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Payer's Edge - Peer Review Best Practices

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PEER REVIEW BEST PRACTICES ACROSS YOUR ORGANIZATION

Early detection and resolution of issues reduces negative consequences for both physicians and hospi-tals. In addition to minimizing harm to patients, it also minimizes liability exposure of practitioners and the hospital’s financial losses. Peer review not only detects and resolves physician performance issues that can lead to loss, but also prevents medical errors through increased transparency and accountability, reduces negative consequences and costs for both the physician and the hospital, and reduces risk of litigation between facility and physicians, when managed properly.

Effective, proactive, educational peer review requires a strong framework. A uniform, detailed framework not only facilitates the peer review process, but also makes peer review a more objective, defensible process. Effective peer review relies on a number of factors:

  • Effective leadership and a supportive culture
  • Efficient operations
  • Effective evaluations
  • Compliance with accreditation standards
  • Ongoing program assessment leading to continuous improvement

Working together, each system should be structured as a joint venture between the medical staff and administration and strongly supported by the hospital's leadership team. This allows the medical staff and administration to create a strong peer review framework that addresses their respective concerns and issues and accommodates the hospital's structures, services, data capabilities, and political environment.

Leadership / Culture Best Practices

The peer review system should be structured as a joint venture between the medical staff and administration and strongly supported by the hospital's leadership team. This allows the medical staff and administration to create a strong peer review framework that addresses their respective concerns and issues and accommodates the hospital's structures, services, data capabilities, and political environment.

The key to effective peer review is leadership's support for developing a strong process that is proactive in nature. A proactive approach to peer review facilitates identification and resolution of potential problems at their onset, thereby increasing a patient's safety and the quality of care.

Commitment to continuous improvement through education, rather than punitive actions, promotes a culture that is open and honest about deficiencies. Peer review should provide objective evaluations in a non-punitive, educational context that supports a healthy culture of continuous improvement. Educational peer review, for both the practitioner and the hospital, is a tool for identifying, tracking, and resolving inappropriate clinical performance and medical errors in their early stages.

Ongoing evaluation of physicians can also uncover problematic practice patterns, as well as physician- and hospital-level issues that need to be addressed. Increased transparency and accountability results from physicians knowing that their work will be objectively evaluated at regular intervals, thereby leading to improved quality of care and patient safety and, over time, reducing a hospital's professional liability claims and costs.

A strong framework for peer review, with clearly defined performance expectations and objective processes, provides practitioners and staff with the knowledge that any concerns they raise regarding a practitioner's performance will be taken seriously and fully investigated by medical staff.

Peer Review Operations Best Practice

In most hospitals, the peer review system is described in the medical staff bylaws, in a peer review policy and sometimes in medical staff policies and procedures. The bylaws should clearly define the structure, policies, and procedures for both internal and external peer review. Well-written bylaws clearly define the purpose of the medical staff and outline the rights and responsibilities of its members; enhance credentialing, privileging, peer review, and performance-improvement processes; and set unequivocal expectations for appropriate behavior.

Effective peer review requires a centralized multidisciplinary peer review system that utilizes a uniform method for peer review activities. The peer review system should be designed with a strong multidisciplinary peer review committee established as a subcommittee of the MEC, which is ultimately responsible to the board for ensuring that the peer review program is carried out by its medical staff in accordance with the intent and procedures documented in the organization's peer review policies. The peer review committee should have overall jurisdiction for the operation of the peer review system, assuring the MEC that all required peer review procedures and required program elements are effectively implemented. This is essentially important for identifying and eliminating COI.

Hospitals should provide peer review committee members with proper training. The peer review process can be streamlined by limiting the number of committees. All peer reviews should be completed within 30 days of initiation, and ideally within one week. Hospitals should make arrangements to have a review conducted externally if it lacks adequate physician resources to conduct timely performance analyses.

Practitioner Evaluation Best Practices

The hospital and medical staff should jointly define what is meant by quality of care, appropriate re-source use, patient safety, professionalism, and accountability for active participation as a team member in the care system. Setting these expectations ensures that practitioners are treated uniformly and held up to the same standards, while ongoing monitoring helps to promote practitioner compliance with these expectations—practitioners may resist and/or protest the hospital’s findings and actions even when they are legitimate.

Once the medical staff leadership has set and communicated practitioner performance expectations, they must ensure that all physicians know that their performance will be measured, how it will be moni-tored, and how it will be compared to that of their peers. Evaluations of practitioner performance should be conducted regularly and not just at the time of re-appointment, and data should be main-tained for all practitioners. Some cases may require further investigation of a practitioner’s performance.

Hospitals must identify triggers for focused evaluations and apply them consistently. All deviations from performance expectations should be investigated, with action taken when warranted.

Examples of cases or events that might trigger peer review include:

  • Unexpected patient death
  • Complication
  • Delay in diagnosis or treatment
  • Wrong site of wrong patient procedure
  • Disruptive practitioner behavior
  • Inadequate hand off among practitioners
  • Missed or wrong diagnosis
  • Serious patient complaint

Hospitals must have a comprehensive COI policy that clearly defines both real and perceived COI and how it is to be avoided. Physicians conducting reviews should be educated about all potential COI is-sues. Hospitals must understand the web of economic, competitive, and social or personal relationships that might raise concerns. Whenever a reviewer is in a professional partnership, competes for patients, or socializes with the physician undergoing review, the question of COI arises.

An educated reviewer will alert the committee chair when a conflict exists and request an alternate re-viewer. If a suitable one is not available, the committee should seek an external peer review. Specific provisions should be made for the use of external peer review when peer review committee members are compromised by COI, when a practitioner under evaluation is in a position of authority on the medical staff or MEC, or whenever the sensitivity of the case makes it difficult for the peer review committee to objectively evaluate cases.

Potential COI are not limited to any one particular specialty. Many hospitals must deal with a limited number of specialists on staff, which increases the potential for professional or personal relationships, just as smaller hospital groups and hospitals in smaller communities face the challenge of matching spe-cialists because the pool of specialists is smaller and the potential for COI is higher.

To meet quality-of-care guidelines, ensure objectivity, and bring about positive outcomes to protect pa-tients, practitioners must review only others who are “like specialists.” That is, cardiologists should be reviewed by cardiologists, not other internal medical specialists. Similarly, general practitioners may not have the training or experience in the multidimensional approaches to treatment or have the most up-to-date information for standards of care used in specialties such as interventional cardiology or neurosur-gery. An evidence-based approach requires review of actual work performed by a specialist with the same credentials and practice experience.

Conclusion

An effective peer review program requires strict adherence to peer review best practices and a strong framework. When used consistently and proactively this peer review system will improve patient out-comes, enhance safety, and mitigate liability for hospitals and physicians.