MRR 037 Peer Review - 1

Kingdom Of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
Ministry Of Health ‫وزارة اﻟﺼﺤــﺔ‬

Directorate Of Health Affairs – Taif ‫ﻣﺪﯾﺮﯾﺔ اﻟﺸﺌﻮن اﻟﺼﺤﯿﺔ ﺑﻤﺤﺎﻓﻈﺔ اﻟﻄﺎﺋﻒ‬
King Abdul Aziz Specialist Hospital ‫ﻣﺴﺘﺸﻔـﻰ اﻟﻤﻠﻚ ﻋﺒﺪ اﻟﻌﺰﯾﺰ اﻟﺘﺨﺼﺼﻲ‬
Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Department HOSPITAL WIDE No of Pages 1 of 5
Policy No. MRR 037/02
Policy Title PEER REVIEW Effective Date 5/2/1433
Review Date 5/2/1435
PURPOSE
The purpose of peer review is to promote continuous improvement of the quality of care provided by the medical
staff at KAASH. The role of the medical staff in peer review is to provide evaluation of performance to ensure the
effective and efficient assignments of the work of the physician.
APPLICABILITY:
Applies to the medical staff of KAASH and others who have delineated clinical privileges.
RESPONSIBILITY:
• Each medical staff department is responsible for peer review activities. Oversight is delegated to the
Medical Executive Committee. The Quality Improvement and Risk Management department are made
aware of situations requiring intensive review through the Risk Occurrence Report. When variations in
performance are noted and particularly when there is an unanticipated patient outcome, it is the
responsibility of the Director of Quality /risk manager to inform the department head of the need to
conduct a review.
• It is the responsibility of the Department head to identify indicators for department specific quality
performance measures. The Quality and risk management Department will assume responsibility for
tracking this data and making it available to the Department head when indicated and at the time of
reappointment.
DEFINITIONS:
• Confidentiality:
• The peer review/quality improvement activities are protected from discoverability. All activities are to be
kept confidential. Only authorized persons have access to monitoring data and/or retrieval of this
information. Authorized persons include medical staff leaders, hospital administration, medical staff
services personnel and quality management personnel, as appropriate.
• Medical Staff Peer Review:
• The medical staff uses an effective mechanism designed to involve medical staff members in activities to
measure, assess and improve performance on an organizational basis. This mechanism is designed to:
Collect data on processes and outcomes and to assess performance in relation to design
specifications of processes, determine the level of functioning of processes, identify opportunities
for improvement and review outcomes in relation to expectations.
Communicate to appropriate medical staff members the findings, conclusions, recommendations
and actions taken to improve organizational performance.
If relevant, identify individual performance as a result of the assessment process. When such a
determination has been made, steps for further review, final recommendations, any actions taken
and follow-up are required.
• Peer Definition:
• A “peer” is defined as a practitioner from the same department or from another, but related department,
with similar clinical privileges. In reference to an external or internal expert, a “peer” is defined as any
qualified practitioner of similar training and experience who can render an unbiased opinion on the quality
or conduct of care for the case.
TQM Stamp
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PROCEDURE:
• When the findings of the assessment process are relevant to an individual’s performance, the medical
staff is responsible for determining their use in peer review and/or the periodic evaluations of a licensed
independent practitioner’s competence, in accordance with the bylaw requirements on renewing or
revising clinical privileges.
• General:
• The Medical Staff Peer Review process involves the collection of data using a variety of methods. These
methods include, but are not limited to, ICD-10 codes, DRGs, Quality Improvement/Education Screens,
pathology reports, internal and external databases, medical staff referral and indicators for quality
performance developed by the medical staff. This collection is done on an ongoing basis and is reported
to or by the TQM department. The TQM department screens these reports for peer review issues in
confirmation with the appropriate Medical Staff Department head.
• The peer review or quality file containing specific peer review information on a practitioner will be archived
separately from the practitioner’s credentialing file in a locked and secure cabinet. Provider specific
information is considered:
Quality and utilization review data
Risk occurrences
Sentinel events
Correspondence to the physician regarding commendations or corrective action
Peer review information will be available to authorized staff who have a legitimate need to know
such as:
Quality Management
Utilization Management
Medical Staff Services
Credentialing, Quality and Medical Executive Committee members
Individuals with a legitimate purpose for access as determined by the organization’s legal
counsel and/or board of directors
No copies of peer review documents will be created and distributed unless authorized by legal
department or unless specified in policy
Circumstances requiring peer review may include, but is not limited to:
Current competence for privileging
Invasive, operative and noninvasive procedures that place patients at risk
Blood usage
Medication use and monitoring
Mortality and morbidity review
Safety management
Risk management
Infection control
Utilization review
Customer satisfaction and complaint review
Sentinel event review
Pathology and clinical laboratory/ results
Assessment of patients (quality of the history and physical)
Education of patients and family
• All medical staff peer review activities are first reviewed with the Department head, and then, when
indicated, by the Peer Review committee.
• The physician receives written notification of the intensified review. The findings of the intensified review
are submitted to the department and the organization’s leaders.
TQM Stamp

• The medical peer review committee assign categories and any case considered to be a Severity 3, 4 or 5
requires a letter to be sent to the physician requesting additional information. Once additional information
is received, a second review by all members of the Peer Review Committee is done to decide on the final
categorization. A letter is sent to the physician notifying him/her of the final category. The physician may
appeal the category decision by requesting a review of the case(s) by the Credentials Committee.
• Medical staff data, involving performance, are assigned a severity index indicating whether the information
and/or case review demonstrated an acceptable standard of care.
• The severity of occurrence is defined as:
0 = Not a question
1 = Occurrence screen met/expected clinical practice/acceptable
2 = Questioned practice not routine/not unexpected/acceptable
3 = Questioned practice unexpected/not acceptable by reviewer
4 = Questioned practice very unexpected
5 = Questioned practice should not have taken place
• Responsibility for Peer Review Processes:
• Cases will be reviewed with the head of department (HOD) or Service in which the variation in
performance occurred. If the head of department or Service concludes that the variation does not
represent an error on the part of the physician, it is labeled a Severity 0, 1 or 2 and no notation is made in
the QI file of the physician. If however, the(HOD) , makes the determination that the event constitutes a
Severity 3, 4 or 5, he/she meets with the physician at the earliest possible time to discuss the variation.
This discussion may result in one of the following actions:
Agreement that the variation was due to unforeseen circumstances and could not have been
prevented. The variation will be trended by the QI Department. Further variations, should they
occur, will be brought to the immediate attention of the (HOD).
Agreement that a variation occurred that might have been preventable. The (HOD) may
recommend a change in or monitoring of a delineated privilege.
The(HOD) and physician do not agree that a variation occurred. The matter is then referred to an
ad hoc Peer Review committee.
When more extensive review of an occurrence is required, a Peer Review committee. will
be established. The medical director in conjunction with the (HOD) in which the
variation occurred will recommend committee members to the program director for his/her
approval ensuring that each is a peer under the definition of this policy. The medical
director will ensure that the meeting time is convenient to the panel members and the
physician. The physician will be notified of the meeting by registered return receipt mail.
• Outcomes of Review by the Peer committee:

• Action taken as a result of the peer review may be changes in policy and procedures or processes,
counseling of an employee or physician, sending a letter of warning or trending occurrences. All cases
assigned a severity index by the (HOD) are placed in the involved physician’s peer review file/Quality
Improvement for use in the reappointment process.
• A physician may be placed on intensified review if a trend occurs. A trend, for the purpose of peer review,
is defined as:
A physician receives two (2) severity 5s within a two (2) year period (the previous year and
current year), or
A physician receives five (5) severity 4s within a two (2) year period (the previous year and
current year), or
TQM Stamp

A physician receives one (1) severity 5 and three (3) or more severity 4s within a two (2) year
period (the previous year and current year).
• Intensified review is defined as:
A thorough review of all the quality improvement monitors with deviations from standards of care,
and untoward events that have been categorized in the two (2) years prior to being placed on
intensified review and for six (6) months thereafter, and/or
A 100% review of all admissions for performance for the next 12 months following Credentials
Committee recommendation, and/or
As defined by the program director/ medical director.
• External Peer Review:
• On occasion, external peer review may be requested by the Credentials Committee. On the basis of the
recommended action of the outside organization the Credentials Committee may determine a need to
limit/suspend privileges by the Medical Staff Bylaws, Rules and Regulations. The medical staff may also
work in cooperation with the reviewing agency to modify physician behavior in anticipation of such
limitations.
• Criteria for making a determination on whether external peer review will be obtained are as follows, but
not limited to:
A request of the physician of concern who does not believe he/she may receive an unbiased
review internally.
The department cannot provide an unbiased reviewer based on issues of competitive or
partnership practices. In the case that the Department head is the subject of the review, this case
will be forwarded directly to the Credentials Committee for consideration and assignment of
external peer review if there is no unbiased expert internally.
• Cases reviewed in Medical Staff Committees are categorized, however, all cases that are considered
possible deviations from the standard of care must be sent to the department in which the practitioner is a
member to be reviewed by the (HOD).
• If one department is required to review the performance of a physician in another department, then the
mandate should be to determine whether or not there has been a deviation from the standard of care.
• External peer review may be utilized under the following circumstances if deemed appropriate by the
Credentials Committee or at the direction of hospital leadership:
Litigation:
When dealing with the potential for litigation.
Ambiguity:
When dealing with ambiguous or conflicting recommendations from internal reviewers of
medical staff committees, or when there does not appear to be a strong consensus for a
particular recommendation.
Lack of internal expertise when no one on the medical staff has adequate expertise in the
specialty under review, or
Lack of expertise when the only practitioners on the medical staff with that expertise are partners,
associates or direct competitors of the practitioner under review and this potential for conflict of
interest cannot be appropriately resolved by the medical staff.
New technology:
When a medical staff member requests permission to utilize new technology or perform a
procedure new to this organization and the medical staff does not have the necessary
subject matter expertise to adequately evaluate the quality of care involved.
Miscellaneous issues:
When the medical staff needs an expert witness for a fair hearing, for evaluation of credential file
or for assistance in developing a benchmark for quality monitoring.
TQM Stamp

QUALITY IMPROVEMENT PROCESS:

• 1-A risk occurrence screen is completed and reviewed regarding variations in practice is completed and
then reviewed by the TQM Department. The (HOD) is notified of cases where variations are deemed
significant by the initial reviewer. The case is reviewed and categorized by the (HOD). The final decision
must be reported to the department or committee requesting the review.
• 2-Medical Departmental heads may request the reviews of the performance of any practitioner whose
privileges are within their scope of service. This review will be most important if there has been any
detection of variant performance within the department, or the occurrence of “near miss” or sentinel
events.
• 3-Citizenship issues that are not directly related to the quality of care are also subject to disciplinary
action. This action, since it is clearly stipulated in the bylaws, will not be subject to review. The corrective
action will be outlined in the bylaws, and enforced without further ado.
• 4-The findings of the peer review activities are communicated within the individual medical staff
departments. Severity assignments are reported to Clinical Risk Management. A regular report is
forwarded to Leadership at least quarterly to monitor peer review decisions and actions for effectiveness.
• A data summary of activity for the current appointment.
• Data summaries for two previous appointments.
• Variance screens which may be considered at the time of the next appointment.
• Results of all morbidity/mortality reviews.
• Results of studies that have been completed under the direction of the hospital medical director.
ACOUNTABILITY:
- All Hospital Health Care Providers
FORM:
▪ Medical Staff Peer Review Checklist
REFERENCE:
• CBAHI Standards/Resources
Approval:
Name Signature Date TQM Stamp
Prepared by DR. Abdul-atif Mayoub (RISK Manager) 14/1/1433
Reviewed by DR. Ahmed Al-Khotani (TQM Director) 16/1/1433
Approved by DR. Khaled Al-Thomali (Medical Director) 20/1/1433
TQM Stamp

MRR 037 Peer Review - 1

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Kingdom Of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬

Ministry Of Health ‫وزارة اﻟﺼﺤــﺔ‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

• Outcomes of Review by the Peer committee:

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

QUALITY IMPROVEMENT PROCESS:

- All Hospital Health Care Providers

▪ Medical Staff Peer Review Checklist

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