By Kelly Davis and Jeff McDonald
The San Diego Union-Tribune
SAN DIEGO — The operations manual for the San Diego Sheriff’s Medical Services Division includes a section outlining the agency’s commitment to continuous quality improvement, or CQI — the old maxim in health care that calls for constantly doing better to progressively boost outcomes.
The policy update from 2022 noted this objective: “To continuously monitor and improve upon the quality of health care delivered in all detention facilities.”
But according to a new report from the San Diego County grand jury, the Sheriff’s Office does not track critical performance indicators and therefore is unable to enact data-driven reforms to better address the medical and mental health needs of people in jail.
The failure is especially important, grand jurors said, because San Diego County jails have for years reported significant numbers of people dying in their custody.
Jurors commended the Sheriff’s Office for “significant improvement in suicide prevention efforts and providing increased mental health treatment” after a 2018 investigation by Disability Rights California found “a system failing people with mental illness.”
“However, much work remains to be done,” the new report says. Having a robust continuous quality improvement process “has the potential to improve operations and prevent deaths.”
The citizens panel, which is convened every year and statutorily required to perform site visits to county jails, focused its review on four specific areas: requests for medical and mental health services, medication-assisted treatment for opioid-use disorder, grievances filed by people in custody and safety checks performed by deputies.
Jurors recommended that data tracking the agency’s performance in these four areas should be displayed in a dashboard on the sheriff’s website.
Sheriff’s officials declined to discuss the grand jury findings before they formally respond, as they are required to do within 60 days.
“We’re still reviewing the report, and we are not ready to comment on it at this time,” department spokesperson Lt. David Collins said by email.
The suggestion that the Sheriff’s Office implement a functioning continuous quality improvement effort is not new.
Experts in correctional health care have told the agency that adopting more consistent performance indicators would save lives.
In a sworn declaration on behalf of plaintiffs currently suing the Sheriff’s Office over its jail practices, Dr. Jeffrey Keller described continuous quality improvement programs in San Diego jails as inadequate — “meaning that critical errors go unaddressed, placing incarcerated people at a substantial risk of serious harm.”
“None of the elements that I would expect to see in an adequate CQI program are present in the jail’s medical system at this time,” he concluded in his August 2024 report. “If CQI is inadequate, mistakes — particularly repeated systemic mistakes like those I have identified throughout this report — are missed.”
This sentiment is echoed by other experts who submitted testimony in the class-action lawsuit.
Dr. Pablo Stewart, a psychiatrist who spent three days early last year touring San Diego County jails and interviewing staff and those in custody, also highlighted a lack of quality improvement processes for the delivery of mental health care.
“In my more than 35 years evaluating and working in detention facilities, I have come across very few, if any, mental health care systems so lacking in effective systems and levels of care,” he wrote.
The 17-page grand jury report includes specific findings and recommendations for improvement.
First, jurors noted that performance indicators could improve jail operations and promote transparency and accountability.
Jurors also found that the Sheriff’s Office lacks metrics to track requests for medical and mental health services. Implementing them could reduce the wait time for medical care and decrease deaths and other adverse outcomes.
Jurors credited a decline in overdose deaths to the implementation of medication-assisted treatment for opioid-use disorder — yet despite this success, they “found no evidence of any metrics that are being used as performance indicators” to make the program more effective.
The sheriff also does not collect data on grievances, a practice that could lead to better policies and improve overall jail conditions.
In his own report, Keller found that while the Sheriff’s Office tracks the number of grievances submitted, there was no analysis of their substance or outcomes.
“This grievance process should be viewed as an opportunity for improvement, not as a nuisance to be swept under the rug,” he wrote.
The grand jury also found that the sheriff does not track safety checks — required at least hourly by state regulations — for continuous quality improvement purposes, another practice that could reduce medical emergencies and save lives.
A 2022 state audit, initiated after a San Diego Union-Tribune investigation found that local jails had the highest mortality rate among California’s largest counties, flagged safety checks as an area that needed more rigorous quality assessment.
“In our review of 30 in‑custody deaths,” auditors wrote, “we found that sworn staff did not always perform safety checks adequately. As a result, they did not realize several individuals had died until hours afterward.”
The final recommendation calls on Sheriff Kelly Martinez to create a continuous quality improvement dashboard display available to the public on the department website.
Sharon Dolovich, director of the Behind Bars Data Project at the UCLA School of Law, said the kind of transparency the grand jury is recommending is key to making sure reforms stick.
“These are public institutions,” she said. “They’re paid for by the taxpayers. Their purpose is to serve the public interest in the name of the public. And if we’re going to know how well they function — and in particular how well they serve their primary purpose of caring for and protecting the people we incarcerate — we need to know what’s going on inside.”
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