Guest Column: Establishing an effective peer review process
An examination of the fundamentals
By Thomas A. Sifner
Chief
Credentialing and Privileging Unit
Department of Veterans Affairs Chicago Health
Care System
In the constantly evolving health care industry, no single issue commands greater attention or consideration than the peer review process. Today, the peer review process has advanced to the forefront of importance for many health care institutions and entities.
Recently, the Joint Commission on Accreditation of Healthcare Organizations has included peer review in its survey process. More importantly, the process allows the medical staff to ensure quality care through a systematic procedure of reviewing their peers and defining a peer review method. All practitioners should be subjected to a consistent, fair, and well-defined process.
The purpose of this article is to provide guidance for the design of the process and to provide suggestions for an effectively functioning peer review process.
First and foremost, it should be explicitly clear to define those circumstances warranting peer review. These conditions for review should be as specific as possible, and as inclusive as practical. The individual circumstances requiring peer review should be written in the bylaws, policy, or hospital memorandum format, so it is clear to the practitioner which variables he or she is being judged upon. It should be recognized that health care institutions are structured differently, and the design should be specific to the institution. These conditions for review should be as specific as possible, clear, and measurable.
These circumstances can be incorporated within the occurrence screening process. That is, readmissions within 10 days, returns to the OR in the same admission, and admissions within three days of an unscheduled ambulatory care visit are examples requiring further review in the peer review process. Other possible examples include, but are not limited to, perceptions of substandard care, professional incompetence, gross negligence, conduct unbecoming, or increased incidence of patient untoward events, as expressed on patient incident reports.
Specify participants in peer review
Second, the participants in the review process should be specified. Generally, this is best accomplished through a peer review panel or committee. The medical director, chief of staff, or their designee serves as the chairperson of this panel. Each department head or section chief is entitled to nominate individuals for the peer review panel. The goal is to create a cross-section of all specialties, all of whom are equally trained, capable, and qualified to review care rendered by a peer. For purposes of design of the peer review process, a peer should be defined as a professional in the same or related specialty of practice as the individual whose services are being reviewed.
Once a panel or committee is established, the chairman can assign a peer reviewer based on the information about the reviewable event supplied to the committee. The chairman should be acutely aware of any conflicts of interest, personality differences, or professional practice arrangements that may preclude the reviewer from being fair and objective.
Because constructive feedback and/or discipline within health care circles should be timely, specific time guidelines should be established. The committee may want to meet monthly or at the call of the chairman. From that point, 30 days should be allowed for a recommendation involving one of its practitioners.
From time to time, circumstances involving external review may occur. Examples include small specialized sections, such as podiatrists at small community hospitals.
In cases like these, peers knowledgeable and experienced to assess professional competence are not readily available; therefore, these issues would need to be referred for external review. In addition, should a situation exist where those available professionals could not be fair and objective in their review, evaluation should be performed by an external review source. Lastly, should there be a bona fide conflict of interest involving the peers, these cases should be referred away for external review.
The reviewee has the right to due process in peer review. Some hospitals and health care institutions have this process explicitly spelled out in their bylaws or personnel manuals. The reviewee should be presented with the facts concerning his peer review with the opportunity to provide a written synopsis to the peer review panel. The peer review panel should give full and impartial consideration to an oral reply as well.
Equally important as the design of a peer review process is the maintenance of an effectively functioning peer review process.
It is imperative the peer review process function consistently and fairly by adhering to all of the established guidelines and policies that govern its implementation. The established design and standards should meet the organization’s goals and objectives for an effective process.
Because all feedback and review should be timely, the established time frames in the design phase should be followed closely. Stipulations for the delay of any peer review should be written into the process, because an occasional delay can be expected in certain circumstances.
Conclusions reached by the individual or panel need to be substantiated by clear reference to current literature and relevant clinical practice guidelines. Use of a numerical scale (1-5), indicating how the practitioner’s care would fit in relation to care delivered by one of his peers, has been useful for many institutions. The number one is generally the same standard of care rendered by his peers, advancing upward to the number five, where the standard of care is far removed from his or her peers under similar circumstances. Be sure to consider personal differences in the delivery method of health care, such as alternative medicine and circumstances surrounding the incident in question.
As is true with all clinical activities within a health care scenario, the peer review process should be incorporated into the organization’s performance improvement activities. The culmination of all these data is useful in provider-specific privileging decisions, as well as risk management activities. All performance improvement activity should be ongoing and monitored for efficiency and effectiveness.
If the peer review process is designed properly and functions effectively, it can be a useful and valuable tool for a health care entity. It should not be viewed strictly as a potential disciplinary process, but as a review mechanism to improve patient care. The Joint Commission will assess not only whether a peer review process exists, but how well it is designed and how well it functions. This will challenge all health care facilities to maintain processes that are in the overall best interest of quality patient care.
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