(From a Chief Medical Officer who recently attended The Peer Review Clinic)

Question: We are implementing the professional practice evaluation (peer review) process that we learned at The Peer Review Clinic.  I know that you recommend that a Leadership Council perform a “triage” function.  We are concerned that adding this step may slow down the process.  Why not just have the multi-specialty Professional Practice Evaluation Committee (PPEC) serve that function?

Answer:  Here are the reasons why we recommend (and most hospitals we work with include in their professional practice evaluation process) a Leadership Council

1. It keeps all of the top Medical Staff Leaders who serve on the Leadership Council – President of the Medical Staff, Chair of the PPEC, CMO/VPMA and perhaps Credentials Chair – in the loop with regard to the cases that are being reviewed in the process.  Certainly, reports from all Department Chairs regarding cases they have reviewed are sent to the PPEC for its review, but that happens on the “back end.”  Having the Leadership Council triage on the front end helps to prevent cases from going into a “black hole” in the Departments and makes sure that cases are reviewed according to the appropriate procedures (See #2 below).  Could the PPEC serve this function?  Yes, but it is harder to schedule a committee to review and make those initial triage determinations so using the PPEC for that function is likely to hamper rather than expedite the process.
2. Not all cases that are identified for review should go through the peer review process, e.g., cases involving unprofessional conduct or that might involve a practitioner health issue.  Many hospitals are using the Leadership Council to address cases of unprofessional behavior that are identified or referred into the process.  Incidents of unprofessional conduct (or to use the Joint Commission’s latest phrase, “behaviors that undermine a culture of safety”) are usually much better and more consistently addressed through a Medical Staff Code of Conduct Policy with a small group of leaders (such as those on the typical Leadership Council) than by Department Chairs alone or by the PPEC.  Likewise, issues involving a practitioner health issue should be addressed through the Practitioner Health Policy, not through the peer review process.

Some hospitals have all cases go to the Leadership Council for triage and referral to the appropriate review process.  Others have “straightforward” cases involving clinical issues go directly to Department Chairs for review and “administratively complex” cases go to Leadership Council.  The “administratively complex” cases are those involving professional conduct or a possible health issue, those involving the Department Chair, or those where a troubling clinical pattern has developed with a practitioner that has not been resolved through previous interventions.

Certainly, a Leadership Council is not absolutely required.  But most hospitals that have implemented it have found it to significantly enhance the effectiveness and efficiency of the process.

Upcoming dates for The Peer Review Clinic:

• October 4-6, 2012 • Fairmont Scottsdale Princess
• February 7-9, 2013 • Disney Boardwalk
• May 2-4, 2013 • Ritz-Carlton, New Orleans