Credentialing becomes a priority for JCAHO
New guidelines go into effect this year
Your medical staff credentialing and peer review policies may be coming under careful scrutiny in the months ahead as the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) takes aim at the effectiveness and professionalism of evaluation processes.
When JCAHO met for its most recent annual Executive Briefings Conference, the peer review process was a topic that commanded specific attention. A list of characteristics for peer review was developed that could eventually be incorporated into JCAHO standards.
Current standards require that peer recommendations and results be considered in credentialing and privileging decisions (MS.5.7, MS.5.12 MS.5.12.3). The standards charge the medical staff with responsibility for conducting peer review activities when issues relevant to an individual’s performance are raised (MS.8.4).
The object of the changes is to make life easier for the surveyors. If the hospital’s peer review process follows the Joint Commission’s guidelines, surveyors should be able to determine whether a peer review process exists in a well-designed, functional mode. The Joint Commission says it will not take decision-making or judgement outcomes away from the hospital. Essentially, surveyors will be looking at the design and function of peer review and credentialing processes.
Peer review can vary quite a bit’
"From the point of view of the standards right now, there is only a loose reference to peer review [MS.8.3]," says Herman Williams, MD, MPH, MBA, medical director for peer review at the Greeley Company in Marblehead, MA. He notes that with the new guidelines, "they’re paying attention to the evaluation of quality work of physicians by physicians. Peer review can vary quite a bit from medical staff to medical staff around the country," he adds. "Everybody is performing it, but the problems inherent in the peer review process are addressed [in the JCAHO memorandum]."
"This all became necessary because the Joint Commission’s standards were lacking in specificity regarding peer review," agrees Christine Otto, CMSC, CPCS, CPHQ, president of Christine E. Otto & Associates, a health care consulting firm in Pasadena, CA. She serves on the JCAHO Professional Technical Advisory Committee (PTAC) for the Hospital Accreditation Program, representing the Austin, TX-based National Association Medical Staff Services. "Information regarding an applicant should be provided by peers of that applicant," Otto says. "The Joint Commission surveyors had the additional burden of trying to determine if meaningful information resulting from peer review activities was utilized and considered during the credentialing process."
The characteristics JCAHO has determined to constitute an acceptable peer review process are outlined in the box accompanying this article. (See box, above.) Facilities that base their peer review plans on the itemized characteristics face a likelihood of making "reasonable" peer review decisions, according to the Joint Commission’s article on process changes in Joint Commission Perspectives (2000; Jan./Feb.:10).
The article states that surveyors will gauge the effectiveness of an organization’s peer review and credentialing processes and determine how effectively the two are joined. Surveyors will use meeting minutes, incident logs, and other information as they sample cases selected for peer review.
Otto further explains that PTAC established that there was a real need for strengthening the peer review process, so the new guidelines can be expected to benefit hospitals and their medical staffs.
But hospitals should begin preparing their peer review processes now. "Many organizations already have peer review guidelines in place," Otto says. "But hospitals will have to look at their methods carefully relative to the new guidelines. As I understand it, surveyors will be looking at medical executive committee minutes and peer review policies."
She adds that the new guidelines are an interesting development because for the last several years, PTAC and the Joint Commission were trying to be less prescriptive in their recommendations and allow hospitals more flexibility with their policies. "But these guidelines were needed," she emphasizes. "There was not enough structure in place in this area."
The guidelines are not altogether rigid. For instance, each facility will now determine time lines for completing an effective peer review. "But the facility must design reasonable guidelines," Otto cautions.
Hospitals also will be expected to specify circumstances for external peer review. As an example, Otto describes a small community with two competing OB/GYN groups. "If one of the competing physicians identifies a potential peer review issue pertaining to a doctor in the other group, that is a situation which would justify going outside the hospital community to find an independent OB/GYN to act as an arbiter in the peer review process."
With the new guidelines, JCAHO defines the properly designed peer review process, as well as the characteristics of an effective peer review.
"Having peer review guidelines will be protective for those individuals being reviewed," Otto points out. "The guidelines will help eliminate some of the subjectivity previously associated with peer review by requiring the medical staff to have objective and well-defined peer review criteria in place."
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