providing mental health &
substance abuse  services for
the people of Alameda County ...  

Click here to go to homepage!

2000 Embarcadero Cove, Suite 400, Oakland, CA  94606
Phone: (510) 567-8100    Driving Directions

Peer Review Policy & Procedure

Policy / Procedure


Alameda County Behavioral Health Care Services (ACBHCS) will require each provider site or other contracted Community Based Organization (CBO) to follow policy and procedure in accordance with the Peer Review Plan described below.  The primary mission of the Peer Review Plan is to facilitate ongoing quality improvement in delivery of services to consumers at the program level.  The process used is intended to be a vehicle for program transformation rather than individual clinician review.  


Topic Selection

Each provider will have latitude to choose a programmatic topic for ongoing exploration which they identify as an avenue to improve quality of care to consumers.  To aid the process of topic selection, ACBHCS encourages the use of brainstorming sessions and staff focus groups.  In keeping with the current shifts in our system priorities toward empowerment, resilience and wellness and recovery, the topic selection process should enhance staff involvement and buy-in to the process and outcomes. 

It is important to decide whether the program’s focus will be on a specific topic or on an issue identified as a current problem, as explained below.  Both approaches are equally valid and useful but carry different implications and mind-sets.  Program choice of Topic vs. Problem as an approach may initially have more to do with ensuring staff buy-in than the actual subject matter, as staff resistance can be higher when focusing on an established problem.

Topics:  Topics can be generated from staff interest, changes in program emphasis, population served, etc. Topics do not imply the need for correction or that an error has occurred, they only imply a desire for potential ongoing change and improvement.

Problems:  Problem identification is usually the result of a negative outcome. It is crucial for the health of any organization, its staff and its consumers to be able to examine problems and identify creative solutions.  Indicators of problems in service delivery can include:

  • Single/sentinel events of major impact
  • Collective events or patterns: problems that together are of concern
  • Trends giving reason for concern over time
  • Issues raised by multiple sources

Peer Review Committee (PRC)

A Peer Review Committee (PRC) will be established by the Center Director/Executive Director/designee at each provider site or program.  Agencies with multiple programs may complete a separate PRC and topic for each site.

Participation in the PRC will be open to all program staff, including clinical and administrative. At least one of the committee participants must be a licensed Mental Health Practitioner.  The Center Director/Executive Director shall assure that the PRC has sufficient resources and authority to carry out its responsibilities as set forth in this plan.

  • The PRC will review, over the course of one fiscal year, at least eight clinical cases, as they relate to the chosen program topic or problem.  Larger programs are encouraged to look at a larger sample to increase the reliability of the data.
  • The PRC will protect the confidentiality of the consumer(s) according to HIPAA guidelines, as delineated below.
  • The PRC will analyze review findings and make recommendations, including staff training needs, changes to program and service delivery.
  • The PRC will perform at least twice yearly self-appraisal of their Peer Review process to assess effectiveness and make necessary improvements.
  • Minutes and summary reports of the PRC activities will be maintained by the provider site.
  • Other functions and responsibilities may be assigned, as determined by ACBHCS.

Committee Documentation:  Compliance and Administrative Reporting

By July 1st of each year, the Center Director/Executive Director will submit to the BHCS Quality Assurance Administrator, a report of Committee activities, findings and recommendations, using the PRC report guideline.  Adherence to these guidelines is essential to maintain consistency in reporting across programs to give the county useful data that can be shared.

The QA Representative will formulate a county-wide summary report of findings.  This report will be made available to the BHCS Training Committee where it will be used to assess needs for specific training programs.  Training will be provided through BHCS to meet broad-based provider needs.  In addition, the findings will be made available to all providers via the BHCS website and an annual conference.

All reports required by this Plan shall be kept separate from consumer clinical records and shall be stored in a locked file.  Peer review reports taken off-site shall not include names or demographic information which could be used to identify individual consumers.  Peer review reports produced within the provider site shall not identify a consumer by name.  Peer review reports and proceedings are subject to all confidentiality requirements as is other information kept in personnel and clinical records.  Participation in the PRC is subject to the same confidentiality requirements as applied to any other form of collaboration and/or consultation among staff.

Overview of the Peer Review Plan

  • Topic Selection
  • Plan a change and implement
  • Peer Review
  • Analyze results and draw conclusions
  • Report

Small Agency Adjustment

Any agency serving 10 or less distinct clients in one fiscal year is not required to do a full Peer Review.  Instead, the Agency will submit to the QA Office an annual letter reflecting what their program has done during the fiscal year to improve clinical care during the fiscal year.  This letter is due on the same cycle as all other Peer Reviews, on July 1st of each year.  If an agency feels they qualify for this exception, they must notify the QA office in writing, no later than October 1st of the beginning of the fiscal year.