Reader Question: Remember diplomacy in peer review process
Serious problems demand some kind of response’
Question: Our medical staff and our peer review department are struggling with how to handle pre-admission records that become part of the in-house peer review process. Obstetrical records, for instance, often include information about prenatal visits before the hospital admission. In a recent case, the peer review physician concluded that the patient should have been admitted earlier, at the time of a prenatal physician’s office visit. Following our peer review process, we sent the attending physician a letter outlining the concerns and required the physician to respond in writing. The physician refused, saying his pre-admission care was not subject to the hospital’s peer review process and the criticism should not go into his reappointment file at the hospital.
Another case involved a nursing home patient who got peritonitis from a feeding tube. The attending said the problem occurred before the patient was in the hospital, so it shouldn’t fall within the scope of peer review. Our physicians are torn, with one group saying they don’t want the hospital’s arm reaching into the physician’s office, and another saying they can’t ignore this information when it is available. What should we do?
Answer: Your physicians are right to think that they can’t just ignore this information if they suspect substandard care. But exactly how you handle pre-admission care in the review process will depend in large part on what you have spelled out in your peer review bylaws, says Janet Brown, RN, CPHQ, head of JB Quality Solutions in Pasadena, CA.
In any case, you will need to exercise some diplomacy to avoid alienating physicians. Much of your response will be determined by the physician’s relationship to the hospital. Is the physician’s office or clinic affiliated with the hospital? If so, then you easily can argue that care provided in that setting is subject to the peer review process. Is the physician a member of the hospital’s medical staff? If so, then there is little question that pre-admission decisions influence the care provided at the hospital and the physician’s competence as a staff physician.
In the examples cited, the physicians have admitting privileges at the hospital. Brown says that is enough reason to include them in the hospital’s peer review process, even when the care in question was provided elsewhere.
"It would be difficult for a physician to argue, with any sincerity, that his decision not to admit a patient had no bearing on his quality of care just because she was sitting in his clinic instead of the hospital building," she says. "The peer review process is about quality of care, and it would be wrong to draw a line at the hospital door and say you don’t care about anything that happened outside. It’s the same physician making decisions in both places."
There are some limitations, of course. The hospital’s peer review committee can’t get involved in just any of the physician’s cases, even when he or she is privileged at the hospital. But realistically, the only way a case would come to the peer review committee’s attention is when that patient is admitted to the hospital. There is ample precedent for reviewing care provided outside the hospital setting, Brown says. When a patient is discharged and then readmitted, state peer review organizations have the right to investigate the intervening care because it clearly can have an impact on the readmission.
However, these situations rarely will be black and white. Even if your peer review committee is justified in questioning the physician’s decisions, some diplomacy may be required to avoid creating animosity among your physicians. The less directly the physician is tied to the hospital, the more diplomatic you must be, she says. If a physician has no direct ties to the hospital other than admitting privileges, and if the situation does not involve a grave error, Brown suggests that you might send just a letter with a friendly tone rather than the standard notification from the peer review committee.
"In those cases and if it looks like just a one-time thing, you could just send a letter stating that the peer review committee has some concerns and leave it at that," she says. "The letter does not require any action by the physicians, so there isn’t much room for them to complain, and you’ve done the right thing by addressing the problem."
Brown suggests that it is entirely appropriate for that letter to be included in the physician’s reappointment file. If it is included, you probably should allow the physician to include a response if he or she chooses. That "courtesy letter" tactic will not be sufficient with more serious concerns, such as a major error or a pattern of questionable care. And she cautions that the hospital must consider potential liability when the peer review committee becomes aware of questionable pre-admission care.
"Serious problems demand some kind of response. At a minimum, you could have the department chair talk to the physician personally and send a letter indicating that your physicians have noticed the problem and recommend the physician seek a remedy," Brown says. "You’ll want to get advice from your attorney when it gets that serious and document everything you do."
Many of these dilemmas can be avoided by spelling out your hospital’s policy on pre-admission care in the peer review process, Brown says. One way would be to state clearly that your peer review physicians will consider all information available in the patient’s chart, even if it involves pre-admission care, and that the physician is obligated to adhere to the hospital’s peer review process as a requisite for privileges. "If you spell it out that clearly, everyone can understand it up front," she says. "Your physicians might not go for something that far-reaching, but you do need to establish some policy, maybe with courtesy letters for pre-admission care that is not a major concern, and put it on paper."
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