Managing Conflict of Interest | PeerPoints Newsletter

MANAGING CONFLICT OF INTEREST IN PEER REVIEW

Conflict of interest is one of the most difficult issues to overcome when conducting peer reviews among colleagues working together at the same hospital. The expanded role of peer review through focused and ongoing evaluation processes makes managing it an increasingly important consideration. Any internal peer evaluation must always factor conflict of interest situations into its process. Avoiding conflicts of interest requires that hospitals and ASCs educate medical staff and establish clear expectations.

Finding a suitable “peer” or “like specialist” within a hospital group or small community is sometimes impossible. If one does exist however, more than likely there are issues surrounding personal or professional relationships, perceived competition for patients or other conflicts of interest. Yet, to conduct a legitimate peer review, it is important for the physician under review to be a “true peer,” that is a physician in a similarly sized hospital with similar capabilities and in exactly the same medical specialty.

In Oregon, some smaller hospitals have banded together in a sort of “evaluation consortium” to handle physician evaluations and to eliminate bias. When necessary, the hospitals refer cases to an independent review organization (IRO) to match a reviewing physician with the one under review. This approach helps them avoid many of the potential conflicts of interest hospital administrators and peer reviewers ought to know. These include cases in which:

doctors who are partners in a business or are members of the same practice group;
doctors have a social relationship (for example, they attend the same small golfing club);
a hospital in which the reviewer has a financial or other interest (i.e., managing employee, medical director, hospital board member or stockholder);
involving groups where the reviewer practices;
a referral relationship exists;
the physician participated in the patient’s care or treatment plan;
any financial or other relationship exists or is contemplated;
relatives who are patients;
the physician has any prior involvement in the specific case under review.

New evaluations increase conflict of interest
The focused evaluation covers credentialing. It is an intense appraisal of a physician’s current competence and credentials and applies to new medical staff applicants and current practitioners who request new privileges. It also applies to practitioners with negative performances or those falling short of the volume of cases required for assessing practice competence.
The ongoing professional practice evaluation goes beyond the historical case-by-case peer review and evaluates clustered practice areas in the hospital. Hospitals and clinics now must supplement traditional evaluation practices with reliable outcome and performance data.
This information can come from many sources such as direct observation; practice patterns; aggregated analyses of resource usage; patient outcomes; complaints; peer review; and comparative performance measurements against large databases like the Society for Thoracic Surgery registry, or the American College of Cardiology and American Heart Association.

Improve conflict of interest awareness
A side effect of the Joint Commission standards is that the increased intensity of physician evaluations bumps up against conflict of interest more frequently. As hospital credentialing and privileging requirements call for more comprehensive peer reviews, hospital administrators and internal peer review committees must always consider conflict of interest when conducting focused or ongoing evaluations. Ignoring probable conflicts of interest opens the door for a “conflicted” specialist physician to review another involuntarily. In the long term, this can only decrease the quality of care, as well as patient safety.

To meet quality of care guidelines, ensure objectivity and bring about positive outcomes to protect patients, practitioners must review only others who are “like specialists.” That is, cardiologists should review cardiologists, not other internal medical specialists.

Demographics, too, can increase the chance a reviewer will have a professional, social or personal connection with other peer specialists that may taint the objectivity of a review. The size of the hospital group and the size of the community are factors for finding “like specialists” with no potential conflict of interest. In smaller communities and hospital groups, it is more likely that a “same specialist” will have a conflict of interest, because the community and the pool of specialists are smaller and the potential for professional or personal interaction higher.

Physicians conducting reviews should be educated about all potential conflicts of interest issues. Hospitals must understand the web of economic, competitive, and social or personal relationships that might raise concerns. Whenever a reviewer is in a partnership, competes for patients or socializes with the reviewed physician, the question of conflict of interest arises. An educated reviewer will alert the committee chair when a conflict exists and request an alternate reviewer. If a suitable one is not available, the committee chair should consider an external peer review.

Once a hospital establishes transparent standards and recognizes the social and professional interconnections among its medical staffs’ relationships, it can manage them. A hospital then can randomly select several cases from all practitioners to meet the ongoing evaluation requirement. Other hospitals are scheduling rotating ongoing evaluations of their medical staff several times a year with independent review organizations to eliminate conflict of interest concerns about their reviews.

Granting privileges and credentials
In the past, hospitals did not treat the credentialing, licensing and privileging of physicians as a peer review activity. Today they must. Due to long standing personal and professional relationships, staff constraints, limited time and similar issues, these processes in the past often defaulted to “rubber stamp” evaluations at some hospitals. Now the Joint Commission recommends all members of the medical staff regularly undergo a professional practice evaluation to re-credential them for continued membership and to reassign privileges and suggests re-evaluations at least every two years.

Re-credentialing involves evidenced based validation of a physician’s knowledge, skills, ability and behavior. As a result, hospitals increasingly view re-credentialing as a peer review activity and put practices in place to:

investigate and assess the professional and personal backgrounds of practitioners seeking initial appointment or applying for new privileges;
assign only the specific privileges supported by the practitioner’s training and experience;
periodically assess all members of the medical staff based on their performance before their reappointment;

Depending on a practitioner’s medical staff status — a new applicant or an existing practitioner requesting new privileges — the peer review process may involve solely a focused review or both a focused and an ongoing review.

For a new applicant, a focused evaluation process qualifies the practitioner for medical staff membership and specific patient care privileges. One way to handle this is to have a non-conflicted, like-specialty peer reviewer who’s currently on the medical staff review a sampling of the new applicant’s cases from other facilities where he already has privileges. For a practitioner requesting new privileges, conducting a focused evaluation after granting privileges can confirm competence further. In either case, when no “same specialist” is available, hospitals can consider an external peer reviewer to find one.

Whenever a current medical staff member requests a new privilege, hospitals must apply the focused evaluation process to qualify them. Again, the commission's standards expect hospitals to base their decision to grant, limit or deny requested privileges on evidence-based and clinical performance information. It is also common for a current member of the medical staff to request privileges for which the hospital has no documented evidence about the practitioner's ability. This may be because of several reasons:

new knowledge, education or techniques;
a low volume of cases;
clinical practice patterns not included in the performance data routinely reviewed by the medical staff; or
an insufficient number of the physician’s cases undergoing peer review.

Hospital quality managers and risk mangers are starting to recognize the importance of removing conflict of interest from the peer review process. To avoid conflict-of-interest concerns during all physician evaluations and ensure patient safety and quality care, a hospital should develop and communicate its policy and expectations regarding conflict of interest to its staff and have a policy in place explaining when it is appropriate to engage external reviewers.

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