MICHAEL D. CREWS
SECRETARY
PROCEDURE NUMBER: 401.006
PROCEDURE TITLE:
CONFIDENTIALITY OF HEALTH SERVICES
MEDICAL
REVIEW
COMMITTEES
INFORMATION
RESPONSIBLE AUTHORITY: OFFICE OF HEALTH SERVICES
EFFECTIVE DATE:
JULY 14, 2014
INITIAL ISSUE DATE:
APRIL 4, 2000
SUPERSEDES:
HSB 15.09.01, SECTION I AND ATTACHMENT #7
RELEVANT DC FORMS:
DC2-813
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ACA/CAC STANDARDS: 4-4410
STATE/FEDERAL STATUTES: SECTIONS 119.07(1), 286.011, 395.0193, 766.101, 945.601,
945.6032(3), F.S., AND ARTICLE I, SECTION 24(a) AND (b), FLORIDA CONSTITUTION
FLORIDA ADMINISTRATIVE CODE: RULES 33-401.701 AND 33-601.901, F.A.C.
Procedure 401.006
PURPOSE: To provide guidelines as to what findings and recommendations of Departmental
Medical Review Committees are confidential, meeting attendance limitations, special requests, and
the proper handling of information.
DEFINITIONS:
(1) CMA refers to the Correctional Medical Authority, whose purpose is to monitor and evaluate
the quality of healthcare services and make recommendations toward the delivery of cost
effective health care to Florida’s prison inmates, as required by section 945.601, F.S.
(2) Comprehensive Health Care Contractor (CHCC) refers to contracted staff that have been
designated by the Department to provide medical, dental, and mental health services at
designated institutions within a particular region. The CHCC will be responsible for
coordinating the quality management program at designated institutions. The CHCC will
utilize staff that is comparable to the Department for the management of the QM program.
(3) Confidential, where used herein, refers to information made confidential by state or federal
law such that the unauthorized use or disclosure would be in violation of state and federal law.
(4) Departmental Medical Review Committees refers to the quality management committees,
mortality review committees, credentialing, and peer review committees and the Reception,
Medical Center Hospital medical committees, or any other ad hoc committees, task forces, or
workgroups charged with reviewing medical information at the institutional, regional, or
statewide levels.
(5) Inmate Identifiers refers to the inmate’s name and DC number that designates the inmate as a
person under the care and custody of the Department.
(6) Practitioner refers to an individual that provides direct or indirect physical health, dental
health or mental health care to include assessments, treatments, x-rays, phlebotomy, and
pharmaceuticals to DC inmates.
(7) Practitioner Identifier refers to the Practitioner’s name and signature or signature stamp.
(8) Specific Quality Management Materials refers to all Office of Health Services quality
management documents that identify specific inmates and/or Office of Health Services health
care Practitioners and all resulting quality management meeting minutes, correspondence, and
reports that are produced from the review of these materials.
________________________________________________________________________________
SPECIFIC PROCEDURES:
(1) Pursuant to sections 945.6032(3), 395.0193(7), and 766.101, F.S., the findings and
recommendations of Departmental Medical Review Committees are confidential and exempt
from the provisions of section 119.07(1), F.S., and section 24(a), Art. I of the State
Constitution. Any proceedings of the committees are exempt from the provisions of section
286.011, F.S., and section 24(b), Art. I of the State Constitution.
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Procedure 401.006
(2) The following specific quality management materials will remain confidential and will be
reviewed and discussed only by staff within the Office of Health Services, CHCC staff, and
CMA quality management committee representatives:
(a) Office of Health Services quality management data collection/aggregation sheets;
(b) mortality review documents, reports, and correspondence, including psychological
autopsies and the findings of any external reviews performed;
(c) individual risk management reports;
(d) quality management committee and credentials review committee meeting minutes from
the Office of Health Services;
(e) reports and attachments to quality management committee and credentials review
committee minutes and correspondence resulting from these meetings;
(f) quality management reports and/or feedback from the statewide quality management
committee to regional and institutional Office of Health Services staff/CHCC staff/medical
review committees and to CMA;
(g) quality management reports and/or feedback from the Office of Health
Services/CHCC/regional staff to the Office of Health Services institutional staff/CHCC
staff/medical review committees;
(h) credentials files of all Practitioners who are subject to the credentialing process;
(i) peer review correspondence and reports regarding credentialed Practitioners;
(j) information, correspondence, and reports received from CMA by the quality management
committee or the Assistant Secretary of Health Services that contain specific inmate and/or
Practitioner identifiers;
(k) nursing quality management site visit reports; and
(l) any other similar quality management materials developed and maintained by the CHCC.
(3) All specific quality management materials will be maintained in secured confidential files
within the medical unit of each institution and each regional health services/CHCC office.
Confidential quality management files in the Office of Health Services in the central office will
be maintained in a secure manner by the central office Quality Management Coordinator.
(4) Copies of all specific quality management materials that are distributed at Departmental
Medical Review Committee meetings will be retrieved by the institutional Quality
Management Coordinator or designee and/or a staff member from the statewide quality
management committee for appropriate disposal.
(5) Attendance at Departmental Medical Review Committee meetings will be limited to authorized
staff (committee members plus invited guests and ad hoc members).
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Procedure 401.006
(6) Any special requests for information will be referred to the Assistant Secretary of Health
Services for resolution. Requests must be submitted in writing to the Assistant Secretary of
Health Services, who will make a determination regarding the release of any quality
management materials.
(7) All committee members shall sign an “Acknowledgement of Responsibility to Maintain
Confidentiality of Medical Information,” DC2-813, and will adhere to the instructions therein.
__/S/____________________________
Secretary
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