Disseminating lessons learned is critical if the process is to have the intended effects of improving quality of care and safety.
As health care organizations revamp their peer review processes, physician leaders are observing a shift from a punitive culture to a supportive environment encouraging performance improvement.
Most of peer review continues to center around the hospital setting because of stringent regulatory requirements, but a few medical group executives have embraced it as a sound business practice as well.
“They are liable for what their partners do,” says Robert Marder, MD, a former physician executive who is a national peer review consultant in Longmont, Colorado. In a physician practice, “peer review is an excellent risk-management tool.”
Regardless of the setting, the process should evaluate physicians over a period of six to eight months based on aggregate risk-adjusted data as opposed to a single case or event. That way, reviewers are “looking at the forest rather than just the trees,” Marder notes.
While each organization’s unique culture leaves an imprint on peer review, some basic principles generally apply in establishing fair and effective standards, says David Perrott, MD, DDS, MBA, FACS, senior vice president and chief medical officer at the California Hospital Association.
A transparent policy free of bias promotes protection for patients, physicians and the organization. “There are many times in which a peer review will be done where positive things have occurred,” says Perrott, an oral and maxillofacial surgeon.
For instance, in mortality cases, peers can provide feedback that physicians not only did “everything in their power,” but also “went to extraordinary means” in striving for better outcomes, Perrott says.
“When there are further actions that need to be taken,” he adds, “they are based upon solid evidence-based decisions that have been supported by their peers.”
To be as objective as possible, reviewers look beyond quality measures, considering that some physicians provide care to a greater proportion of underserved, lower-income patients with compromised health literacy, says James Gutierrez, MD, FACP, chair of community internal medicine and a member of the board of governors at the Cleveland Clinic.
Physicians are asked to express any challenges or concerns about their work environment. This allows reviewers to “take their temperature as far as their career satisfaction,” he says.
Peer review also should be “a two-way street,” offering physicians an opportunity to comment about their supervisors, he says.
If the feedback from multiple physicians suggests a recurrent theme in a manager’s questionable style or approach, the process serves as a useful “report card on leadership,” Gutierrez notes.
Most unexpected outcomes involve hospital systems, so peer review committees should ideally include representatives from nursing and pharmacy because many improvement opportunities lie in those areas, says Mark S. Williams, MD, MBA, JD, CPE, chief clinical officer at Palmetto Health, an integrated system based in Columbia, South Carolina.
Committee members should constantly reinforce the notion that physician peer review is not a “blame game,” he says. In addition, to maintain physicians’ trust, observing confidentiality of the proceedings is paramount, says Williams, a past president of the Southern Medical Association.
“That leads to one other challenge: When you have confidential discussions and conclusions, how do you share the lessons learned from peer review?” he adds.
Disseminating this information “often involves a degree of generalization and teaching but is critical if the peer review process is to have the intended effects” of improving quality of care and patient safety.
Peer review typically remains confidential within an organization. It is not subject to disclosure or legal discovery in 48 states, says Lisa Diehl Vandecaveye, JD, MBA, HRM, FACHE, general counsel for The Joint Commission, which accredits more than 4,000 of approximately 5,000 hospitals in the United States.
Based on peer review findings, a hospital’s organized medical staff should monitor and evaluate physician performance in specific areas or procedures that need further development, says Ana McKee, MD, executive vice president and chief medical officer at The Joint Commission.
Even more importantly, McKee says, “The organization needs to provide the learning environment and resources for that individual to improve.”
Susan Kreimer is a freelance health care journalist based in New York.