CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES
Health Care Department Operations Manual
Chapter 1, Article 2 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee Page 1 of 3
1.2.11 CCHCS Systemwide Pharmacy and Therapeutics Committee
(a) Procedure Overview
(1) Th
e California Correctional Health Care Services (CCHCS) Systemwide Pharmacy and Therapeutics (P&T)
Commi
ttee shall provide overall direction to Pharmacy Services at all California Department of Corrections and
Rehabilitation (CDCR) institutions.
(2) The Systemwide P&T Committee shall report to the statewide Quality Management Committee (QMC).
(3) The Systemwide P&T C
ommittee shall oversee subcommitteees including, but not limited to, the Systemwide
Medication Management Subcommittee.
(4) Institutions shall have a local Medication Management Subcommittee that reports to the local QMC to oversee
medication management practices including local medication storage, distribution, administration and utilization
locally; however, changes to approved, standardized pharmacy policies and procedures, the standard practice model,
and the CCHCS Drug Formulary must be approved by the Systemwide P&T Committee. Recommended changes
to policy, procedure, or the formulary shall be submitted to the Regional Deputy Medical Executive (DME) and
Statewide Chief of Pharmacy Services for consideration by the Systemwide P&T Committee as appropriate.
(b) Purpose
To en
sur
e the safe, rational, evidenced-based, cost-effective, standardized use of therapeutic drugs and develop policies
and procedures related to medication management within the CDCR.
(c) Procedure
(1) M
embership
(A) The
chairperson is appointed by the Deputy Director, Medical Services, or designee, for a two-year term
(eligible for reappointment) and shall be responsible for the Systemwide P&T Committee meeting.
(B) The chai
rperson shall assist the Deputy Director, Medical Services, in selecting the other members of the
Systemwide P&T Committee and determining terms of service.
(C) Voting members shall include the f
ollowing, or the members shall assign a permanent designee with decision-
making capacity:
1. Two Headquarters Physician Managers or designee
2. Four Institutional or Regional Physician Managers or designees
3. Deputy Director, Nursing Services or designee
4. On
e Headq
uarters Chief Nurse Executive
5. Ch
ief of Psychiatry Support, Statewide Chief Psychiatrist or designee
6. Chief of Telepsychiatry, Statewide Chief Telepsychiatrist or designee
7. One Senior Psychiatrist (Headquarters or Institution) or designee
8. One Psychiatric Inpatient Program Psychiatrist or designee
9. Deputy Director, Dental Services or designee
10. Statewide Chief, Pharmacy Services or designee
11. Two Headquarter Pharmacy Services Managers
12. One Deputy Medical Executive, Quality Management or designee
(D) The Systemwide P&T Committee shall maintain a list of permanent designees for voting members. Designees
for voting members of the Systemwide P&T Committee are permitted. Prior notification to the chairperson at
least three working days in advance is requested when a designee shall attend for a voting member. All
designees must sign a confidentiality statement pursuant to Section (c)(3)(D).
(E) Non-voting members shall include:
1. Pharmaceutical Program Manager and Pharmaceutical Consultant II, Department of General Services
2. Support Staff
(F) Ad hoc membership status without voting privileges shall be offered to court-appointed experts (e.g., Plata and
Coleman), pharmacy representatives, and others.
(G) Guests for S
ystemwide P&T Committee meetings are permitted. Prior notification to the chairperson at least
three working days in advance is requested. All guests must sign conflict of interest and confidentiality forms
pursuant to Section (c)(3)(D) and understand that their attendance is as an observer and comments during the
meeting are at the discretion of the chairperson.
CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES
Health Care Department Operations Manual
Chapter 1, Article 2 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee Page 2 of 3
(2) Duties
The Systemwide P&
T Committee is responsible for overseeing policies and procedures related to all aspects of
medication use within CCHCS including, but not limited to:
(A) Maintaining a formulary of medications, including standardizing the strengths and dosage forms for
medications used across institutions.
(B) Reviewing procurement and medication selection processes to promote cost-effective formulary management.
(C) Conduc
ting regular therapeutic category reviews for formulary selection.
(D) Ensuring that pharmacy services address the health care and security needs of the institution.
(E
) Reviewing and monitoring medication usage and therapeutic use of medications within the CDCR.
(F) Evaluating medication use and promoting safe medication practices.
(G) Evaluating medication therapies and providing input to the development of disease management guidelines.
(H) Reviewing and approving proposed changes to pharmacy policies. The Systemwide Medication Management
Subcommittee shall be consulted for policymaking on any matters related to medication management processes.
(3) Meetings
(
A) Th
e Systemwide P&T Committee shall meet monthly or as often as necessary at the request of the chairperson.
(B) Meetings via teleconference shall be made available to members of the Systemwide P&T Committee.
(C) A record of the proceedings shall be kept which records committee activities, recommendations, and attendance.
(D) Confidentiality/Non-Conflict
1. The proceedings and records of the Systemwide P&T Committee shall be kept confidential and protected
from discovery to the extent permitted by law.
2. Members and participants shall provide a completed copy of a Conflict of Interest Form and a
Confidentiality and Non-Disclosure Agreement. These documents are available on the CCHCS Pharmacy
Services site on Lifeline. Completed copies of each document shall be maintained with the Systemwide
P&T Committee records. Members may not have any financial or business relationships with entities doing
business with the State of California.
(E) Voting
1. Each voting member shall have one vote. A quorum is designated as 50 percent of voting members,
excluding vacancies.
2. The Systemwide P&T Committee may use electronic voting to address issues when it is determined that
waiting until the next scheduled meeting is suboptimal. Electronic voting may be used to resolve an existing
agenda item or to address an urgent or emergent new agenda item.
(4) Subcommittees
T
he Systemwide P&T C
ommittee may charter standing subcommittees and establish ad hoc workgroups to plan
and develop new or modify existing programs. Standing subcommittees include, but are not limited to:
(A) Sy
stemwide Medication Management Subcommittee
The Systemwide Medication Management Subcommittee is a multidisciplinary group that works to ensure
medication practices support the safety of the individuals served and improve the quality of care by developing
and modifying processes as they relate to planning, procurement, ordering, preparing and dispensing,
distribution, storage, and administering medications with the goal to reduce any potential harm that could be
caused by medications. This subcommittee’s charter shall include reducing variations, errors, and misuse; using
evidence-based practices, guidelines, and standards to develop medication management processes; and
managing critical processes to promote safe medication management throughout the organization.
(B) 340B Over
sight Subcommittee
The 340B Oversight Subcommittee assists in monitoring, directing, and overseeing the CCHCS’
implementation of its 340B Program. The 340B Oversight Subcommittee’s reporting provides direction and
ongoing surveillance of the organization’s 340B Program for compliance with policy and federal rules.
(C) Nutrition Subcommittee
The CCHCS Nutrition Subcommittee oversees the Outpatient Dietary Intervention procedures and diet
education handouts to ensure clinically accurate information regarding appropriate nutritional choices.
CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES
Health Care Department Operations Manual
Chapter 1, Article 2 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee Page 3 of 3
References
• California Civil Code, Division 1, Part 2.6, Chapter 1, Section 56 et seq.
• California Evidence Code, Division 9, Chapter 3, Section 1157
• Ca
lifornia Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 5, Article 2, Section 3413 (b)
• California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72375, Pharmaceutical Service
- Staff
• California Code of Regulations, Title 22, Division 5, Chapter 4, Article 3, Section 73351, Pharmaceutical Services
- Policies and Procedures
• California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Section 79781, Required Committees
• California Government Code, Title 2, Division 5, Part 2.6, Chapter 2.5, Article 10, Section 19990
• California Government Code, Title 9, Chapter 7, Article 1, Section 87100 et seq.
• California Penal Code, Section 5024.2
• Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.4, Quality Management Program,
Statewide Governance
• Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.12, Outpatient Dietary Intervention
• Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.4, CCHCS Drug Formulary
• Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.36, CCHCS Pharmacy Policy and
Pr
ocedure Manual Review, Revisions, and Additions
Revi
sion History
Effe
ctive: 03/2007
Revised: 11/29/2023