Field Report:  Initiating Peer Review in Ambulatory Care

Arizona-based Banner health system standardized the process across multistate divisions, with consideration of the legal issues, tactics and flow implementation. Each case further improves patient safety and care.

ABSTRACT: Standardizing physician peer review in the ambulatory setting is evolving as value-based reimbursement and population health grow. In this article, the authors show how one large health care system in the western United States standardized ambulatory care provider peer review across multistate divisions, with consideration of the legal issues, specific tactics and process-flow implementation.


Banner health is a health care system of more than 50,000 employees, based in Phoenix, Arizona. It is one of the largest health care systems in the United States. Its stated values help define its culture, actions and behaviors. They are:

People Above All — By treating those we serve with compassion, dignity and respect.

Excellence — By acting with integrity and striving for the highest quality care and service.

Results — By exceeding the expectations of those we serve and those we set for ourselves.

Physicians, obviously, are integral to high-quality patient care. The Banner Health operational model is a mixture of employed and independent physicians. The former are employed through Banner-University Medical Group and Banner Medical Group. BMG is separated into divisions: Arizona East, Arizona West and Western Region. The BUMG and BMG physicians are a combination of inpatient (primarily hospitalists, intensivists and other specialists) and ambulatory physicians.

Medical peer review is the process in which a committee of physicians examines the work of its peers and determines whether the physicians under review have met certain care standards in rendering medical services. Over the past year, Banner Health has expanded its inpatient peer-review process to the ambulatory setting with the growth of BMG and the addition of BUMG.

All potential peer-review inquiries are sent through an online reporting tool to a centralized review team. This team consists of registered nurses serving as specialists who receive referrals from many sources: event reports, patient complaints, infection prevention reports, data reports, administrators, the Clinical Performance Assessment and Improvement department, the Risk Management team and others.

A specialist reviews the electronic medical record and other relevant information to determine whether the case meets certain criteria for peer review (see Figure 1). If it does, the specialist summarizes the medical record and submits it, digitally and securely, to the ambulatory chief medical officer or peer-review chair.

snyder figure 1 peer review indicators.jpg

Confidentiality a Priority

The CMO or chair then assigns the case to an appropriate physician reviewer who is a member of the corresponding regional medical group’s peer-review committee. The case then goes through a formal process of investigation, discussion and scoring.

Committee members continuously must meet qualifications and requirements as BUMG or BMG physicians. They also must demonstrate leadership skills, must complete training in Just Culture methodology, and may not have conflicts of interest.

Under Arizona law, PRCs are legally protected entities. Confidentiality is essential to maintain legal protection. The following message is displayed and read aloud by the CMO or committee chair before each meeting:

Executive Session is now convened. This is a highly confidential meeting to review professional practices or specific physicians and the information discussed should not leave this room. Please do not take any written material with you and I suggest that you do not take notes. Per the confidentiality/Peer Review Policy, the Medical Staff Assistant will collect ALL Executive Session agendas and packets at the end of the meeting.”

After each meeting, attendees are reminded of the requirement for confidentiality.


  1. CREATE A LEARNING ENVIRONMENT: A learning culture is the foundation of patient safety. It is a culture that is eager to understand risk at both the individual and organizational level. We can see risk by observing the design of systems in which we work, our behaviors and the behaviors of those around us. We must all be willing to learn from our mistakes and to share this learning in a manner that supports system design and continued safe choices.
  2. CREATE AN OPEN AND FAIR ENVIRONMENT: To create a learning environment, organizations must move away from an overly punitive reaction to events and errors. We must ask the erring provider to report the event so that others may not be denied the learning opportunity. A strong safety culture reinforces accountability for safety across all levels of the organization, from CEO to staff. It is a system of accountability that does no focus on the human error or the unintended consequences, but instead focuses on the quality of our decisions in providing excellent patient care. From CEO to staff, we must be accountable to our patients for the choices we make as their caregivers.
  3. DESIGN SAFE SYSTEMS: It is the system in which we work that has the greatest overall influence on the safety of the patient. We must design health care delivery systems that anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the patient.
  4. MANAGE BEHAVIOR CHOICES: While we must anticipate as humans we all  make mistakes, it is our management of behavioral choices that will allow us to achieve the safety outcomes we desire. A strong safety culture puts a premium on critical decision-making skills — and asks every health care provider to continuously evaluate the risks inherent to the choices we make.

The committee members use the Just Culture methodology when scoring cases. It focuses on patient safety by creating an open learning environment. It proactively manages risks and behavioral choices while ensuring accountability. It helps design safe systems, responds fairly and consistently, and focuses on learning through open dialogue. It encourages reporting of mistakes and hazards. To ensure this, there are four cornerstones to a Just Culture environment (see Figure 2).

The Committee Process

After a case is entered into a secure digital tracking system, it is assigned to a committee member, who reviews it and formulates an understanding based on the written documentation. After this comes one of the key aspects of Just Culture — contacting the care provider to understand the rationale for decisions and choices made in the case. This initial review seeks to understand the outcome and to explain what happened, what normally happens, what procedure is required to make it happen, why it happened, and what was the cause or were the causes of the outcome. At this point, the committee member summarizes the event and uses the Just Culture process flow (see Figure 3) to recommend a score. The process flow helps guide the reviewer and group discussion toward appropriate scoring.

At the PRC meeting, the reviewer presents the case with evidence-based research to the committee members, summarizes the conversation with the provider, and answers questions posed by the committee. The reviewer then takes the group through the process flow and to the score. Discussion and deliberation on the scoring process ensues until the committee agrees upon a score. The physician being reviewed has the right to appeal under due process.

Issues reviewed can involve a breach in a duty to produce an outcome, which is primarily provider-controlled; a breach in a duty to follow a procedural rule (a organizational system or policy put in place to ensure safe outcomes or avoid negative events); or a breach in the duty to avoid unjustifiable risk or harm.

If a breach is identified, the committee evaluates the decisions and choices that led to it. Those can be classified as human error or at-risk behavior. Based on these choices, the committee decides whether to console, coach or discipline the provider, or to fix a systemic problem.

  • Consoling the physician is a supportive, nondisciplinary discussion between the PRC reviewer and the physician to engage in better future choices.
  • Coaching is the first step in the disciplinary action process; the physician is put on notice that performance is unacceptable.
  • Disciplinary action can be taken if the physician’s performance is beyond remediation. It is dictated by the bylaws, rules or regulations of Banner Health.

Solutions Are a Priority

By clearly identifying the outcome and the multifaceted causes, the risks are accurately addressed and a solution is implemented that prevents reoccurrence. By fixing a systemic problem, the solutions aim to avoid multiple negative outcomes in the future. System problems are referred to the clinical performance program for development of an action plan and follow-through. The action plan’s progress and outcomes are reported back to the committee.

Occurrences are tracked for patterns and trends. That allows for intervention, as necessary, that address behavior and outcomes. Possible interventions include consoling or counseling, involving a mentor or proctor, requiring continuing medical education, reviewing future cases by the committee, and formal corrective action.

Just Culture not only makes medicine safer for patients, it also takes into account the needs of providers and seeks to place wellness around them. To that end, the committee publishes a yearly newsletter to educate all providers on topics that can be universally applied, allowing them to benefit from what the committee learned.

Barriers to the implementation of physician peer review in the ambulatory setting did occur. Some early obstacles were simple to overcome, as they dealt with learning how to submit a case as well as the types of cases to submit. The goal is to input all patient complaints, payer complaints, operational process issues, and any identified safety hazards or near misses.

snyder figure 3 cr.jpg

Some providers did not feel comfortable identifying a case for review, believing peer review is a punitive process. To prevent referral barriers, the Just Culture concept was explained and the process for referral to peer review was made simple. The value of Just Culture is that it allows for a system of accountability that does not focus on the human error or the unintended consequences, but instead focuses on the quality of the decisions in providing patient care. Scoring in Just Culture enables process improvement that leads to a safer and more-effective health care environment. Education around Just Culture has led to more cases being reviewed and more process improvement occurring. By doing so, everyone learns from mistakes, and this learning is shared in a manner that supports system design and safe choices.

Getting Up to Speed

As with any new process, there was a learning curve to understanding Just Culture and how to score cases. The current models use objective algorithms to assist with identifying problems with human error, system design or poor behavioral choices. The PRC can rely on CMOs, the clinical performance department, the risk management team and other staff members to ensure full understanding of the process.

Physician reviewers involved in peer review typically say their involvement improves their own practice of medicine. Some say hindsight is 20/20. By retrospectively reviewing a case from a “balcony perspective,” reviewers understand without emotional attachment what led to the medical outcome. By reviewing cases that are submitted for peer review — studying them, discovering through interviews the process by which decisions were made, and understanding the scoring methodology — committee members better understand obstacles to patient care and ensure systems are in place to proactively prevent errors.

For example, documenting a patient visit or a phone conversation is typically more succinct yet more thorough after understanding Just Culture. Accordingly, there are multiple examples of how we have improved our practice. If a patient seems disgruntled, we now are more proactive in resolution, as well as complete documentation of resolution and follow-up. When receiving records from an emergency department or another doctor’s office, providers not only read them more thoroughly but also call the provider for any needed clarification. Also, if a patient needs follow-up, we now call the provider who needs to do so or have a process for reliable follow-up.

Physician peer review is essential to continually improve medical practice and support of physicians. A variation in practice might have multiple root causes, including a system failure or individual issues. With the continued evolution of physician peer review, each case helps to further improve patient safety and care. This work is critical to care for increasingly complex patients and for an ever-increasing volume of patients, with more than 11,000 new Medicare beneficiaries entering the health care system every day.

Betty A. Hinderks Davis, MD, is a former physician executive with the Banner Medical Group’s Arizona West division. She is a board-certified dermatologist in the Phoenix, Arizona, area.

Jesus Bracamonte, MD, is a board-certified family medicine physician who serves as divisional primary care medical director for Banner Health and as a member of the quality review committee.

Teressa Mitchell, BSN, MBA, RN, CPHQ, is a former clinical performance assessment/improvement specialist for Banner Health’s Arizona West division. She is quality improvement director at Banner Del Webb Medical Center.

Tom Snyder, RN, BSN, MBA, CLSSBB, FACHE(c), is director of quality improvement for Banner University Medical Center in Phoenix, Arizona.

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