So in January 2008, Judge Henderson replaced Sillen with J. Clark Kelso, a law professor (and former clerk to then-9 ^th Circuit Appeals Court Judge Anthony Kennedy) who had overhauled some of the states largest systems, including insurance and information technology. This was the most broken of the things that Ive been involved with, comments Kelso. ^[9]

Kelso took the job for three reasons. One was legal: he hoped to prove the current Supreme Court wrong in its reluctance to give district courts the authority to require government to carry out legally-mandated reforms. A second was personal: he admired Judge Henderson, who was nearing retirement, and wanted to help him reform prison healthcare. But most important, Kelso felt he could do the job. He says:

Id have real power and independence to come up with a plan, have [Henderson] approve it, and implement the thing, without too much interference from political forces. So I thought I could be successful at it.

System changes . Kelsos goal was to put in place a sustainable system that would thrive and survive after the receivership went out of businesshopefully by 2014and control of prison healthcare reverted to the state. To do that he needed to change not only the culture, but the organizational structure. One problem was that corrections personnelnotably the wardenremained in charge of each prison, including healthcare. Corrections officers historically had a single priority: security. Increasingly, this was at odds with the physician priority to provide compassionate care. Each prison already had a chief medical officer (CMO), but the CMO reported to the warden. The Receivers Office public affairs officer, Nancy Kincaid , notes:

The wardens were so entrenched in their culture, and custody didnt understand healthcare, usually didnt agree Their focus is putting all their resources towards security and safety. [Kelso] said we need management that knows healthcare. ^[10]

Listen to Nancy Kincaid discuss medical personnel reporting to wardens.

The solution was to create a new position within each prison of chief executive officer, or CEO. The CEO was the prisons senior healthcare official, charged with managing its resource needs from staff to administrative support, procurement and technology. The CEO had authority equal to the warden, but reported directly to Kelso. Eventually, CCHCS created and filled 25 CEO positions (to restrain costs, a few oversaw two prisons). The CEOs came from a medical management background. The arrangement was challenging, concedes Kelso.

Its been an often difficult thing to manage. Organizationally, its a little awkward when theyve got a bunch of employees who dont report to the warden.

In November 2010, Kelso brought in Dr. Steven Tharratt as statewide medical executive to coordinate all medical services across the states 33 prisons. Kelso also successfully sued the State Personnel Board to transfer physician review from the boardwhich knew nothing about medicineto a panel of three independent physicians. CCHCS had also instituted educational programs for physicians, along with a pilot program at the University of California-San Diego to bring medical students and residents into prison medical facilities.

Kelso also updated information technology. Many prisons still kept paper records; some of the older doctors had no idea how to use a computer. Installing IT for prisoners health records was additionally complicated because it required special security measures to meet privacy requirements. But by 2010, CCHSC had outfitted every prison with fiber optic lines and installed some 10,000 computers statewide.