Part one in a two-part series
Peer review: Complying with JCAHO’s standards
A framework for legally defensible peer review
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
The present-day model for hospitals’ organized medical staff was first introduced in 1919 by the American College of Surgeons.
The same basic model persists to this day. Peer review activities have always been an important responsibility of medical staff. Since 1919, accreditation and certification requirements and liability concerns have reshaped the peer review process. Elements such as "due process" and immunity for "good faith" peer review are now integral components of peer review.
However, the basic intent remains the same — to ensure that competent and reputable physicians practice in the hospital.
Perhaps because medical staff peer review has been around for so many years, we take it for granted that everyone has a clear understanding of what this review entails. However, the recently issued revisions to the intent statement of the Joint Commission on Accreditation of Healthcare Organization’s Medical Staff Standard (MS.8.3, Peer Review) are forcing hospitals to revisit the definition of peer review and the processes involved.
The revisions, which were effective for accreditation in mid-2000, require that the medical staff have these components:
- definition of circumstances that require peer review;
- definition of "peer" and specification of the participants in the peer review process;
- method for selecting peer reviewers in specific circumstances;
- established time frames for peer review activities, including time frame for obtaining results of peer review;
- definition of the circumstances in which external peer review is required;
- mechanism to allow the individual whose performance is under review to participate in the peer review process;
- peer review program that is consistently followed within each department/discipline;
- mechanisms to ensure that the process of peer review is conducted in a legally defensible manner;
- mechanisms to ensure that minority opinions and views of the individual under review are considered during the peer review process;
- access to peer review information that is useful for credentialing purposes and for monitoring the quality of patient care;
- methods to track and trend peer review information and monitor of the effectiveness of peer review decisions.
These requirements are not prescriptive, in that no specific definitions or processes are required. The medical staff retain the right to make whatever decisions are appropriate to the circumstances in their facility and within the constraints of any applicable state or federal laws.
These new medical staff requirements don’t imply that the peer review process in your facility needs to be reinvented. What the Joint Commission has given hospitals is a framework for effective and legally defensible peer review. Since peer review has been done for years, you’ll probably find that many of the definitions and processes required by this framework are already in place. The statements necessary to meet the medical staff peer review requirements are likely to be scattered throughout several different documents, either the medical staff bylaws, rules, and regulations or in policies and procedures.
What is needed are clearly written explanations. You may find that a particular issue, such as external review, has never been discussed by the medical staff (usually because the question has never come up). Focus on finding the missing or unclear definitions, statements, policies, or procedures. Then start the medical staff discussion and approval process that needs to take place in order to meet the Joint Commission’s requirements. In this two-part series, the issues mostly commonly missing or ill-defined in medical staff peer review processes are discussed.
Peer review can be initiated for a single event or for a pattern of practice or behavior. It is up to the medical staff to define what constitutes an event or pattern that is subjected to peer review. This definition should be as specific as possible without creating unnecessary work for peer review committees. A statement such as the following may suffice: "Peer review will be initiated whenever the activities or professional conduct
of any practitioner with clinical privileges may appear to be detrimental to patient safety, to the delivery of quality patient care, or disruptive to the facility." The medical staff may choose to define the types of situations that will be investigated further through the peer review process. This may include, but should not be limited to, the situations of possible or suspected:
- exposure of patients to a risk of harm;
- unprofessional conduct;
- inadequate patient care;
- nonconformity to the minimum standards of medical practice;
- impairment of the person’s ability to practice for any reason.
Remember, initiation of peer review does not in any way suggest wrongdoing by a practitioner. The medical staff must carefully word statements so as not to imply that peer review is a punitive or disciplinary action. Peer review should be viewed as an educational process for physicians to assure quality medical services.
Along with the general statement of the circumstances for which peer review will be initiated, the medical staff can include a description of the methods for identifying circumstances requiring peer review. For example:
- concurrent and retrospective case review by designated hospital staff using criteria and/or occurrence screens approved by the medical staff;
- patient care studies initiated by the medical staff that are conducted for the purpose of analyzing, reviewing, and evaluating the quality of patient care;
- written referrals received by the medical staff president from an officer of the medical staff, the chair of any medical staff standing committee, the hospital’s chief executive officer, or a representative of the hospital board of directors.
The circumstances requiring peer review must be consistent among all departments of the medical staff, although the process for identifying cases or patterns can vary slightly. Consistency is an important aspect of a legally defensible peer review process.
Medical staff departments can formulate their own rules and regulations for the conduct of peer review activities, but such rules and regulations should be consistent with the medical staff bylaws or general rules and regulations.
In next month’s Quality-Co$t Connection column, you’ll find a definition of peer review, a description of reviewer qualifications, plus examples of the situations in which external reviewers may be used by a medical staff.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content