed the risk management practices at the Department of Corrections, the California Youth Authority, and other law enforcement agencies in the state. As a result of that review, the panel recommends significant changes to the state’s current practices. Specifically the panel recommends that the new Department of Correctional Services adopt a “top-down” approach to risk management. The panel also recommends that the Department of Correctional Services include an Office of Risk Management that reports directly to the Secretary of Correctional Services. That office should have responsibility for overall planning and implementation of the risk management program. A cornerstone of the new Office of Risk Management would be an “early warning” system that combines effective communication between levels of the organization, careful trend analysis in inmate complaints, and rigorous self-audit to ensure compliance with policy and corrective actions. This system, in turn, will contribute to greater accountability at all levels of the organization. At present, significant risk in the state correctional system is in its system for providing health care services to inmates and wards, which has frequently been criticized for poor management and quality of care. Health care also represents the largest litigation expense for the department. After reviewing the health care delivery models of several other states, the panel recommends that the new Department of Correctional Services create an Office of Health Care Administration to administer health care services for inmates and wards. In addition, the new department should explore entering into an agreement with the University of California to explore ways to improve the efficiency and efficacy of health care services. The panel also recommends the new Department of Correctional Services increase its use of contracted health care services.

The Office of Risk Management

The Department of Corrections and the California Youth Authority presently lack a risk management system that effectively coordinates critical risk management functions such as communication, litigation support, self-audit, analysis, and policy development. Numerous oversight entities, including the Bureau of State Audits, the Office of the Inspector General, the Senate Advisory Commission, the National Institute of Corrections, the Little Hoover Commission, the Board of Corrections, medical experts, consultants and the California Legislative Analyst Office have identified deficiencies in both of these departments that can be attributed either directly or indirectly to ineffective risk management and poor accountability for managing risk. To remedy the problem, the Corrections Independent Review Panel recommends that the new Department of Correctional Services create an Office of Risk Management to coordinate and implement a department-wide risk management strategy. Critical to this strategy will be improved communication between levels of the organization, an effective “early warning” system to identify and mitigate risks, and coordination of litigation activities both internally and with the Office of the Attorney General. The Office of Risk Management should also assume responsibility for and streamline the process used to create and revise department regulations.

Fiscal Impact

In fiscal year 2002-03, costs incurred by the Department of Corrections for plaintiffs’ attorney fees and federal court monitors in five major class action lawsuits totaled $5.9 million. [1] Implementing the risk management system recommended here could reduce future litigation and settlement costs and lower expenditures for employee resources now spent to carry out court-imposed sanctions. [2] In addition to reducing the number of lawsuits and adverse court rulings, implementing the recommendations would improve operations and thereby reduce the number of inmate appeals. It is not anticipated that staff resources would be eliminated as a result of the panel’s recommendations.

Background

The lack of a monitoring, correcting, and accountability process that feeds into a review and revision of regulations, procedures, and training, has resulted in numerous class action lawsuits against the Department of Corrections and millions of dollars in costs for settlement expenses, court monitoring, and plaintiff’s attorney fees. The same problems with self-auditing, correcting, and staff accountability exist at the California Youth Authority. The California Youth Authority has been the subject of numerous reviews by outside experts that found significant systemic problems. [3] The Board of Corrections spearheaded an effort in 2000 to improve the institutional operations of the California Youth Authority. After a thorough review, the board’s recommendations included improving communication among superintendents, strengthening media activities, improving health care services, implementing a computerized maintenance tracking system, restructuring the ward discipline policy, assessing Americans with Disabilities Act compliance, implementing efforts to support and further the department’s rehabilitative mission, and strengthening the department’s present and future leadership. [4] The California Youth Authority is now under federal court scrutiny as a result of the class action lawsuit Farrell v. Harper, filed by the Prison Law Office. [5] A settlement agreement has been written and is currently being reviewed for approval by the California Youth Authority administration. Implementing an effective risk management system is critical to enabling the new Department of Correctional Services to resolve present litigation, reduce future litigation costs, and help ensure effective use of state dollars.

Risk management must be coordinated from the highest levels of the organization.

To establish an effective risk management program, the new Department of Correctional Services should establish an Office of Risk Management headed by a Deputy Secretary of Risk Management who will report directly to the Secretary of Correctional Services. The office will consolidate divisions, units, and existing staff from the current Department of Corrections and California Youth Authority. The new Office of Risk Management will add a necessary function to the new department by identifying practices, policies, and conditions that represent potential legal or fiscal risks. Centralizing this function allows formerly piece-meal efforts to identify risks—which have often been treated as low priority—to be scrutinized and systematically tracked and to lead to the development and implementation of statewide risk management plans.

After evaluating the department’s current practices and speaking with experts from across the country, the panel identified five critical areas on which the new Office of Risk Management should focus:

  1. Organization structure and communication
  2. Litigation support and coordination
  3. Development of an “early warning” system
  4. Assuming control over and streamline the regulation process
  5. Increasing accountability throughout the department

Organization Structure and Communication

The new Office of Risk Management will take responsibility for a department-wide risk management strategy. To effectively integrate the current structure of individual groups focused on discrete risks and processes, the Office of Risk Management will create a new organizational structure and ensure clear communication across the department’s operating units.

Executive risk management committee.

The new Office of Risk Management will use a committee approach to manage risk. At the first level will be the executive risk management committee, chaired by the Deputy Secretary of Risk Management, and comprised of other deputy secretaries within the new department. The executive risk management committee will report directly to the Secretary of Correctional Services. By virtue of its placement, this headquarters executive-level committee will have a “birds-eye” view of the department’s risks and can map strategies and policy to mitigate the risks. The primary function of the executive risk management committee will be to advise the Secretary on risk management issues and to develop an overall risk management strategy. This committee must also establish the risk management methodologies and reporting standards used throughout the organization, and empower the regional risk management committees to monitor risk in their regions and report their results to the executive committee. The committee will also oversee the internal audit function that ensures compliance with the risk management strategies. Special areas of focus could include training, personnel assignment changes or counseling, and developing and recommending regulation and procedure changes to the Secretary.

Regional risk management committees.

The second-level risk management committee will be a sub-committee to the executive level and will operate in each of the department’s eight regions – six adult regions and two youth regions. The eight regional risk management committees will be chaired by their respective regional directors and will include wardens, superintendents, regional parole managers, and the risk management coordinators from that region. This committee will make reports to the executive-level risk management committee and will develop implementation and training plans for recommendations made by the executive-level committee. Each institution should have an assigned risk management coordinator, who will report to the warden or superintendent and serve as a coordinator for risk management implementation and training at the institutional level. This coordinator will also be a permanent member of the local institution’s existing quality management committee and will identify risk management issues and facilitate communication between the institution and the regional risk management committee.

Communication is key.

The Secretary of Correctional Services will conduct regular meetings and receive risk assessment reports from the Directors of Youth and Adult Operations— whose participation on the executive risk management committee will keep them apprised of risk management matters. Similarly, the regional risk management committees must meet regularly to assess risk management issues within their respective regions and to communicate information from the executive risk management committee to the local institutions. The importance of communication was expressed by a risk management expert from the California Highway Patrol, who told the Corrections Independent Review Panel that the strategic function of executive management is to review field and staff operations and provide counseling, assistance, and guidance. Effective risk management techniques and procedures should be recognized by executive management in its meetings, and input should be provided to the Secretary of Correctional Services for consideration of new regulations and procedures, and statewide application. [6] Similar comments were made during a correctional forum organized by the panel in April 2004 that assembled correctional experts from across the country. During the forum discussions, Secretary Joseph Lehman, Secretary of the Washington State Department of Corrections, commented on the importance of presenting evidence-based policies and procedures to positively maintain working relationships with the legislature:

What changed our dialogue with the Washington State Legislature is that we approached our requests based on applied risk management principles and evidence-based practices (a direct result of applying audit recommendations and industry standards in risk management). What we can argue effectively is evidence-based practices. [7]

Successful management planning requires the participation of each employee. Administrators should ensure that members of their divisions have an opportunity to contribute to the process of proposing strategies and goals and to the development of associated action plans. Encouraging participation from employees at all levels acknowledges that every member has an important part in the development and implementation of an effective management plan. [8] It also imparts the message that risk management is the responsibility of all employees in the department. The new organizational structure for the Office of Risk Management should facilitate good communication and more effective assessment and mitigation of risk. But beyond the new structure, the department must develop a strong sense of accountability through all levels of the organization.

Accountability

The Inspector General has found that the department lacks accountability.

The Office of the Inspector General has conducted approximately 45 separate audits of Department of Corrections procedures, systems, and management practices. In each instance, the Office of the Inspector General identified systemic problems of ineffective operational procedures, lack of accountability, and the absence of an effective process for correcting known problems. One significant example is an October 2002 report of the Office of the Inspector General, titled, “Management Review of the Audit Functions of the California Department of Corrections Office of Compliance.” [9] The report states:

...that the Office of Compliance does not follow appropriate professional standards in performing its audit functions and that audit activity is inadequately coordinated with the needs of executive management and is not targeted towards issues posing the highest risk to the department. The review also revealed a fragmented internal audit organization in which ineffective planning and monitoring of audit assignments has led to a significant backlog of reports.

Accountability begins with an annual risk management plan.

Guided by the recommendations from the executive risk management committee, the Secretary of the new Department of Correctional Services should develop an annual risk management plan. The function of risk management planning, leading to accountability, is one of selecting organizational objectives and the policies, programs and procedures for achieving those objectives. An effective risk management program requires (1) identification of risks, (2) minimization of risks, (3) monitoring risk management program results, and (4) management accountability. Above all, there must be a strong commitment to the program at all levels in the department. [10]

“If you can predict it, you can prevent it.”

The primary purpose of risk management planning is to design and maintain a system that will eliminate or minimize risks and enhance organizational accountability. [11] A periodic planning and review process should be conducted in sufficient depth to properly evaluate the effectiveness of the new department’s risk management practices. A sound system of internal auditing, accounting, and administrative control provides the tools for use by management to continuously evaluate and, as necessary, improve operations. [12]

Accountability also requires periodic assessment and measurement of performance.

The Office of Risk Management must ensure command-level accountability for risk management throughout the new department. According to a former director of California Department of Corrections, staff accountability and responsibility in large and complex agencies require the practice of eight management principles: (1) leadership, (2) setting goals and objectives, (3) clear role definition, (4) administering consequences, (5) standardization, (6) walk-the-talk, (7) systems and data, and (8) provide feedback. [13] Managers at all department levels must be held accountable for employee performance and excessively risky conduct that occurs within their operations. All levels of management must be committed to controlling risk by implementing appropriate systems for preventing and controlling predictable trends that have an adverse impact to the organization. [14] Regular reviews should be conducted by the Directors of Youth and Adult Operations to ensure that risk management plans are effectively implemented. In turn, performance evaluations for these administrators should depend on how well they successfully, or unsuccessfully, implemented their plans and fulfilled the department’s risk management expectations. When exceptions are found during these evaluations – whether positive or negative – the deviation from the established norm should be evaluated and shared with the department’s Risk Management Committee. As shown in Table 1, many law enforcement agencies use a results-based performance measurement system. One popular management accountability model was implemented by the New York City Correction Department in 1994, and was later used by the Los Angeles Police Department in the late 1990s. The accountability model used by New York City Correction Department asserts that every unit within the department affects how the agency performs its mission as a whole. Managers must be agency-focused, not narrowly unit-oriented, and they must be aware of and participate together in realizing the agency’s goals and objectives. Monthly accountability meetings, involving all managers are held to discuss facility conditions, identify problem areas, and develop strategies for achieving objectives. The staff reporting during these meetings is judged solely on their knowledge of their commands and their skills at problem solving, not on their public speaking abilities or how well they recite numbers. Those unable to grasp the program are replaced. Conversely, those who embrace the concept of accountability and its results are promoted through the ranks. [15] [16] Similarly, the Operations Chief of the Los Angeles Police Department conducts a formal monthly performance evaluation of commanders from various department commands. Commanders are not admonished for having problems in their commands, but for not having action plans to resolve the problems experienced by their commands. [17] To provide a model for exceptional performance by wardens Secretary Lehman of the Washington State Department of Corrections noted:

There are five questions to ask top performing wardens to find out how effectively they deal with an issue: (1) What alternatives or options were considered? (2) What were the expected results? (3) What data was tracked? (4) What barriers were encountered? (5) What actions were taken to improve the problem? [18]

There must be consequences for poor performance.

Monthly meetings are not only a good means of evaluating staff performance, but also an opportunity to help staff understand expectations and consequences. During a meeting with several correctional experts, in Sacramento on April 27, 2004, former Director of Corrections, James H. Gomez and Secretary of Washington State Department of Corrections, Joseph Lehman, shared a perspective on the topic of accountability,

If you want people to be accountable and responsible, there must be clear consequences and that means firing them when they are no longer productive to the organization. It is also important to help them understand the ‘why’ when issuing policy. You need to make sure your people understand policy so they can be more accountable. [19]

Secretary Lehman added, “When they do not understand the ‘why’ of a policy, you will only get compliance and not commitment.” [20]

Litigation Support and Coordination

The Office of Risk Management must support and coordinate all litigation within the new department, including class action, individual inmate lawsuits, and contractrelated litigation, and must also supervise compliance with court orders. To accomplish this function, the Office of Risk Management must develop a strong relationship with the Office of the Attorney General, effectively use the department’s own attorneys, and use a team strategy when monitoring compliance or defending the department.

A strong and clear relationship with the Office of the Attorney General is critical.

An important component of any risk management program is a strong litigation function that works effectively with all stakeholders to meet litigation challenges. Lawsuits expose the departments to millions of dollars of risk. Whether or not cases are high profile, all litigation requires effective representation by litigators and their support staff. At present the departments use the legal services of the Office of the Attorney General pursuant to Government Code Section 12511, for the defense of civil litigation brought against them. Litigation services cannot be provided in-house unless there is a conflict of interest declared by the Office of the Attorney General and approved by the Department of Finance. [21] A team approach between the new department and the Office of the Attorney General will advance the efforts to reduce the number and fiscal impact of civil cases. [22] To ensure that the Office of Risk Management obtains satisfactory legal services from the Office of the Attorney General, it must identify reasonable performance measures to ensure that the legal services are being adequately provided. This is especially important if the department is to be held accountable for losses that occur in litigation arising from employee performance. An equitable way to create those performance measures is to require the Office of the Attorney General and the new Department of Correctional Services to enter into a memorandum of understanding regarding the scope and terms of the representation. [23] A memorandum of understanding would allow all parties to articulate their concerns at the outset, negotiate mutually acceptable terms and limitations, set measurable standards for service and, most importantly, provide recourse to the parties for breach of the memorandum of understanding. In addition to developing clear performance measures, the Office of Risk Management should hold regular meetings with the Office of the Attorney General to discuss case strategy and resolution, including which cases to settle. Further, at the end of each case, the Office of Risk Management should conduct a case assessment to improve its risk management policies, employee training programs, internal procedures, and litigation protocols with the staff members of the Office of the Attorney General.

Litigation response will also include teams of in-house attorneys.

These attorneys will work with the Office of the Attorney General staff to provide departmental supervision, participate in case defense and strategy, monitor conflicting counsel contracts, and develop and report on the fiscal impact of proposed and actual settlements and judgments. A team of legal processing staff will also provide assistance with discovery, processing of subpoenas, and training on litigation-related matters. By working together, these litigation response components would perform litigation trend analysis, and identify areas of risk requiring department-wide change.

Cross-functional teams are especially effective for litigation compliance.

The use of interdisciplinary—or cross-functional teams—enables the Office of Risk Management to efficiently solve department-wide problems. Headed by a risk management project manager, a cross-functional compliance management team will be responsible for initial planning and continued compliance with major litigation or other risk management issues. These compliance teams will be comprised of staff from key organizational units throughout the department. The staff on these teams report directly to risk management project managers from the Office of Risk Management for the duration of the project despite being officially assigned to other organizational units of the new department.

Developing an “Early Warning” System

A key component of an effective risk management strategy is developing a method to pinpoint risks that exceed acceptable levels. Part of this strategy is accomplished by creating a sound organizational and communication structure, but this new structure must also identify useful data and measure and monitor the data for “early warning” signals of risk. One of the first challenges for the executive and regional risk management committees will be to identify the top 10 or 20 potential risks within the department and recommend a strategic plan.

Inmate appeals should be used as an early warning indicator.

The Department of Corrections has an established inmate/parolee appeal system that is designed to ensure that every inmate/parolee has an avenue to file a complaint regarding “any departmental decision, action, condition, or policy which they can demonstrate as having an adverse effect upon their welfare”. The ability of inmates to address real concerns and issues in a timely manner is an important management tool for administrators. [24] [25] The new department must review these appeals to see if there are any trends, similarities, common errors by staff, or lack of clarity in a regulation or procedure. This analysis will determine whether there is a problem and what needs to be addressed to prevent the problem in the future. This type of analysis and corrective action is the cornerstone of an effective risk management function in the new department. Before any effective analysis of the inmate/parolee appeals can occur, however, serious deficiencies within the existing process must be remedied.

First, the inmate appeal process must be fixed.

The Office of the Inspector General conducted a formal review of the Inmate Appeals Branch, as well as reviews of specific institutions, and found that the inmate appeals system is seriously flawed. [26] In a February 2001 report, the Inspector General noted that the appeals process was deficient in quality, untimely, and inadequate in substance and accuracy. Further, in its review of the Inmate Appeals Branch and four institutions, the Office of the Inspector General identified lack of training and standardization as significant impediments to an effective appeals system. [27] Based on the known deficiencies in the department’s inmate/parolee appeal process, as articulated in various Inspector General reports, the Corrections Independent Review Panel concluded that the appeal process should be streamlined. Currently, there are too many steps in the appeal process, there is no statewide analysis of appeal statistics, and there is lack of detail in the appeals data. As an example, at the first level of review, inmate discipline is the most appealed issue within the department. However, the department does not know what specific issues or concerns are being raised by inmates and parolees about the inmate disciplinary process because the department statistics do not adequately reflect the details of the complaints. The complaints are simply categorized as “discipline.” Further study should be conducted to determine whether the problem is a training issue or a poorly written regulation. At the California Youth Authority, ward grievances are tracked in a similar manner. [28] [29] Similarly, inmates frequently appeal medical issues, yet the highest level of review does not involve a medical staff person. This lack of medical staff at the highest appeal level is a potential liability for the department. The current appeal process for the Department of Corrections consists of one informal level of review and three formal levels. The current system requires the informal, first, and second level of appeal review be conducted at the local level. Each appeal must be reviewed by the appeals office, given a category, logged into the stand-alone database, and forwarded to the appropriate supervisor or manager. The inmate is interviewed at either the first or second level of appeal review in order to ensure that the issue is thoroughly understood. The third level of review is conducted at the Director of Corrections level by the Inmate Appeals Branch.

Some appeals should be stopped after the first denial.

Some appeal issues do not warrant being carried through all levels of review. For example, if an inmate appeals not receiving half-time credit reduction while on a work assignment waiting list, the appeal response (answer) would deny the inmate’s request because under California law, half-time credit is not allowed unless the inmate actually has a work assignment. In this situation, the initial answer should end the process because the appeal response will not change at a higher level. Yet, under the current system the inmate is allowed to continue to appeal the decision all the way to the department director level. This is a waste of staff time and resources. The Office of Risk Management should consider revising the regulations to streamline the appeals process. This should include limiting the type of appeals that can be appealed to the highest levels of the department.

Better analysis of appeal statistics is needed.

Each institution and regional parole office maintains an inmate appeal tracking system, but these stand-alone databases are not linked to the current Inmate Appeals Branch appeal tracking database, which is responsible for the third level of appeal review. Moreover, the lack of a centralized, system-wide database makes it impossible to complete any thoughtful analysis of appeals to identify any potential risk management issues or trends. Instead, only basic raw data is compiled. As shown in Tables 2 and 3, the Department of Corrections tracks the number of appeals completed and granted at the first, second, and third levels of appeal. [30] Also, it categorizes appeals into 18 broad categories, which is useful for identifying the prevalence of appeals by category, such as property, medical, or discipline. Yet, because it only has raw data, the department can not “drill down” into the data and understand the possible causes of appeals and, in turn, determine where improvements in regulations, procedures, or training could be addressed as a risk management function. The current appeal data system must be enhanced into a state-wide database that serves the risk management needs both at an institutional and statewide level.

Best practices and “lessons learned” can be found in many places.

As noted above, the appeals process has no system in place to capture lessons learned from completed and granted appeals at the three levels of appeal review. The Office of Risk Management must develop systems and processes that will identify problems and best practices throughout the Department of Correctional Services. Litigation and court filings are another area where careful analysis might reveal lessons learned. However, currently the Department of Corrections and the California Youth Authority both lack a coordinated system that would make it possible to review court filings in order to resolve litigation early on and to revise regulations, procedures, or training to eliminate or reduce the potential for another case on the same issue. Also, because there is no system to pass lessons learned from litigation to the field, there is no proactive action or motivation to take steps to reduce future loss. [31] To solve this gap in communication, the executive risk management committee should recommend to the Secretary a system for disseminating the information of lessons learned from litigation and critical incidents at the institutions and facilities. A similar point was made during two separate interviews conducted by the panel with Donald Specter, Director of the Prison Law Office, [32] and the Chief Counsels of the California Youth Authority, the Department of Corrections, the Board of Prison Terms, and the Prison Industry Authority, [33] who expressed a need for the department to document and communicate the lessons learned from civil cases against the departments resolved via trial, judgment, or settlement. The preparation of assessment reports on civil cases that have been resolved should include detailed procedures for reducing the reoccurrence and costs of similar lawsuits. Information from resolved cases should be incorporated into employee training programs and used to improve department policies and procedures on an ongoing basis. Lastly, a comprehensive risk management system includes the ability to identify patterns of at-risk performance by individual employees and groups of employees that, when analyzed, would be an early warning for management. Managers can make informed decisions about employees or monitor at-risk employees with an automated computer system that systematically identifies critical risk factors such as patterns of use of force, critical incidents, overtime, sick leave, employee injuries, total personnel strength, appeals, grievances, active/new court filings, and other factors relevant to risk management as determined appropriate by the Secretary. [34]

Streamlining Policy Practices

At present, the Department of Corrections and the California Youth Authority use an unnecessarily cumbersome and time-consuming internal process to create and revise regulations and procedures that govern their respective operations. The process is made even more complex by a requirement that once regulations and procedures are approved internally they must be further approved by another government agency, the Office of Administrative Law. The panel recommends that this slow and archaic process be streamlined by having the Civilian Corrections Commission approve department regulations and procedures.

The current process of changing internal regulations and procedures is too cumbersome.

The current Department of Corrections internal process requires that any policy or regulation change be first described in a policy concept statement, which is then routed through the chain of command for review and approval by each one of the department’s deputy directors and the department director. If the policy concept is approved, the next step requires that draft language be developed with input from both internal and external stakeholders. The draft language is then circulated to all deputy directors for review and approval. If the various deputy directors have suggested changes, the new language must once again be routed to all other deputy directors for review and approval. Once all deputy directors have approved the draft language, it is presented to the director of the Department of Corrections for final approval. The California Youth Authority has a similar process, but after internal review of existing regulations and policies, it “works around” the formal process by publishing new or revised policies in the form of manuals so as to implement operational changes before revising the affected regulation. A Department of Corrections project to revise inmate property regulations and procedures clearly illustrates the cumbersome and time-consuming nature of the existing policy revision process. This project has been “in process” for more than fifteen years. To further illustrate the impact of this convoluted policy approval process, in fiscal year 2000-01, 10,291 appeals were filed regarding inmate property. The staff time required in each case to interview the inmate, investigate the allegation, and respond to the appeal would have been reduced if the department had implemented a new inmate property regulation and procedure years ago, instead of being restricted by the current practices and regulations.

Regulations must also be approved by the Office of Administrative Law.

Under the Administrative Procedures Act (Government Code, Sections 11340 through 11359) the Office of Administrative Law must approve the department’s regulations. This requirement adds further delay and complexity when policies or regulations need changing. The Office of Administrative Law has summarized its requirements in a 25-page document titled “How to Participate in the Rulemaking Process.” First, an initial statement of reasons for the proposed change must be prepared along with the data relied upon to support the proposed change, alternatives considered, and impact on jobs within the state. [35] The department must then publish the proposed changes, send a copy to any person who has requested one, hold public hearings on the proposed changes, and post the proposed changes on its website. [36] The department must then “consider all relevant matter presented to it before adopting, amending, or repealing any regulation” and the department must respond to any written comment received in the final statement of reasons. [37] Not all agencies, however, are required to follow the Administrative Procedures Act. According to the Government Code, Section 11340.9, certain functions of the Franchise Tax Board and the State Board of Equalization are exempt from the Act.

The new Civilian Corrections Commission could approve new or revised regulations.

Effective management of the new Department of Correctional Services will require new regulations and revisions to old regulations. The new department can accomplish this more quickly and still provide public input by using the Civilian Corrections Commission to approve regulations. As discussed in more detail in Chapter 1 of this report, A Reorganization Plan for Corrections, the Commission will hold periodic public meetings at which appropriate consideration and public comments will be accepted regarding any proposed changes to the internal management of the Department of Correctional Services. This new process will allow the department to revise regulations in a timely manner in adherence to the evolving standards of conditions of confinement and relevant court orders. (See the appendix to this report for proposed statutory changes in this regard.)

Recommendations

The Corrections Independent Review Panel recommends the following actions be taken:

  1. Establish an Office of Risk Management in the new Department of Correctional Services
  2. Establish a position for the Deputy Secretary of this office.
  3. Establish an executive-level Risk Management Committee.
  4. Establish a Risk Management sub-committee in each region.
  5. Establish a Risk Management Coordinator position at each institution.
  6. The Secretary of the Department of Correctional Services should develop an annual risk management plan that will provide specific risk management objectives for the department during the next year.
  7. The Office of Risk Management should approve the type of standardized risk management statistical data collection that is compiled and evaluated monthly by the Regional Directors.
  8. The executive level Risk Management Committee should meet regularly to evaluate risk factors of employee performance and institutional operations.
  9. The executive level Risk Management Committee should recommend to the Secretary a system for disseminating “lessons learned” that could play a significant role in the department’s risk management efforts.
  10. The Secretary of Correctional Services should receive quarterly risk assessment reports from the Directors of Youth and Adult Operations to assist with planning and strategy development to prevent adverse fiscal impact to the department.
  11. The Directors of Youth and Adult Operations should convene monthly meetings with their respective Regional Directors to discuss performance issues and risk prevention measures.
  12. The Regional Directors should review the monthly operational performance of their respective subordinate administrators based on department risk management statistical data and provide direction and guidance to subordinate managers.
  13. Youth superintendents, regional parole managers, and prison wardens should conduct monthly meetings with their respective staffs to discuss performance issues and risk prevention strategies.
  14. The new department should establish an operational memorandum of understanding with the Office of the Attorney General.
  15. The Deputy Secretary of Risk Management and the Chief Assistant of the Attorney General’s Office should meet monthly to discuss the status of litigation cases.
  16. The new department should revise the California Code of Regulations to identify specific types or issues of appeals that can and cannot be filed at the next level after an appeal is denied.
The Office of Risk Management should do the following:
  1. Develop clear and concise regulations that require wardens, parole administrators and executive staff to be interactive in the appeals/grievance process as a risk management function.
  2. Develop a training program that provides guidance to Inmate Appeals Branch examiners and Institution/Regional Parole Appeals Coordinator in how to appropriately and accurately respond to inmate and ward appeals.
  3. Revise regulations and policy to mandate that inmate/parole appeals related to medical/dental/mental health care and treatment be responded to by licensed medical staff at each level of appeal review.
  4. Develop a networked system-wide appeals database via improved information technology.
  5. Propose legislative changes to the California Government Code to eliminate the applicability of the Administrative Procedures Act to the new Department of Correctional Services.
  6. Revise the California Department of Corrections Operations Manual, Section 12010 to streamline the internal regulation and procedure revision process.

Improving Health Care Services

The administration of health care for state prison inmates has been criticized in recent years for providing inadequate health care, not complying with and resolving ongoing federal litigation, and not managing its budget. As a result, instead of improving and optimizing its health care system on its own, the Department of Corrections has been forced to act via multiple federal court orders. [38] Meanwhile, the department’s annual health care budget has rapidly escalated to $1 billion in the past five years. Effective plans to address or control the federal court’s concerns about quality and accessible care and the rising costs remain elusive. In the words of one critic, “there is no evidence that a health care system exists.” [39] Similar concerns have been expressed about the health care services provided to wards at the California Youth Authority. [40] [41] Litigation against the California Youth Authority, Farrell v. Harper, also concerns health care services. A settlement in that case is pending and is expected to include extensive requirements for the reform of health care and other services in California Youth Authority institutions. The Corrections Independent Review Panel recommends that the new Department of Correctional Services create an Office of Health Care Administration that will oversee an orderly transition from the current health care system to one that is largely operated by contracted health care providers. Because this transition would take place in phases over several years, the panel recommends that the new Department of Correctional Services initiate discussions with the University of California for the development of a pilot project to improve correctional health care delivery and determine the potential for a single source health care provider. In addition, the new Office of Health Care Administration should initiate interim contracts with other private health care providers. Lastly, the panel recommends that the new department obtain accreditation for its health care programs, take steps to resolve a chronic nursing shortage, improve pharmacy services, and delegate responsibility for seriously mentally ill inmates and wards to the Department of Mental Health.

Fiscal Impact

Following implementation of the panel’s recommendations, the budget from the Health Care Services Division would be combined with the Youth Authority’s health care budget to form the total health care budget for the new Department of Correctional Services. This combined budget must remain in place to support the panel’s transitional and long-term recommendations and allow the recommendations to be fully implemented. As efficiencies generate cost savings, the savings should be invested in information technology infrastructure, electronic medical records, telemedicine capabilities, contracts with community providers and personnel training and education.

Background

The provision of health care in the Department of Corrections by its current method has resulted in cost increases from $566 million in fiscal year 1999-00 to $879 million in fiscal year 2002-03. [42] The per inmate per year cost for health care provision has escalated from $3,521 [43] [44] in fiscal year 1999-00 to $5,461 per year or $14.96 per day in fiscal year 2002-03. [45]

Health care services are provided to inmates and wards by a variety of staff.

Doctors, nurses, psychiatric technicians, psychiatrists, social workers, psychologists, dentists, dental assistants, laboratory technicians, radiological technicians, and medical technical assistants are the primary providers of health care. Inmate medical care that cannot be provided in one of the four prison hospitals or sixteen correctional treatment centers (step-down facilities) is provided by local community hospitals, usually under a negotiated contract rate. Specialty medical services such as dermatology and orthopedics, when not available within the department are also contracted with local providers. As oversight to this, the current Department of Corrections Health Care Services Division provides direction on policy and clinical operations to each prison. The Health Care Services Division is also responsible for contract management, utilization of services, and all clinical aspects of litigation compliance. A similar system exists in the California Youth Authority. The Youth Authority is gradually evolving towards a health care service delivery system comprised of correctional treatment centers, intermediate care facilities, intensive treatment programs, specialized behavior treatment programs, specialized counseling programs, sex offender programs and outpatient housing units.

Class action lawsuits.

The Department of Corrections is currently involved in multiple class-action lawsuits, the two most prominent of which are Coleman v. Wilson and Plata v. Davis. The Coleman case went to trial and the federal court ruled that the department was “deliberately indifferent” to the mental health needs of seriously mentally ill inmates. The department in this case has been under federal court monitoring by a special master since 1995. The Plata class action case alleged constitutional violations in the provision of medical care to all inmates. This case was resolved with a settlement agreement that requires the department to establish and implement system-wide standards of medical care on an eight-year implementation schedule that began in 2003. Reaching compliance with the results of these primary cases promises to be a long and costly effort.

Costs for contracted health care and pharmacy services are out of control.

The Health Care Services Division is responsible for medical contracts with community hospitals and pro- viders for health care that is not provided by the department. An April 2004 Bureau of State Audits report stated that the department does not negotiate for the best rates, that staff is untrained in contract negotiation, and that medical contract costs are rising. [46] Similarly, pharmacy costs have been rising. In July 2003, the Office of Inspector General conducted a survey of the pharmaceutical expenditures of the department. The survey revealed that despite a two percent decrease in the inmate population between fiscal years 1999-00 and 2002-03, the department’s pharmaceutical expenditures increased 111 percent, from $63 million in 1999-00 to $133 million in 2002-03. During the same period, the national consumer price index for pharmaceutical drugs increased only 22 percent. California’s prison population is comparable in size to those of the Federal Bureau of Prisons and the Texas state prison system, yet costs have increased at a much faster rate. [47] In Texas, pharmacy costs were approximately $39.9 million in 2001 and decreased in 2002 to approximately $36.2 million. [48]

The Office of Health Care Administration

The Corrections Independent Review Panel recommends that the new Department of Correctional Services create an Office of Health Care Administration to replace the extensive organization currently in place in the Department of Corrections. This new office will include a headquarters office, comprised of several senior project or program managers experienced in health care, to manage a series of individual provider contracts. The panel recommends a similar management structure in each of the eight regions (six adult and two youth) to provide local health care contract management. These regional managers would participate in the development of a statewide contract management plan with the headquarters staff and would receive contract management training prior to assuming duties in their assigned regions. The Office of Health Care Administration would become primarily a policy and management oversight organization under the direction of an experienced health care administrator and would rely on other parts of the new department, such as fiscal and risk management, for support. In addition to administering and managing the individual provider contracts, the Office of Health Care Administration will develop major policies concerning the primary programs of medical, mental health, public health, dental, and quality management. Also, it will oversee the implementation of these policies by the specific program and contract managers in each of the eight regional offices of the new department. Each local manager would be assigned responsibility for one of these primary programs in their region. The administration of policy in the primary programs may be carried out through a committee structure in the central office and in the regional offices. The new Office of Health Care Administration will eventually replace the existing Health Care Services Division. Many of the Health Care Services Division’s current functions will be shifted to other units of the new department and to the various contracted service providers. (See Table 4)

Experienced, qualified managers will likely require higher salaries.

One problem the new office will face is obtaining managers with the necessary skills and experience to effectively administer service provider contracts. A survey of salaries will be necessary to determine the level of pay necessary to acquire the managers needed to operate the new system of health care. These managers will work at all levels: central office, regional offices, and local institutions. If the recommendations made by the panel are to be successful, the new department must attract project managers who are well-versed in health care issues, contract negotiation, and managing contractors across a state as large as California. In addition to being challenged to obtain experienced and qualified managers, the new Department of Correctional Services must also address employee recruitment and retention problems within its existing health care system. Even though the panel’s recommendations may eventually lead to private or university-managed health care services, it may be several years before the recommendations are fully implemented. Meanwhile, there are many types of health care practitioners that the department has difficulty retaining. These include nurses, physicians, psychiatrists, psychologists, and pharmacists. It is currently so difficult for the department to recruit and retain individuals from many of these professions that it frequently uses registries – a form of “temporary” employment agency for health professionals – to fill vacant positions. This is a costly solution for two reasons. First, because the registries charge “market” rates plus an overhead fee for these practitioners, the hourly rate is much higher than what the department currently pays its employees. Second, registry staff is unfamiliar with the department’s practices and procedures, may prescribe more costly treatment and therefore require greater supervision. To remedy this problem, the new department should also conduct a survey of salaries for these professions and seek appropriate salary adjustments where justified.

Establish a correctional health care advisory group.

This group will provide consultation on policy and direction to the Office of Health Care Administration for the development of an integrated system of health care. The state of Florida has instituted a group of advisors that provide independent oversight and review of all health care operations. [49] The new department should endeavor to establish a similar advisory group. This group will provide objective data and opinion on correctional health care, educating both internal and external staff regarding the trends in the correctional health care specialty. This group will make recommendations to the Secretary of Correctional Services for all aspects of health care in the new department. In addition, the inclusion within this advisory group of the primary clinical directors of the health services and mental health departments can serve to assist in addressing public health needs and mental health treatment. To fully implement the panel’s recommendations, the Office of Health Care Administration will need to use a phased approach – a series of simultaneous activities designed to complete the overall management structure for the new system of health care. These tasks together form a three-phase plan where each phase is in transition until all health care is provided by a single-source contractor. The first phase involves creating the new organizational structure for the Office of Health Care Administration. The second phase transitions the current health care provision by state employees into one in which certain health care services are contracted with several different providers. During this transitional period, certain improvements will be necessary because they cannot wait until the final phase is fully implemented. This includes obtaining accreditation for the medical facilities, reducing pharmacy costs, improving mental health services, and recruiting more nurses. In the third phase, the panel recommends that the new Department of Correctional Services develop a relationship with the University of California to address various options, including management or provision of health services within current department institutions. This entire three-phase implementation will be overseen by the central office staff and the local program managers within the Office of Health Care Administration and will be managed simultaneously. (Note: program managers must be experienced managers who may be but are not expected to be clinicians.)

An Interagency Agreement with the University of California

The panel looked at the best practices from other state correctional departments as possible solutions. A few states have contracted with their state universities to provide all health care for their correctional departments. Other states have contracts with private companies to provide management only or management and staffing for inmate health care. Still others have a combination of both contracts with private companies and a contract with state universities. As recommended earlier, the Department of Correctional Services must develop both an immediate plan and a long-term plan to streamline and improve the delivery of health care. The panel recommends developing an interagency agreement with the University of California that would include addressing the goal of producing the long-term solution.

Explore an interagency agreement with the University of California.

The panel discussed with University of California officials the concept of developing an interagency agreement for certain aspects of health care services throughout the prisons and youth institutions. [50] The initial task for the new Department of Correctional Services is to enter into discussions with the university about the university’s ability to provide advice and consultation on approaches to improve the efficiency and efficacy of health care. University officials expressed willingness to meet with the new department to discuss potential levels of university participation. These levels of participation may include one or more of the following:

  1. On-going advice and consultation by university faculty experts.
  2. Membership of university officials on committees or panels pertaining to correctional health care services and policies.
  3. Contracting with university campuses to provide specialty services (such as telemedicine).
  4. University faculty or staff providing a range of health care services at the institutions of the new Department of Correctional Services.
  5. Establishment of a pilot project to provide health services involving one or more institutions with potential expansion of the pilot project in future years.

Other states are using contracts with universities and private providers.

For example, the Texas Department of Criminal Justice improved access to care, improved chronic care compliance, and saved dollars by contracting with the University of Texas Medical Branch. [51] In 1993, the 73rd Texas Legislature established a committee called the Correctional Managed Health Care Committee to develop a managed health care plan for the entire Texas Department of Criminal Justice system. The committee developed and implemented plans leading to the university system assuming responsibility for all health care for inmates. The Texas State Comptroller has estimated that this program has produced an overall cost savings of $125 million in the first five years despite the fact that the prison population has doubled during that same period. [52] In addition to Texas, the Ohio Department of Corrections reports decreased costs and increased quality through its contractual agreement with Ohio State University. Before contracting with the university, corrections contracted with local hospitals and had little success negotiating best rates. Now Ohio gets Medicaid rates for inpatient hospitalizations and Medicare rates for specialty services from the university. [53] This has led to major cost savings for the department. In total, thirty-eight state corrections departments have employed some form of privatization of healthcare. [54] In addition to Texas and Ohio, Arizona, Iowa, Massachusetts, and Connecticut have formed contracts with university providers to provide much or all of the inmate health care services. Other states may have a partial contract with a university hospital or a private vendor. A contract with university systems and/or private contractors allows the correctional staff to focus on what they know best, custody operations, and allows health care experts to provide health care.

Support for university-provided health care to inmates and wards.

There is support in the community and the literature for university-provided health care to inmates and wards. In 2001 the California Policy Research Center sponsored a research by University of California, Santa Cruz, Professor Nancy Stoller, to look at access to care issues for women prisoners in California. Dr. Stoller found that the primary problems in the four women’s prisons centered on access to care, inadequate management, dependence on medical technical assistants who have a dual and sometimes conflicting role of custody and medical care, and lack of accreditation for the health care programs. [55] The report of that research recommends that clinical services be provided by an independent, non-profit agency, such as the Department of Health Services or the University of California. Dr. Stoller concluded that the advantages of using a university are improved access to care, prestige for the services provided, increased inmate confidence in health care providers, in-depth experience, opportunities to teach interns and residents from the medical school about inmate care, medical ethics and increased opportunity for current on-going education for staff, [56] [57] but notes there are some potential problems that statewide provision of services would present for the University of California. [58] Donald Specter, Director of the Prison Law Office in San Francisco, who has brought several health care-related cases against the department, also suggests the idea of contracting health care services from the University of California. [59]

Key logistical issues require further study.

An accurate assessment of the costs of operation for the institutions in a potential University of California “pilot region” is essential in order to establish a cost base for the agreement, along with a clear delineation of the scope of services to be provided. In order to facilitate an interagency agreement, a specific description of needed expertise, consultation, or any other potential assistance should be established by a special task force of health care, custody, financial and other managers (potentially including university managers). This would serve as a basis to discuss a pilot project that would be of benefit to both parties.

Upon full implementation, the Office of Health Care Administration’s functions change.

The evolving relationship between the department and the contracted health care is expected to require eventually only policy, liaison, and oversight functions to be carried out by the Office of Health Care Administration. In summary, the restructuring of correctional health care results in a relatively small central office headed by an experienced health care administrator, supported by a group of program managers providing policy, oversight, and contract management of a full range of private provider health care services. The system of care that is to be developed would be in transition for a period of up to five years, in which time the pilot project of the University of California could expand. Litigation management is retained within the department pending the dismissal of the lawsuits during this period. During this transition period, there are several improvements – discussed in the next section – to the health care system that the Office of Health Care Administration must address. These cannot wait until the university pilot project is fully implemented.

Interim Contracts and Other Improvements

While the new Office of Health Care Administration pursues the panel’s primary recommendation for a university-managed health care system, it must simultaneously develop contracts for health care services elsewhere in the state. In addition, the department’s health care system will continue to need improvements in mental health services, pharmacy services, accreditation of treatment facilities, and nursing recruitment.

Contracted health care services.

Simultaneous with a pilot project developed in conjunction with the university, the new office of Health Care Administration must also develop contract management and direct provision of health care services for regions of institutions that are not included in the initial pilot project. The office should develop these contracts with active consultation with university representatives, who could assist in selecting providers and scopes of service as a means of preparing a foundation for expansion of the university pilot program into other regions. Necessary contracts should be developed as independent, related functions and would include: mental health services, medical primary care, medical specialty care, community in-patient care, pharmacy (procurement, inventory management, prescriptions and dispensing management), dental care, utilization management, invoice review and approval, ancillary services, clinical registries and a re-emphasis of the responsibility of the Department of Mental Health for mental health services for adult inmates and wards. The use of contracted health care providers is intended to address deficiencies in health care services identified by the courts in the Coleman and Plata cases rather than asserting that specific cost savings may be obtained through this method. However, it is clear from these two cases that the management of health care and the qualifications of many of the clinicians providing it need improvement. Experts in both of these cases have expressed major concern and frustration over the inability of the current medical and psychiatric staff to comply successfully with the established policies and the court’s orders. [60] Under proper, qualified management, use of private providers of discrete sets of services has the potential to improve this situation. Moreover, the use of contracted providers is recommended as a transitional strategy pending the development and outcomes of the initial pilot project.

Mental health services.

In part because of litigation, the need for mental health services has rapidly increased within the Department of Corrections over the past few years. Mental Health Services are provided to approximately 17 percent of the current inmate population. Despite the Coleman litigation, which required the department to meet its constitutional obligation and seven years of monitoring by a court-appointed special master, the department has not been able to resolve this case. As a result of the Coleman litigation, the department established a decentralized system of mental health care. Similar mental health service problems exist within the California Youth Authority, which has been described as having a patchwork of specialized mental health programs unique to their respective institutions with differences in staffing, operating procedures, and physical resources. [61] A December of 2003 report of findings of mental health treatment services in youth facilities, conducted by two subject matter experts, was highly critical of the department’s programs and services. The report found that:

Mental health care provided by the CYA is not adequate and does not conform to community standards or to the professional standards identified….and that….the vast majority of youths who have mental health needs are made worse instead of improved by the CYA correctional environment. [62]

One possible solution to the gap in mental health services is to clarify the role of the Department of Mental Health, which is mandated by law to provide for the needs of the mentally ill population within California. For the prison population, the Department of Corrections is required to negotiate agreements with the Department of Mental Health to provide mental health services for inmates on a limited and contractual basis. The Department of Mental Health acts as a “gate keeper” and determines which inmates it accepts into Department of Mental Health facilities based on various inmate characteristics and behaviors. Additionally, the Department of Mental Health has the authority to return any inmate it believes is a danger to its staff. Because the Department of Mental Health is the unquestioned state expert in providing care for seriously mentally ill patients, the panel recommends that it not be allowed the option of rejecting inmates referred by the new Department of Correctional Services. Instead, the Department of Mental Health should be designated by statute to provide mental health services for state prison inmates at the “enhanced outpatient” and “inpatient” levels of care. (Enhanced outpatient care refers to inmates who require a structured housing unit and weekly clinical staff contact in order to function within the prison setting. Inpatient care refers to those inmates who are a danger to themselves or others because of a mental illness and need inpatient care with 24-hour nursing support.) The budget of the Department of Correctional Services can be adjusted to delegate funds to the Department of Mental health for this care.

Pharmacy services.

Although the panel recommends that the department negotiate an agreement with the University of California under which the university would eventually provide or oversee the provision of pharmacy services, there are several improvements that the new department should initiate immediately. The department should change the pharmacy program structure from a decentralized system with pharmacies in each institution to a system with two or three regional pharmacies or one large central pharmacy, consistent with the model used in other states. [63] During the period that it takes for the transition plan, the new department will need to contract with a professional pharmacy benefits manager to provide consistent pharmacy management services throughout the state. According to a report by Fox Systems Inc., a consulting firm retained by the Department of Corrections in 2001, that change would provide the following benefits:

  • Allow more efficient operations and possibly the use of automated dispensing machines.
  • Increase buying power of pharmaceuticals to negotiate for best price.
  • Increase standardization of operations and prescribing practices.
  • Reduce the impact of staff turnover and vacancies in rural areas where pharmacist recruitment is difficult.
  • Reduce prescription errors. [64]

In addition to a centralized pharmacy, the new department must develop new pharmacy software to streamline the procurement and dispensing process. Currently, each institution maintains its own independent pharmacy database using the Pharmacy Prescription Tracking System, a badly outdated 20-year old information system that lacks the capability to perform functions needed to control costs, prevent drug waste, fraud and abuse and is not linked with other institution pharmacies. [65]

Better coordination in transporting inmates who require medical services.

The department incurs significant overtime costs to transport inmates to medical services. In addition, delays in accessing medical services are attributable to transportation problems. A general inability to make these transfers on a timely basis is one of the major ongoing concerns of the Coleman special master. To mitigate these problems, the department should develop a training process for non-clinical institution staff that educates them about the requirements for access to care within the institutions and the custody administration’s responsibilities for this function. A “health care transport team” would assure prompt and efficient transportation of inmates and wards to necessary health care appointments or admissions outside of the institutions. This team would be responsible for health care transports only.

Statutory changes required.

Changes in state law are needed to support the application of the recommended contracting process. Current California law has specific guidelines for civil service employees and contract employees. In order to provide authority for the contracts that are required in this recommendation, contract language needs to conform with the exceptions to the civil service requirements for use of state employees. One or more of these exceptions can be utilized in the transitional organization, especially the one permitting temporary pilot projects: all private provider contracts need to be so characterized, or the exception for costs savings. Additional authority should not be needed for contracting with the university. (See the appendix to this report for recommended statutory changes.)

Nursing recruitment and retention.

Similar to the proposed improvements to the pharmacy services, certain nursing problems need correcting. The nursing shortage in California and the nation are reaching all-time highs. [66] This has severely affected the Department of Corrections. Currently the department has 244 vacant registered nurse positions, which is a 22 percent vacancy rate statewide. Some institutions with a large medical mission have up to a 50 percent vacancy rate. [67] One idea is to link graduating nursing students with a correctional nursing clinical experience. This would move the eligible candidates closer to the actual vacancies and increase the success of filling vacant positions. Another method the department could use to reduce its nursing shortage would be to develop a nursing student sponsorship “20/20” program, similar to one that has been successfully used in the Department of Mental Health. (In that program, the Napa State Hospital and Napa Community College have a cooperative agreement.) In the 20/20 program, nursing students are hired into a full-time job and would work 20 hours for the new Department of Correctional Services while attending college in an accredited nursing program. The students would be required to sign an agreement to work full-time for the department following completion of the nursing program for the same period of time that they were sponsored. This becomes a training/internship program for future civil service nurses, creating a nursing “pipeline.” One possible source for the nursing students in a 20/20 program would be medical technical assistants or psychiatric technicians currently working for the Department of Corrections or the California Youth Authority who apply for and are accepted into an accredited registered nursing program. Nursing students who do not currently work for the department could also apply for sponsorship. Positions for these sponsorship nurses could come from existing registered nurse vacancies. The 20/20 sponsorship program would assist the department in meeting the nursing shortages by providing a means of achieving career goals of qualified employees and supplying a future pool of nurses.

Registry services.

The various nursing registries with which the Department of Corrections presently contracts are not meeting all of the department’s needs. In fiscal year 2000-01 the department spent approximately $6.1 million for approximately 48,600 nursing hours needed to fill staff vacancies. Registry nurses may work one day for the department or several months filling in for staff vacancies, medical leave, and sick days. The state currently contracts with several different registries. The registries charge differing rates and may have different levels of expectations for the nurses they hire, resulting in inconsistent services to the department. To resolve this problem, the Office of Health Care Administration should develop a regionalized approach to registry services. One possibility for help in developing a nursing registry would be to partner with the Foundation for California Community Colleges, a non-profit corporation that is an official auxiliary organization of the Board of Governors of the Community Colleges. The foundation provides management services that bring together cost-effective solutions for government agencies and ongoing benefit for the community college system.

Accreditation for health care programs.

As has been discussed elsewhere in this report, the Department of Corrections is involved in a class action lawsuit, Coleman v. Wilson. In that case, the court concluded that there were system-wide deficiencies that demonstrated the prison’s “deliberate indifference” to inmate mental health needs. The court concluded its findings by ordering the Department of Corrections to implement various forms, policies, standards, consulting experts, procedures and regulations to improve the situation. [68] In order to prevent the implication of deliberate indifference, a department must know what the problems in the department are and take action to correct them. To accomplish this, many correctional departments across the United States seek outside recommendations as an additional means of monitoring their health care programs, keeping up to date on best practices, and getting an independent look at their health care operations. This type of scrutiny is provided by seeking accreditation for each institution. Accredited institutions have a stronger defense against litigation because seeking accreditation indicates an interest in problem identification and improving the practices of the health care program. Accreditation also assists an institution in identifying processes that are working well. It also improves staff morale, as staff feel a sense of professionalism when their institution is given accreditation and deemed “among the best” in the nation. [69] Accreditation also gives the institution a set of industry standards from which to coordinate internal processes and policies. Finally, accreditation would link California with many other states to identify and share best practices. Accreditation also makes good sense from a risk management perspective. Accreditation standards have helped the nation’s correctional facilities improve the health of their inmates, provide efficient, effective care, improve program effectiveness, and reduce the risk of litigation and inmate complaints. There are several options available for seeking accreditation. The California Medical Association has been providing accreditation to detention facilities since 1979. The program is operated through the association’s Institute for Medical Quality branch. [70] The National Commission on Correctional Health Care and the American Correctional Association has published national standards for accreditation of institutions. Both are respected entities, experienced in corrections. The commission focuses solely on health care in prisons and has developed extensive experience with prison health care programs. [71] The new Department of Correctional Services should seek accreditation after the implementation of the new contracted medical services.

Recommendations

The new Department of Correctional Services should take the following actions:

  • Establish an Office of Health Care Administration.
  • The objective of the new Office of Health Care Administration should be to establish a new system of health care based on managed care practices.
  • Establish a top level health care administrator to manage the Office of Health Care Administration, and support this position with experienced program managers, resulting in a new, streamlined central office function.
  • Establish program managers at the regional level to manage local health care service delivery.
  • Conduct a salary survey to demonstrate the salary levels required in order to obtain the experienced managers needed to manage this complex process.
  • Utilize the Litigation Management section of the Risk Management Unit of the new department to provide monitoring and implementation of court-ordered requirements.
  • Establish an agreement with the University of California for the development and operation of a pilot project at a defined group of institutions. This project needs to be managed strategically with the goal of expanding it to the entire health care system of the new department.
  • Provide a transitional organization that will establish contracted health care services at the regional and local level in areas where the university pilot project is not yet operational.
  • Establish a management group with members from the new department with university involvement to plan and implement the transition from current operations to the new planned health care provision.
The new Office of Health Care Administration should take the following actions:
  • Utilize private health care providers for management and provision of all health care direct services by clinical specialty: one contractor to provide for mental health services, medical primary care, medical specialty care, community hospital in-patient care, pharmacy, dental services, utilization management, invoice control, laboratory and x-ray, and necessary clinical staff registries.
  • Purchase and implement a statewide pharmacy database system.
  • Transfer responsibility to the Department of Mental Health for mental health care of seriously mentally ill inmates and wards.
  • Ensure that the private health care provider contracts are managed specifically by designated, experienced program managers in the regions, overseen by program managers in the new central office.
  • Provide specialized training for custody administration on their responsibilities for assuring inmate and ward access to health care within the institutions. This is an especially critical component when contracted entities will provide direct services.
  • Establish dedicated “health care transportation teams” to transport inmates and wards who require higher levels of care provided outside of the institutions.
  • Establish a Correctional Health Care Policy Advisory Committee that includes representation from the University of California, the health care community, and state health officials.
  • Develop a relationship with the Foundation for California Community Colleges and community college registered nursing programs to facilitate recruitment of nurses into the new Department of Correctional Services.
  • Develop an interagency agreement with the Foundation for California Community Colleges to provide services for developing and operating a sponsorship program or “20/20” program at several institutions to sponsor nursing students in these community colleges.
  • Utilize the institutions as clinical sites for local community college nursing programs.
  • Contract with the Foundation for California Community Colleges to develop a regional registry of nursing services through a Foundation for California Community Colleges “cooperative purchase contract” with a qualified vendor(s).
  • Require health care programs at each institution to achieve and maintain accreditation by a nationally recognized correctional entity.

Appendix

TABLE 1
Accountability Models Used by Various Organizations

*Source: Correctional Forum Panelists (John Vanyur, Federal Bureau of Prisons, Gary Johnson, Texas, Joseph Lehman, Washington State), April 27, 2004.
**LAPD’s Computer Statistics (COMSTAT) was inspired by New York City Department of Correction’s Total Efficiency Accountability Management System (TEAMS).
***Interview with Assistant Chief Ed Fincel, California Highway Patrol, May 5, 2004.

TABLE 2
Summary of appeals completed and granted by fiscal year
for each level of appeal review

TABLE 3
Summary of top three categories of appeals and the percentage
it represents of the total number of appeals completed
at each level of appeal review by fiscal year

TABLE 4
Current Health Care Services Division functions that will move
to the new Department of Correctional Services

Endnotes

[1] The five major class action lawsuits are: Coleman v. Wilson; Plata v. Davis; Madrid v. Wilson; Armstrong v. Wilson; and Clark v. Davis.
[2] The Department of Corrections Legal Affairs Division estimates total payments of approximately $5,952,000 in fiscal year 2002-03 for plaintiffs’ attorney’s fees and special master fees alone in the Armstrong, Clark, Coleman, Madrid, and Plata cases. That amount does not include the millions of dollars that must be set aside to implement court mandates resulting from the class action lawsuits.
[3] Jerry Thomas Consulting, “Evaluation of sex offender programs,” September 2003, p. 2; Michael Puisis and M. LaMarre, “Review of Health Care Services in the CYA,” August 2003, p. 6.
[4] Board of Corrections, “Institutions Operations Quality Assurance Project”, California Youth Authority, October 2000.
[5] Farrell v. Harper, Superior Court for the State of California, County of Alameda.
[6] Interview with Assistant Chief Ed Fincel, California Highway Patrol, Risk Management Expert, May 5, 2004.
[7] Remarks by Joseph Lehman, Secretary of the Washington State Department of Corrections, Correctional Forum panel discussion, April 27, 2004.
[8] California Highway Patrol “Command Management Planning Manual,” page 1-2.
[9] Office of the Inspector General, “Management Review of the Audit Functions of the California Department of Corrections Office of Compliance,” October 2002, p. 1.
[10] “Report of the Rampart Investigation” (a division of the Los Angeles Police Department), Independent Review Panel, Executive Summary, November 16, 2000, p. 136.
[11] Assistant Chief Ed Fincel, California Highway Patrol, Risk Management Expert, interview, May 5, 2004.
[12] Commander Stuart Maislin, Los Angeles Police Department, Risk Management Group, interview, May 5, 2004.
[13] James H. Gomez, President and Chief Executive Officer of the California Association of Health Facilities and former Director of the California Department of Corrections from April 1991 through January 1997, speaking at a Correctional Forum panel discussion on April 27, 2004.
[14] Gary L. Johnson, Executive Director of the Texas Department of Criminal Justice, remarks during a Correctional Forum panel discussion on April 27, 2004.
[15] Thomas McCarthy, “TEAMS Turns Around the New York City Correction Department,” Large Jail Network Bulletin (1999)
[16] Deputy Commissioner Thomas Antenen, Office of Public Information, New York City Department of Corrections, interview, April 30, 2004.
[17] Detective Jeff Godown, Office of Operations, Los Angeles Police Department Detective, interview, May 3, 2004.
[18] Joseph Lehman, Secretary of the Washington State Department of Corrections, remarks during a Correctional Forum panel discussion on April 27, 2004.
[19] James H. Gomez, President and Chief Executive Officer of the California Association of Health Facilities, and former Director of the California Department of Corrections from April 1991 through January 1997, remarks during a Correctional Forum panel discussion, April 27, 2004.
[20] Joseph Lehman, Secretary of the Washington State Department of Corrections, during a Correctional Forum panel discussion, April 27, 2004.
[21] Government Code Section 12511 provides that the Attorney General has charge, as attorney, of all legal matters in which the State is interested, except the business of The Regents of the University of California and of such other boards or officers as are by law authorized to employ attorneys.
[22] Interview with Chief Counsels of the Youth Authority, Debra Ashbrook, the Department of Corrections, Kathleen Keeshen, the Bureau of Prison Terms, Terry Farmer, and the Prison Industry Authority, David Beales, April 20, 2004.
[23] See proposed legislation in the appendices to this report.
[24] California Code of Regulations, Title 15, Division, Article 8 Section 3084 Inmate Appeals
[25] Department of Corrections Operations Manual, Section 54100.1, Inmate/Parolee Appeals
[26] Office of the Inspector General, “Review of Inmate Appeals Branch,” February 2001; Office of the Inspector General audits at Salinas Valley State Prison, March 2000; California Rehabilitation Center, August 2000 California Substance Abuse Treatment Facility at Corcoran, February 2001; Salinas Valley State Prison, September 2003
[27] Ibid.
[28] California Code of Regulations, Title 15, Division, Article 5, Ward Grievance Procedures
[29] Department of Youth Authority, “Institutions & Camps Operations Procedures,” Section 7000-7140
[30] The Inmate Appeals Branch does not capture the total number of appeals filed, only the number of appeals that have been completed, (i.e., responded to).
[31] Interview with Chief Counsels of the Youth Authority, Debra Ashbrook, the Department of Corrections, Kathleen Keeshen, the Bureau of Prison Terms, Terry Farmer, and the Prison Industry Authority, David Beales, April 20, 2004.
[32] Donald Specter, Prison Law Office, interview, April 15, 2004.
[33] Interview with Chief Counsels of California Youth Authority, Debra Ashbrook, California Department of Corrections, Kathleen Keeshen, Bureau of Prison Terms, Terry Farmer, and Prison Industry Authority, David Beales, April 20, 2004.
[34] Commander Stuart Maislin, Los Angeles Police Department, interview, May 5, 2004.
[35] California Government Code, Sections 11346.2 and 11346.3
[36] California Government Code, Section 11346.4
[37] California Government Code, Sections 11346.8 and 11346.9
[38] Armstrong, Coleman, Clark, Madrid, and Plata
[39] Dr. Louis Vismara, Consultant to the Senate Rules Committee, interview May 4, 2004.
[40] Patterson and Trupin, “Report of Findings of Mental Health and Substance Abuse Treatment Services to Youth in CYA,” December 2003, pgs. 10, 13-16,
[41] Puisis & LaMarre, “Review of Health Care Services in the California Youth Authority (CYA),” August 22, 2003. Pgs 42-58.
[42] Department of Corrections, Health Care Services Division report provided by Lindsay Grater, April 26, 2004.
[43] Ibid.
[44] Population data from http://www.corr.ca.gov/OffenderInfoServices/Reports/Projections/S00Pub.pdf
[45] Population data from http://www.corr.ca.gov/OffenderInfoServices/Reports/Projections/F03pub.pdf
[46] California Bureau of State Audits, “CDC: Needs to Better Ensure that it Obtains Medical Services Contracts that are in the State’s Best Interest and its Payments are only for Valid Medical Claims,” April 6, 2004.
[47] Office of the Inspector General, “Survey of Pharmaceutical Expenditures,” p. 3, July 2003.
[48] PowerPoint presentation provided by E.J. Pedersen, President, University of Texas Medical Branch ,Texas Department of Criminal Justice, “What is Correctional Managed Care?,” May 26, 2004.
[49] Florida Corrections Commission, 1995 Final Report retrieved online from http://www.fcc.state.fl.us/fcc/reports/final95/health.html
[50] Meeting with Dr. Michael Drake, Vice President of Health Affairs, University of California, Oakland, California, May 3, 2004,
[51] University of Texas Medical Branch, Ben Raimer, MD, “Correctional Health Care in the Texas Department of Criminal Justice”, 2002, p. 1
[52] Government West, “Correctional Health Care In the Texas Department Of Criminal Justice”, online http://www.govwest.com/correctional_hea.asp
[53] Telephone interview with Kay Northrup, Deputy Director of Health Care, Ohio Department of Corrections, Columbus, Ohio, April 16th, 2004.
[54] National Institute of Corrections, “Corrections Agency Collaborations with Public Health”, p.2-3. September 2003.
[55] Stoller, Nancy, “Improving Access to Health Care for California’s Women Prisoners” California Program on Access to Care, (Santa Cruz, 2001) The views and recommendations in this report are those of the author and do not necessarily represent those of the California Policy Research Center or the Regents of UC.
[56] Ibid.
[57] Telephone interview with Nancy Stoller, Professor of Community Studies, UC Santa Cruz, Santa Cruz, California, May 7, 2004.
[58] Ibid.
[59] Interview with Donald Specter, Prison Law Office, Sacramento, California, April 16, 2004.
[60] Dr. Jeffrey Metzner, court appointed expert in Coleman; and Dr. Ronald Shansky, medical expert in Plata, April 2004.
[61] California Youth Authority, Statewide Health Care Program, Kip Lowe, Deputy Director, Health Care Services, April 2004.
[62] Report of Findings of Mental Health and Substance Services to Youth in (CYA) facilities, Eric Trubin, Ph.D and Raymond Patterson, M.D., December 2003.
[63] Fox Systems, Inc. Health Care Services Division Pharmacy Services; Current Pharmacy Services Process. November 6, 2001.
[64] Fox Systems, Inc. Health Care Services Division Pharmacy Services; Alternatives for Improvement December 20, 2001.
[65] Office of the Inspector General. “Survey of California Department of Corrections Pharmaceutical Expenditures,” July 2003.
[66] Keating, S. & Sechrist, K. “The Nursing Shortage in California: The Public Policy Role Of The California Strategic Planning Committee For Nursing”. Online at http://www.nursingworld.org/ojin/topic14/tpc14_2.htm
[67] California Department of Corrections, Director’s Monthly Report, April 2004, provided by Richard Curtis, R. N. Recruiter, Selections and Standards Division, Sacramento, California.
[68] Coleman v. Wilson, U.S. District Court, Eastern District of California.
[69] Interview Ronald Shansky, MD., Board Member National Commission on Correctional Healthcare and California Department of Corrections consultant for Plata settlement, March 15, 2004.
[70] California Medical Association, Website, www.cmanet.org accessed May 12, 2004.
[71] Stoller, Nancy “Improving Access to Health Care for California’s Women Prisoners” California Program on Access to Care, Santa Cruz, 2001. p. 12.