Part two of a two-part series
How to assure appropriate peer evaluations
State in bylaws how decisions will be made
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
Peer review within the organized medical staff is a systematic effort to evaluate and analyze medical care services delivered to patients and to assure the quality and appropriateness of these services.
The goal of peer review is to maintain and improve the quality of medical care. To adequately fulfill their responsibilities, the medical staff should have clear definitions of how peer evaluations will be conducted and what constitutes an adequate review process. Last month in Part 1, suggestions for defining the circumstances requiring peer review were offered. Peer review descriptions and external review are covered this month.
Peer review is the process by which the practices of a physician or independent practitioner are examined to determine whether medical care services are being provided in compliance with applicable standards of care. This definition seems straightforward until it is applied to the process of peer review as it is now conducted in many hospitals. The hands-on medical record review that was first required so many years ago by the American College of Surgeons has been replaced by multilevel reviews conducted by both physicians and nonphysicians. It is not uncommon to find nurses or health information management professionals conducting first level peer review using screening criteria approved by the medical staff.
Cases identified through this process may then be evaluated by a medical staff department chairman or by a physician member of a designated peer review committee. It may not be until some aspect of patient care has been questioned that the case actually undergoes review by peer practitioners. These multilevel review steps should be clearly described in the medical staff rules and regulations or peer review procedures.
The question arises: Who are the peers conducting the reviews? If practitioners are not specialized in the area over which they are to conduct review, they may have difficulty in appreciating the full nuances of the case that they are reviewing. Ideally, a peer reviewer involved in making final determinations about the quality of medical care provided by a physician or an independent practitioner meets all of the following qualifications:
- holds a clinical specialty appropriate to the case under review;
- has medical practice experience appropriate to the case under review;
- is not an economic competitor of the practitioner under review;
- has no bias or conflict of interest with the practitioner under review.
The ideal cannot always be attained. Nonethe-less, when peer review may result in an adverse determination, it is important to involve practitioners with appropriate clinical expertise who have no bias or conflict-of-interest issues. When internal peer reviewers are not available due to the small size of the medical staff or a lack of practitioners that meet the above criteria, the medical staff should seek independent external review. External review services are available from various medical professional groups, peer review organizations, and proprietary medical review firms. To judge the appropriateness of an external reviewer, the medical staff should seek out a practitioner that meets at least the above criteria.
In some facilities, the medical staff require that external reviewers be licensed to practice in that state and be currently engaged in the required specialty or not more than five years removed from the practice of the specialty. In addition, it is common to require that external reviewers be board-certified in the specialty. If the external reviewer is a nonphysician health professional, he or she should be licensed and have demonstrated expertise in the field.
The medical staff procedures governing the peer review process should state the minimum qualifications for internal and external peer reviewers. In a multitiered peer review process, this may involve defining qualifications for people involved in each level of review. Reviewers that have a significant influence on the final peer review determination should meet the most stringent qualification criteria.
It is important to state in medical staff bylaws or rules and regulations how peer review decisions will be made. Spell out the steps of the process and the details of the appeals mechanisms. In addition, identify the grounds for final judgments that are made about the appropriateness, medical necessity, or efficiency of services. These factors may include, but are not limited to:
- medical care recommendations published in relevant evidence-based clinical practice guidelines and practice standards developed by professional medical societies, boards, and associations;
- community standards of practice;
- professional opinions of reviewers, including minority opinions;
- views of the physician or groups of physicians under review.
The American Medical Association recommends that final peer review decisions should be based upon acceptable medical practices, rather than considerations of cost or contractual limitations. If appropriate, this statement can be incorporated into the medical staff peer review policies.
If an adverse peer review decision occurs and the practitioner involved requests a hearing, it should be clearly stated in the medical staff bylaws that the hearing panel will consist of practitioners who are not direct economic competitors with the physician involved or who stand to gain through a recommendation or decision adverse to the physician. The physicians on the hearing panel need not be in the same specialty as the physician under review. However, they should be sufficiently knowledgeable in the areas of medical practice that are under question to be able to render a decision. Most medical staff bylaws already contain a detailed description of the appeals and hearing process.
New peer review intent statement
Many institutions typically define how peer review will be conducted in the medical staff bylaws, medical staff departmental rules and regulations, and/or quality management department procedures. The new peer review intent statement in the Joint Commission standards (MS. 8.3) does not require that hospitals create a separate policy document.
However, you will be expected to produce evidence that each issue has been adequately addressed by the medical staff. At the time of the survey, the surveyor will want see that your peer review program is systematic, consistent, nonbiased, and allows for timely improvement of patient care when problems are identified.
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