Optima Healthcare Insurance Services

ABBREVIATED
GUIDELINES
FOR
EFFECTIVE PEER REVIEW
A summary of essential information
for the CEO, Chief of Staff & Medical Staff Leadership

September 2013

References
1. Effective Peer Review, A Practical Guide to Contemporary Design
By Robert J. Marder, MD and Mark A. Smith, MD, MBA, FACS
2. Optimal Review edition Focusing on Effective Peer Review, Winter 2008
3. HCPro MS Leader Connection Tip of the Week, August, 2010
4. HCPro MS Leader Connection Tip of the Week, July, 2011

Limitations of Report
These materials are provided as a service to the owner/insured facilities of California Healthcare Insurance
Company (CHI) and are intended to identify certain risk exposure issues that may be of general interest to certain
CHI members. The materials do not constitute legal advice or legal services nor are they intended to amend,
modify, waive or otherwise alter any of the rights and obligations of CHI or any CHI member under existing
insurance coverage. Because the suggestions and information set forth herein are general, they may not apply to
each CHI member’s particular set of legal or factual circumstances. Accordingly, a CHI member should not take
(or refrain from taking) any action based on the suggestions and information contained herein without first
consulting with such member’s risk management team or other professional advisors in accordance with its
customary business practices.
 ESSENTIALS OF PEER REVIEW
Checklist for Effective Peer Review Process

 A culture of accountability has been defined by the Medical Staff and incorporated in the
Medical Staff Bylaws, Rules and Regulations, Policies, and informational brochures.
 The medical staff has determined which indicators require immediate peer review, and
which indicators can be tracked with a threshold determining review.
 A “peer” is defined, and selection criteria for qualifying to participate in the peer review
process are defined. Examples are provided of when specialty to specialty peer does and
does not need to be used.
 Physicians participating in peer review receive multi-level training on the process, ways
to manage conflicts of interest, the investigation process, timelines and documentation.
Peer physicians have the opportunity to interact to discuss processes.
 Protocols for the peer review process are clearly defined, and include the role of all
parties involved in the process, timelines to be met, and documents to be generated.
 The policy on peer review includes specific reasons which require outside peer review.
 A system has been developed for maintaining all documents associated with any peer
review activities. A policy defines what and what is not protected, and how documents
will be managed and secured.
 The process of investigating an event requiring peer review is defined.
 Models for interventions or corrective actions are provided to the peer review committee.
 For physicians with acceptable practices, letters or quarterly reports are sent to physicians
which include the reason the case or situation fell out for review or indicators, the fact no
concerns were discovered and as appropriate, positive comments about the physician’s
management of cases.
 For physicians with unacceptable practices, letters are sent to the physicians who are
being reviewed and include the reason the case was identified, clear questions generated
from a preliminary review and, for follow-up after the review meeting, the rationale and
associated guidelines behind the concern for a practice.
 Due process for hearings and appeal are clearly defined.
 Findings are integrated into quality, safety, risk management and credentialing.
 There is a system for routinely providing feedback to leadership for improving the
process.

Abbreviated Guidelines for Effective Peer Review/Optima 2

 Effective Peer Review Starts With the Credentialing Process

The organization can ensure it brings in the most qualified and appropriate physicians who are
committed to best practices within the organization by setting the highest standards possible for
medical staff appointment. Selecting a Task Force to set the standards for membership, giving
the medical staff an opportunity to discuss and revise, and then integrating these expectations
into appointment, reappointment, and physician performance evaluations will set the foundation
for effective peer review. This checklist can also be used during the transition of medical staff
leadership to promote understanding of the culture and processes established in the organization.

Checklist for Creating an Effective Process

 Physician performance dimensions have been defined
Set expectations for technical quality of care, quality of service, patient safety and patient
rights, resource use, peer and coworker relationships, and citizenship.
 Cultural values and behaviors have been selected
Sources to assess: Bylaws, rules, regulations, policies; medical society recommendations;
leadership experience and vision; current common practices; case review findings; patient
and family feedback and incident reports.
 Key performance issues are identified
Sources to assess: Medical staff indicators, administrative and staff complaints, patient
satisfaction data, case review findings, incident reports, and leadership experience.
 Each cultural and performance behavior is articulated as an expectation
Process: Have one or two “author” a list for discussion, have a group triage the list for
inclusions and exclusions, have the author rework controversial expectations, discuss
revisions, then determine initial list for distribution and feedback.
 Obtain Medical Staff feedback and approval
Process: Modify after MEC review, distribute to Medical Staff for feedback within
defined timeframe, discuss at either department or staff of the whole meetings, modify
again and submit final draft to MEC for approval.
 Develop mechanism to communicate expectations
Opportunities: Appointment orientation, reappointment, physician performance
evaluation, each time medical staff policies updated, general staff meetings.

Defining Peer Review

What Peer Review IS

“Peer review” is the evaluation of an individual practitioner’s professional performance and
includes the identification of opportunities to improve care. Peer review differs from other
quality improvement processes in that it evaluates the strengths and weaknesses of an individual
practitioner’s performance, rather than appraising the quality of care rendered by a group of
professionals or by a system.

Abbreviated Guidelines for Effective Peer Review/Optima 3

Peer review is conducted using multiple sources of information including: 1) the review of
individual cases, 2) the review of aggregate data for compliance with general rules of the
professional staff and clinical standards, and 3) use of rate measures in comparison with
established benchmarks or norms.

What Peer Review Is NOT

“Peer review is NOT mortality and morbidity conference, a root cause analysis, nor a systems
improvement process.”

Example of Separating Root Cause/Systems Improvement and the Peer Review Process

Scenario Root Cause Analysis Role: Systems Peer Review Role: Individual

Wrong site How did our systems fail so that a Why did the Dr. operate on the wrong
surgery – surgeon could operate on the wrong site?
Left knee knee?
instead of Were known policies such as site
right knee How are surgeries booked? confirmation and time outs ignored?
How accessible is the clinical Did the doctor proceed without waiting for x-
information? rays?
How do we train new staff on prevention Did the doctor ignore concerns by the staff?
of wrong site surgery?
How do we mark sites?
Are we using checklists?

Choosing Indicators for Peer Review

Establishing the types of indicators to be used, and how they will be used, helps set the tone for
fairness and is the guidepost for selecting the appropriate “peer”. Greeley organizes indicators
into three groups: review, rule and rate indicators.

Type of Indicator Comments

Review Indicator
Identifies a significant event that
ordinarily requires analysis by
physician peers to determine cause,
effect and severity.
Rule Indicator
Represents a general rule, standard,
professional guideline or accepted
practice where individual variation
does not directly cause adverse
patient outcomes. Ideally should
always be in compliance. Isolated
deviations only represent a minor
variation.
Most common type of review. Analysis required by appropriate
peer review committee. Documentation of communications to be
maintained in medical staff file for immediate action and/or future
reference.
Example: Patient dies in recovery room.
Group determines target number of events per indicator that will
trigger review. As individual rule indicators occur, findings
automatically sent to provider with copy in medical staff file. Once
threshold met, referred to chairpersons of quality committee and
appropriate department for decision on how to proceed.
Document decision in file.
Example: Physician orders medication not on formulary for
challenging case, or leaves surgery for personal business with no
patient injury.

Abbreviated Guidelines for Effective Peer Review/Optima 4

 Type of Indicator
Rate Indicator
Cases or events that are aggregated
for statistical analysis prior to
review by appropriate committee
or administrative function. Can be
expressed as average, percent, and
ratio. Target range is established
for each rate indicator and is based
on internal targets.
Comments
Feedback provided to individual physician on a regular and timely
basis. Physicians falling outside target range are referred to
leadership of appropriate medical service to determine if any action
warranted.
Example: Target range for elective inductions is that 100% of
babies are at least 39 weeks prior to elective induction.
FOR ALL 3 INDICATOR REVIEWS, PHYSICIANS
SHOULD BE PROVIDED LETTER OR REPORT WHEN
DOING WELL, OR NO ACTIONS TO BE TAKEN.

Identifying a Peer

Who is a Peer
A peer is an individual practicing in the same profession and who has expertise in the appropriate
subject matter. The level of subject matter expertise required to provide meaningful evaluation
of a practitioner’s performance will determine what “practicing in the same profession” means
on a case-by-case basis.

For quality issues related to general medical care, a physician (MD or DO) may review the care
of another physician. For specialty-specific clinical issues, a peer is an individual who is well-
trained and competent in that specialty area. Being a peer requires impartiality, objectivity, fair
mindedness, and willingness to let the peer review committee make the final decision.

Challenges to selecting a peer can include lack of leadership to provide objective oversight,
conflicts of interest and competition in a small department, lack of internal structure to ease the
peer review process, and mistrust of process due to past failures of system.

Example of Use of Peers: Same Doctor (Interventional Cardiologist) – Different Scenarios

Scenario 1 Scenario 2 Scenario 3

Patient had cardiac catheterization,
and began to bleed into the
retroperitoneum, becoming
hypotensive and anuric. Dr. delayed
fluid resuscitation and blood
transfusion and patient developed
acute renal failure.
Issue: Basic hemorrhagic shock.
Any physician can evaluate care.
Post catheterization patient has
developed hematoma at site of
puncture; hemoglobin has decreased
by 1 gram and now hypotensive. Dr.
orders Hgb level for following
morning. Patient has developed
acute renal failure in morning.
Issue: Same as scenario 1
Any physician can evaluate care.
Patient had multiple stents in
coronary arteries and patient later
suffered a myocardial infarction.
Issue: Did stents contribute to MI?
Need technical assessment by
Board certified interventional
cardiologist

Abbreviated Guidelines for Effective Peer Review/Optima 5

Resources for Medical Staff Leadership Development and Peer Review Training

1. The Greeley Company, Danvers, MA

www.greeley.com
 The 2014 Leadership Seminar Series includes: Clinical Integration, Peer Review Boot
Camp & the Medical Executive Institute.
 Also, the Greeley Medical Staff Institute provides customized education and training
that will help create consensus for change and implementation of practical and
sustainable solutions.
2. Horty, Springer, & Mattern; Pittsburgh, PA
www.hortyspringer.com
 The 2014 Courses include: The Complete Course for Medical Staff Leaders, The
Credentialing Clinic & the Peer Review Clinic.
3. HCPro Healthcare Marketplace resources:
a. Effective Peer Review: The Complete Guide to Physician Performance Improvement,
Third Edition by Robert J. Marder, MD. Published: 5/30/2013.
b. The Medical Executive Committee Manual by Mary J. Hoppa and William F. Mills.
Published: 10/11/2013.

Abbreviated Guidelines for Effective Peer Review/Optima 6

 Outsourcing Peer Review

When to Outsource Peer Review

 Litigation – dealing with the potential for a lawsuit
 Ambiguity – there are vague or conflicting recommendations from internal reviewers or
committees, and conclusions will directly affect membership or privileges
 Lack of internal expertise – no one else on staff has adequate specific expertise and the
case requires technical expertise of that specialty
 Conflict of interest – qualified reviewers have a business – or other conflict of interest
 New technology – physician is providing service new to hospital
 Miscellaneous issues – expert witness for fair hearing, evaluation of credential file,
assistance for developing benchmark for quality monitoring, other circumstances deemed
appropriate by MEC or governing body

The above conditions can apply to both focused and ongoing practice evaluations.

Resources for Outsourcing Peer Review

California
1. Medical Peer Review Services, LLC, Los Angeles, CA
www.mprsllc.com
2. Institute for Medical Quality, San Francisco, CA
www.imq.org
3. Advanced Medical Reviews, Los Angeles, CA
www.admere.com

Other National Organizations*

4. AllMed Healthcare Management, Portland, OR
www.allmedmd.com
5. MD-Review, Ketchum, ID
www.md-review.com
6. American Medical Foundation for Peer Review and Education, Philadelphia, PA
www.medicalfoundation.org (non-profit)
7. Independent Medical Expert Consulting Services, Lansdale, PA
www.imedecs.com
8. National Peer Review Corporation, Northbrook, IL
www.nationalpeerreview.com
9. Permedion, Westerville, OH
www.hmspermedion.com
*There are numerous organizations across the country available to assist – these are just a few examples.

Abbreviated Guidelines for Effective Peer Review/Optima 7

 Elements of an Effective Peer Review Policy

 Purpose
 Goals
 Definition of key terms
 Conflict of interest explanation
 Source of authority and oversight for peer review process
 Statutory authority
 List of persons authorized to have access to peer review information
 What will comprise peer review documentation
 How peer review documentation will be protected
 What indicators will trigger internal peer review
 What circumstances will require external peer review
 Who will be selected to participate in the peer review process
 How conflicts will be managed
 Thresholds for intensive review
 Time frames for completing peer review

Peer Review Policy and Procedure Sample:

Providence Health & Services – Oregon (PHSOR)

Professional Staff Peer Review Policy - 2013

This policy includes attachments of the following:
 The Assessment of Clinical Competence
 Peer Review Process & Timelines
 Professional Staff Performance Indicators
 Peer Review Form

See also PHSOR Professional Staff Bylaws, Policies & Procedures.

Abbreviated Guidelines for Effective Peer Review/Optima 8

 When Your Peer Review Program is Not Functioning Well

Signs There is a Problem with the Peer Review Process

 There is a general attitude within the medical staff that peer review is painful, a waste of time
or punitive.
 The process of completing peer review is cumbersome for the reviewer and reviewee.
 No training program exists on how to conduct peer review.
 Physicians participating in peer review do not meet timelines and are vague in comments.
 Cases “disappear” with no results.
 All cases are treated equally instead of falling into the appropriate indicator category.
 Criteria for review are too broad, too narrow or too subjective.
 No guidelines or models are available for how to move findings into performance
improvement.
 Competing biased physicians are allowed to review each other.
 One physician intimidates the reviewers.
 No benchmarks exist for rule and rate indicators.
 Because the patient does not incur injury, the reviewer or department chair finds no fault with
medical staff ignoring policies.
 Too many invalid reviews have occurred, undermining the medical staff’s belief in peer
review.
 Concerns of reviewer are not supported by data; burden of proof that a problem exists is not
met.

How to Move From an Ineffective to an Effective Peer Review Program

 Analyze the Process

 Use the checklist to analyze current practices and obtain feedback from Medical Staff
leaders
 Prioritize the use of resources for measuring physician performance

 Eliminate Bias
 Standardize and coordinate the case review process to ensure reliability
 Select relevant physician measures for all performance dimensions or general
competencies
 Ensure consistent interpretation of physician performance data
 Use multidisciplinary committees to provide first level review
 Ensure any conflicts of interest are known to the peer review committee

 Ensure Accuracy
 Ensure that data is systematically collected and analyzed
 Prevent inaccurate data from creating a cloud of distrust over the entire performance
report
 Take the time to use references to support the reviewer’s report

Abbreviated Guidelines for Effective Peer Review/Optima 9

 Take Action
 Prioritize the use of resources for measuring physician performance
 Ensure availability of physician performance data for feedback and reappointment
 Ensure that identified performance improvement opportunities are addressed
 Provide physician leaders with the information to help mentor both the peer review
process and the poorly performing physician

Additional considerations:

Don’t underestimate the many sources of bias which may undermine peer review:
 Fear of retribution from a colleague, either personally, professionally, or economically
 Fear that an adverse peer review judgment will have a negative effect on a colleague’s
professional and personal life
 Anger toward a competitor or colleague for a perceived wrong that deserves retribution
 Desire to protect or shield a colleague, partner, employer, and/or employee from potential
damage to his or her reputation or standing
 Desire to protect or shield a group of individuals (e.g., department, division, private
enterprise) from potential damage to reputation or standing
 Certainty regarding analysis despite subsequent evidence to the contrary
 Selective elimination of information that does not confirm an initial analysis or impression
 A tendency to base judgments on information that is readily available, most recent, or that
contains strong emotional content
 Inadvertently linking current circumstances to patterns or perceptions established in the past
 Maintaining an irrational commitment toward an issue, despite mounting evidence to the
contrary
 Inappropriately ascribing a pattern to random events
 Inappropriately surmising a decision or action based on retrospective analysis
 Overestimating one’s ability to judge and analyze a situation correctly, despite evidence to
the contrary

Liability coverage for peer review activities: Coverage is most commonly found in the Hospital
Professional Liability policy, the individual professional liability policy or the hospital’s
Directors and Officers policy. Because the terms of policies can change, or certain
circumstances may require a Reservation of Rights letter from the carrier, it is best not to address
specific coverage within the medical staff peer review policy. If an individual participating in
the peer review process is concerned about coverage, it is best to discuss options with the
individual at the time peer review participation begins.

Original: 05/09
Updated: 07/11; 09/13

Abbreviated Guidelines for Effective Peer Review/Optima 10