Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_90-cv-00520/USCOURTS-caed-2_90-cv-00520-1105/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF CALIFORNIA 

RALPH COLEMAN, et al., 

Plaintiffs, 

v. 

GAVIN NEWSOM, et al., 

Defendants. 

No. 2:90-cv-0520 KJM DB P 

ORDER 

In an order filed September 3, 2020, the court directed the parties to file briefs 

addressing specific questions presented in the order. Sept. 3, 2020 Order, ECF No. 6846, at 24-

27. The questions all concern “interim steps toward full and durable implementation” of the two 

primary remedial plans in this action, the Program Guide and the Compendium of Custody 

Related Remedial Measures (hereafter Compendium). Id. at 25. The parties have filed the 

required briefs and accompanying evidence. See ECF Nos. 6936, 6936-1 (Defendants’ Brief and 

Evidence); ECF Nos. 6937, 6937-1 through 6937-4 (Plaintiffs’ Brief and Evidence). The parties 

have also filed responsive briefing and evidence as authorized by the court, ECF No. 6946. See

ECF No. 6969 (Plaintiffs’ Reply); ECF Nos. 6971, 6971-1, 6971-2 (Defendants’ Reply and 

Evidence). 

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I. BACKGROUND 

A quality assurance program and a quality improvement process are required parts 

of the remedy in this action. See Coleman v. Wilson, 912 F. Supp. 1282, 1308 (E.D. Cal. 1995); 

see also, e.g., Mar. 3, 2014 Order, ECF No. 5092, at 4-51 (quoted in ECF No. 6846 at 10); Aug. 

30, 2012 Order, ECF No. 4232, passim. Quality assurance and quality improvement are 

components of an adequate quality management system: quality assurance focuses on 

quantification of system performance, while quality improvement focuses on the quality of that 

same system’s performance. See, e.g., ECF No. 4205 at 74-75.2 

Defendants’ expert previously has testified via declaration “that defendants cannot 

provide adequate mental health care without some form of quality assurance.” Coleman v. 

Wilson, 912 F. Supp. at 1308. The Eighth Amendment requires access to “adequate” mental 

health care; a quality assurance program is a necessary part of ensuring the adequacy of the 

mental health care delivered in a system the size of defendants’ Mental Health Care Delivery 

System (MHSDS). Id. As early as 1998, the Special Master reported to the court that 

[a] strong quality assurance system is the best, and perhaps the only, 

long-term method for continuing evaluation and enhancement of the 

quality of mental health series delivered by the defendants to 

seriously mentally disordered prisoners in the California Department 

of Corrections. If effectively implemented and thoroughly 

institutionalized in the defendants’ mental health delivery system, its 

impact will inure to the benefit of the plaintiff class long after the 

court has ceased to monitor this case. Quality assurance is the critical 

key to an enduring remedy. 

Special Master’s Recommended Schedule for Implementation of Defendants' Quality Assurance 

Plans, filed July 20, 1998, ECF 958, at 3 (quoted in Twenty-Sixth Round Monitoring Report, 

ECF No. 5439, at 104). 

1

 This order was signed February 27, 2014 and is referred to in the court’s September 3, 

2020 order by that date as well as its ECF number. It was entered on the docket in this action on 

March 3, 2014 and is referred to here by that date and its ECF number. 

2

 Citations to page numbers in documents filed in the Court’s Electronic Case Filing 

(ECF) system are to the page number assigned by the ECF system and located in the upper right 

hand corner of the page. 

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 Full implementation of a quality improvement process is equally integral to a 

durable remedy in this action. In 2012, the court adopted the Special Master’s recommendation 

and ordered defendants, over the following six months, to 

review and assess their existing quality assurance process and . . . 

develop an improved quality improvement process by which they can 

address issues with the quality of care that is delivered, as described 

in the Special Master’s Twenty-Fourth Round Monitoring Report. 

The quality improvement process shall be developed from the 

standpoint of it being the beginning of a transition by CDCR 

[California Department of Corrections and Rehabilitation] into selfmonitoring by its own DCHCS [Division of Correctional Health Care 

Services]. 

ECF No. 4232, at 5-6. Defendants objected to the recommended order on three grounds: 

(1) their quality assurance process was “‘constitutionally adequate’” and “‘an order directing 

Defendants to revise a presumptively constitutional process” was “not needed’”; (2) the order was 

“‘unnecessary and could be counterproductive’” because of efforts by the Receiver, in Plata v. 

Brown, No. 01-1351 JST (N.D. Cal.), “to implement a ‘comprehensive remodeling and revision 

of CDCR’s health care quality assurance process, of which mental health’s quality assurance 

process is a subset’”; and (3) they were willing to work with the Special Master without a court 

order. ECF No. 4232 at 2 (quoting Defs.’ Objections, ECF No. 4212, at 1-2). Noting that 

defendants’ prior comments to the Special Master about the draft recommendation had signaled 

their acquiescence in it, ECF No. 4232 at 3, the court refused to entertain defendants’ objections 

because they had not complied with the requirement set forth in the Order of Reference, of 

presenting their objections to the Special Master in the first instance. Id. at 3-4. The court 

specifically noted its concurrence in the Special Master’s finding that development and 

implementation of the quality improvement process would be integral to completion of the 

remedy in this case. Id. at 4-5. 

After the court extended the initial six month deadline, see Apr. 23, 2013 Order, 

ECF No. 4561, at 2, on August 2, 2013, the Special Master filed a report on the work required by 

the August 30, 2012 order. ECF No. 4730. The report included “recommendations for further 

work on the quality improvement process” but no recommendations for specific court orders. 

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ECF No. 5092, at 2.3 In its order denying plaintiffs’ subsequent request for specific orders on the 

Special Master’s report, the court reiterated its finding that defendants had not objected “to the 

Special Master’s recommendation that they be ordered to review and assess their existing quality 

assurance process and develop an improved quality improvement process as part of the transition 

to self-monitoring and the end of federal court oversight; indeed, . . ., they acquiesced in the 

recommendation.” Id. at 4. The court also reiterated that “defendants’ development and 

implementation of an improved quality improvement process” is “a key component of a durable 

remedy” in this action. Id. at 4-5 (quoted in ECF No. 6846 at 10). CQIT is the “comprehensive 

tool that, once finalized, defendants will ultimately use as part of” that quality improvement 

process. ECF No. 6846 at 10. 

II. UPDATE/IDENTIFY KEY CQIT INDICATORS 

The first and fourth questions raised in the September 3, 2020 order are whether 

the court should “allow a period of six months for defendants, under the supervision of the 

Special Master who may seek input from plaintiffs as appropriate, to update the key indicators in 

CQIT [the Continuous Quality Improvement Tool] to reflect any changes required by the 2018 

Update to the Program Guide. . . . [and] identify key indicators for CQIT to reflect the material 

provisions of the Compendium.” ECF No. 6846 at 25, 26. The parties are in general agreement 

that the court should order this update. See ECF No. 6936 at 94; see also ECF No. 6937 at 3. In 

consultation with the Special Master, the court has now determined this update can be finalized 

within three months from the date this order is filed. 

Plaintiffs request the court direct the inclusion of their counsel from the beginning 

of this process, rather than at the discretion of the Special Master. See ECF No. 6937 at 3, 6; 

ECF No. 6969 at 4. The 1995 Order of Reference provides that the main work of the Special 

3

 This order was signed February 27, 2014 and is referred to in the court’s September 3, 

2020 order by that date as well as its ECF number. It was entered on the docket in this action on 

March 3, 2014 and will henceforth be referred to by that date and its ECF number. 

4

 References to page numbers in documents filed in the Court’s Electronic Case Filing 

(ECF) system are to the page number assigned by the ECF system and located in the upper right 

hand corner of the page. 

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Master is “with the defendants in this litigation”; at the same time, because this is an adversarial 

proceeding in which “[a]ll parties are entitled to the advice of counsel as this litigation proceeds”, 

the Special Master is also “directed to consult with counsel for all parties as necessary in the 

discharge of his duties.” Dec. 11, 1995 Order, ECF No. 640, at 2-3. The court finds no reason to 

depart from this long-standing direction. Plaintiffs’ request is denied. 

Defendants contend that while some CQIT indicators “measure compliance with 

provisions of the Program Guide that reflect constitutional obligations” this is not true of all 

CQIT indicators; some measure compliance with California Department of Corrections and 

Rehabilitation [CDCR] policies “designed to inspire best practices and for administrative 

coordination, among other reasons, and not simply to reflect what is minimally required in a 

constitutionally adequate system.” ECF No. 6936 at 8. They contend it is critical that those 

CQIT “indicators that measure compliance with constitutionally-mandated functions are 

identified and distinguishable from those that do not carry such import, but instead are used to 

enhance or improve performance.” Id. at 9. 

These contentions misperceive the remedial function of the quality improvement 

process and CQIT. For the reasons explained above, it is settled in this action that full 

implementation of the quality improvement process, including CQIT, is essential to a durable 

remedy in this action. For that reason, implementation of all components of CQIT is essential to 

the proper function of this key remedial requirement; the court’s questions did not invite parsing 

of that tool in any way that would impede this function. Identification of “key” indicators and 

confirmation of the degree of compliance required for each indicator serves separate remedial 

functions by facilitating assessment of the degree to which full implementation of the remedial 

plans in this action remains to be accomplished. Once full implementation is accomplished using 

these measures, what will remain is a demonstration that these fully implemented remedies are 

durable. 

After review of the record, and considering that CQIT has been under development 

for several years, the court concludes that a three month period is sufficient to update CQIT’s list 

of key indicators. That will be the order. 

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III. CONFIRM UPDATED LIST OF KEY INDICATORS AS COMPREHENSIVE 

LIST OF MATERIAL PROGRAM GUIDE/COMPENDIUM PROVISIONS FOR 

COMPLIANCE PURPOSES 

The second and fifth questions are whether the court should “confirm that the 

updated list of key indicators in CQIT that pertain to Program Guide requirements may properly 

be considered a comprehensive list of the material provisions of the Program Guide, that, taken as 

a whole and met at the requisite degree of compliance, signal constitutionally adequate 

compliance with the Program Guide.” ECF No. 6846 at 25, 26. 

Plaintiffs argue that compliance with the CQIT key indicators can signal 

constitutionally adequate compliance with the Program Guide only “in combination with an 

overall systemic view of the system that includes review of a significant number of individual 

patient cases to determine whether failures are occurring in a pattern that creates a substantial risk 

of serious harm to patients.” ECF No. 6937 at 4, 6. In the reply, defendants contend the CQIT 

review process “already contains a qualitative component that includes both patient interviews 

and a review of individual patient files, in concert with extensive onsite tours over several days.” 

ECF No. 6971 at 5. 

As discussed above, CQIT is the implementation tool for the quality improvement 

process that is a necessary component of complete remediation in this action. The Special 

Master’s Twenty-Sixth Round Monitoring Report, filed May 6, 2016, includes a thorough 

overview of the ongoing development of the comprehensive Continuous Quality Improvement 

(CQI) process, for which CQIT is “[t]he self-auditing tool.” ECF No. 5439 at 104-113. That 

overview is incorporated into this order by reference.5

 It shows that implementation of the 

quality improvement process in its entirety, assuming implementation can be achieved, will result 

in a process by which defendants not only continuously “measur[e] performance indicators but 

also . . . identify[] and craft[] resolutions with system-wide application, and thus . . . improv[e] 

the [mental health] care that is delivered throughout CDCR prisons.’” ECF No. 5439 at 110 

5

 No party raised objections to the Twenty-Sixth Round Monitoring Report. See Aug. 9, 

2016 Order, ECF No. 5477, at 1. 

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(quoting Special Master’s Report on Defendants’ Quality Improvement Process, ECF No. 5730, 

at 3). 

 Defendants contend it is “critical” to “identify those material CQIT indicators that 

undeniably measure a constitutionally adequate mental health care delivery system” in order to 

avoid requiring of them more than the Eighth Amendment requires and running afoul of the 

needs-narrowness-intrusiveness requirement of the Prison Litigation Reform Act. ECF No. 6936 

at 11.6 In their opening brief, defendants also argue that “CQIT was not designed to measure 

CDCR’s provision of the minimum level of services and care that should be provided to Coleman

class members to meet constitutional standards.” Id. at 5. In reply, defendants modify that 

position to contend CQIT has two purposes: “not only . . . to measure CDCR’s provision of the 

minimum level of services and care that should be provided to Coleman class members to meet 

constitutional standards,” CQIT is “also . . . intended to be aspirational, reflecting best practices 

and encouraging improvement. ECF No. 6971 at 2. 

 As discussed above, the quality improvement process serves an integral remedial 

function in this action: defendants’ assumption of responsibility for self-monitoring the adequacy 

of mental health care delivered to the plaintiff class. This function is as essential to the 

constitutional remedy as are individual components measured by CQIT. Viewed through this 

lens, defendants’ contention that CQIT includes components that exceed constitutional minima is 

misplaced. While key CQIT indicators must be identified as an aid to measurement of 

compliance with remedial plans in this action, namely the Program Guide and the Compendium, 

that identification is but a component of full implementation of CQIT and the quality 

improvement process. As discussed above, full implementation of CQIT and the quality 

6

 The needs-narrowness-intrusiveness requirement is found in 18 U.S.C. § 3626(a)(1)(A), 

which provides in relevant part: ”Prospective relief in any civil action with respect to prison 

conditions shall extend no further than necessary to correct the violation of the Federal right of a 

particular plaintiff or plaintiffs. The court shall not grant or approve any prospective relief unless 

the court finds that such relief is narrowly drawn, extends no further than necessary to correct the 

violation of the Federal right, and is the least intrusive means necessary to correct the violation of 

the Federal right.”

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improvement process is required as part of the constitutional remedy in this action to the same 

extent as all other court-ordered remedies. 

 Defendants also suggest that “once compliance with a key indicator is durably 

achieved, that requirement should be terminated from this case, as envisioned by this Court’s 

July 12, 2018 order.” Id. (citing ECF No. 5852 at 8:12-17). This contention is, at best, 

premature. As the September 3, 2020 order observes, the complex remedy for the persistent 

Eighth Amendment violation identified in this action must be both fully implemented and durably 

sustained. See ECF No. 6846 at 29. Defendants’ ultimate constitutional obligation is to provide 

the tens of thousands of seriously mentally ill inmates in their custody with “access to adequate 

mental health care,” Coleman v. Wilson, 912 F. Supp. at 1298, as well as to remedy the identified 

custody-related violations of plaintiffs’ constitutional rights. Meeting that obligation will require 

durable implementation of all material aspects of court-ordered relief as well as, ultimately, 

demonstrating the ability to assume full responsibility for self-monitoring. The question of 

whether these remedial objectives can be achieved in full without full court supervision 

continuing until they are met is not before the court at this time. 

The court does not address the other arguments raised by the parties in response to 

questions two and five, either because it would be premature to do so or because the issue 

presented has already been addressed by the court. 

After review of the parties’ briefing, the court anticipates confirming that the 

updated list of key indicators in CQIT that pertain to Program Guide requirements is properly 

considered a comprehensive list of the material provisions of the Program Guide, that, taken as a 

whole and met at the requisite degree of compliance, signals constitutionally adequate compliance 

with the Program Guide. 

IV. ESTABLISHMENT OF PERCENT COMPLIANCE RATE FOR KEY 

INDICATORS 

The third and sixth questions focus on the percent compliance rate for the 

identified key indicators, and specifically ask why the court should not “confirm that a 90 percent 

compliance rate for each key indicator for which the court has not previously expressly 

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established a different compliance requirement will indicate, as to that key indicator, the 

constitutional minimum has been met.” ECF No. 6846 at 25, 26. Plaintiffs contend a 90 percent 

compliance rate should be confirmed provisionally, “subject to resetting key indicators at a higher 

level” if the review of a significant number of patient cases, which they suggest is required to 

confirm the constitutional adequacy of defendants’ delivery of mental health care, reveals 

ongoing deficiencies. ECF No. 6937 at 4; ECF No. 6969 at 7. Defendants, on the other hand, 

suggest “substantial compliance” is the appropriate standard “as opposed to rigid quantitative 

percentages.” ECF No. 6936 at 12; ECF No. 6971 at 7-9. 

The remedial phase of this action has proceeded on the principle that adequate and 

durable implementation of the comprehensive set of remedial plans finally developed in this 

action will achieve the constitutional remedy. With the court’s approval, the Special Master has 

for years used a 90 percent compliance rate as the target for monitoring most of the key measures 

in those plans. Generally, the court is inclined to confirm this compliance rate. It will, however, 

direct the Special Master to file findings and recommendations recommending different 

compliance rates, if any, for one or more of the key indicators on the completed list, providing the 

parties a final chance to weigh in before court approval. 

V. UPDATING CQIT 

The court also required the parties to address whether the finalized CQIT “should 

be subject to annual updates when the Program Guide and the Compendium are updated.” 

ECF No. 6846 at 24 n.11. The parties appear to agree that CQIT must be updated as necessary to 

remain congruent with the Program Guide and the Compendium, though they have some 

differences over the precise method for assuring this congruence. Compare ECF No. 6937 at 5 

with ECF No. 6936 at 9; ECF No. 6971 at 4. 

The court previously has observed “[t]he ‘key indicators’ in CQIT are likely 

equivalent to the material provisions of the Program Guide and the Compendium that may not be 

modified without court approval,” ECF No. 6846 at 24 n.11, and neither party disputes this. 

Consistent with this determination, once the key CQIT indicators have been identified, defendants 

will be required to seek leave of court before making any substantive change to any key CQIT 

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indicator. They may do this by including a request for court approval of such changes with the 

annual updates to the Program Guide and the Compendium, or they may file individual requests 

for approval when they request court approval of modification to any material provision of the 

Program Guide or the Compendium. In either event, they shall include with the annual updates to 

the Program Guide and the Compendium a certification that the requirements of this order have 

been met together with a list identifying any material change to a key CQIT indicator or a 

statement that no such changes have been made in the preceding year. The court anticipates any 

such changes will be rare given that the remedial planning for this action has been lengthy and 

comprehensive, and is essentially complete. See, e.g., July 9, 2019 Order, ECF No. 6214, at 4; 

Aug. 3, 2020 Order, ECF No. 6806, at 14; ECF No. 6846 at 3-4. While defendants will also be 

expected to update CQIT as necessary, if at all, to ensure it fulfills its equally important role in 

enabling defendants to assume responsibility for self-monitoring and ending federal oversight, 

they will not be required at this time to obtain court approval for updates outside those proposed 

for key indicators. 

VI. ADMINISTRATIVE SEGREGATION UNIT (ASU) ENHANCED OUTPATIENT 

PROGRAM (EOP) TREATMENT IMPROVEMENT PLAN 

The court’s September 3, 2020 order also required the parties to address “why the 

court should not confirm a 90 percent compliance rate for the required review of and compliance 

with all elements of defendants’ Administrative Segregation Unit Enhanced Outpatient Program 

Treatment Improvement Plan (the Plan), including the conduct of a review every 30 days of all 

EOP inmates housed in ASU hubs for over 90 days.” ECF No. 6846 at 27. Plaintiffs contend 

that (1) EOP inmates should no longer be housed in administrative segregation; or, at a minimum 

(2) the entire EOP ASU Treatment Improvement Plan should be revisited; and (3) if EOP patients 

remain in administrative segregation, the court should confirm the 90 percent compliance rate. 

ECF No. 6937 at 10-11. Defendants contend the court should not confirm the 90 percent 

compliance rate for the Plan because the Plan “has been incorporated into the EOP Hub 

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certification process,” which is being reviewed by the Special Master, and “because certain 

indicators do not lend themselves to a numerical threshold.” ECF No. 6936 at 14-15. 

While plaintiffs are not precluded from making an appropriate motion, the first 

two issues raised by plaintiffs are not currently before the court and are not addressed by this 

order. Given the parties’ agreement that the Plan has been incorporated into the EOP Hub 

certification process and that the Special Master is currently reviewing that process, the court will 

defer resolution of this question until the Special Master’s review is complete, while maintaining 

this issue as a very high priority. 

 In accordance with the above, IT IS HEREBY ORDERED that: 

1. Within three months from the date of this order, defendants shall, under 

the supervision of the Special Master who may seek input from plaintiffs as 

appropriate, update the key indicators in the Continuous Quality Improvement 

Tool (CQIT) to reflect any changes required by the 2018 Update to the 

Program Guide and the Compendium of Custody Related Remedial Measures. 

2. Defendants shall file the updated list of key indicators within three months

from the date of this order. 

3. The court defers confirmation of the compliance rate for each key indicator 

pending defendants’ compliance with paragraph 2 of this order and 

consideration of findings and recommendations filed by the Special Master, if 

any, for a different compliance rate for one or more of the key indicators 

followed by resolution by this court of objections, if any, to such findings and 

recommendations. 

4. After the list of key CQIT indicators has been finalized, defendants will be 

required to seek leave of court before making any substantive change to any 

key CQIT indicator. They may do this by including a request for court 

approval of such changes with the annual updates to the Program Guide and 

the Compendium, or they may file individual requests for approval when they 

request court approval of any material provision of the remedy. In either 

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event, defendants shall include with the annual updates to the Program Guide 

and the Compendium their certification that the requirements of this order have 

been met together with a list identifying any material change to a key CQIT 

indicator or a statement that no such changes have been made in the preceding 

year. 

DATED: December 16, 2020. 

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