peer review process

February 10, 2022

Posted on by Courtney Patterson

QUESTION:
We have a physician who was brought in through a contract with a locum tenens company.  Within the first couple of weeks, he had several horrible outcomes in cases.  We started to review his cases through our peer review process and we are considering a precautionary suspension.  Our CMO just told us that the hospital has instructed the company that the physician can no longer be scheduled at our hospital.  This will result in the termination of his clinical privileges.  Should we suspend his privileges anyway, continue with our peer review process, and then report him to the National Practitioner Data Bank?  We are concerned that he is just going to go someplace else and hurt patients again.

OUR ANSWER FROM HORTYSPRINGER ATTORNEY SUSAN LAPENTA:
We understand the desire to follow your peer review process, especially when there are serious concerns about the clinical care provided by a physician.  The peer review process is, by design, thoughtful, deliberative, and educational with built-in collegial efforts, progressive steps, and, when needed, opportunities for improvement.  As successful as the peer review process can be, it is not well suited to address concerns about physicians who are brought into practice on a temporary basis.

That does not mean you should ignore those concerns.  However, your medical staff may not be in the best position to evaluate, address, and resolve the concerns identified in a physician who is practicing at your hospital on a temporary basis.  In fact, once the hospital has exercised its rights under the contract with the locum company and instructed the company not to schedule the physician again, there is not much left for the medical staff to do through its peer review process.  It difficult to review a physician’s care when the physician is no longer practicing at the hospital and there is no action left to take after the physician’s appointment and privileges have been terminated through the contract with the locum company.

In fact, this is an area where the National Practitioner Data Bank, through its Guidebook, has been very clear.  If a physician’s clinical privileges are terminated as a result of a contract, that termination is not an adverse professional review action and should not be reported to the Data Bank.

If you are concerned that the locum company is going to turn around and place the physician in another hospital, you may want to put the company on notice of your specific concerns.  The company should have a process for evaluating the care and competence of the physicians and other practitioners it is placing.  But be careful what you say to the locum company.  Your communication with the company may not be protected under your bylaws, or state or federal law.

To protect yourself, request the locum company to have the physician sign an authorization and release so that information about the physician’s practice can be shared.  Additionally, if you receive a request from another hospital who is seeking to privilege this physician, you can request an authorization and release before providing any information, including the standard “name, rank, and serial number.”  A request for an authorization should send a message that there are issues that require further review and evaluation.

January 23, 2020

Posted on by hortyspringer

QUESTION:  Our hospital is part of a health system. Is there any way we can take advantage of our size and resources to improve our peer review process?

ANSWER:  Yes! Health systems have many options for improving their professional practice evaluation (“PPE”)/peer review processes that aren’t available to individual hospitals. Here are a few examples.

1.  System PPEC

Health systems can create a system Professional Practice Evaluation Committee (“System PPEC”) with representatives from each hospital in the system. The System PPEC could:

(a) serve as a resource for the PPECs of individual system hospitals;

(b) compile triggers for PPE/peer review, OPPE data indicators, and criteria for Informational Letters, and share those with local PPECs for their approval; and

(c) compile and disseminate best practices and lessons learned from each system hospital.

The System PPEC would assist local PPECs, but the local PPEC would remain responsible for all decisions regarding a review.

2.  System Specialty Review Committees

System Specialty Review Committees comprised of specialists from system hospitals could be appointed to review cases upon the request of a system hospital. The PPEC at the entity requesting the review would retain full responsibility for deciding what to do with each case. The System Specialty Review Committee would simply serve as another source of expertise for that PPEC.

System Specialty Review Committees could also monitor aggregate data related to system practitioners and facilities in their specialties and disseminate best practices and lessons learned through the review process.

3.  PPE/Peer Review Clearinghouse Policy

Systems could develop a policy by which central administrative personnel serve as a “clearinghouse” for case review services. System hospitals would notify the clearinghouse of practitioners who have agreed to provide case review services for other system hospitals. A hospital that requires a case review would contact the clearinghouse, which would identify a practitioner who has agreed to provide such services.

4.  PPE/Peer Review Services Agreement Between Facilities

Under this option, one system hospital (the “PPE Services Provider”) could provide PPE/peer review services to another system hospital (the “Requesting Hospital”). The PPE Services Provider and the Requesting Hospital would execute an agreement to describe their respective obligations. The services to be provided by the PPE Services Provider might include case review services, regular participation in meetings of a PPE/peer review committee, and assistance with the FPPE process to confirm practitioner competence.

5.  PPE/Peer Review Services Agreement For Individual Reviewer

Under this option, an individual practitioner who has privileges at one system entity would
provide PPE/peer review services directly to another system entity. Essentially, the practitioner would be serving as an external reviewer for the facility requesting services. The system could develop a template agreement by which these services are provided.

October 11, 2018

Posted on by hortyspringer

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QUESTION:    Our peer review process uses a case review form that asks physicians to score cases:

1 is  “exemplary care,”
2 is “meets the standard of care,”
3 is “below the standard of care,” and
4 is “significant deviation from the standard of care.”

It seems most of our cases end up being a 2, even when there are concerns.  Is there a better way?

 

ANSWER:      Yes!  Ditch the scoring, and adopt a new form that focuses on narrative explanations to answer three key questions:

(1) is there a concern?;
(2) if so, what’s the nature of the concern?; and
(3) how can the concern be addressed?

One problem with “scoring” cases (or otherwise categorizing them) is that the focus of the review becomes assigning a score rather than fixing any concerns that are identified.

Also, physician reviewers may be uncomfortable indicating that a physician’s care was “below the standard of care.”  As a result, they choose a more favorable score even if there are concerns.

If reviewers are willing to say that care falls “below the standard” or was “inappropriate,” the physician who receives the score is more likely to be on the defensive.  This undercuts efforts to make the peer review process educational rather than punitive.

For more tips on how to make your peer review process more effective, join us in San Francisco from Nov. 15-17 for The Peer Review Clinic.

June 29, 2017

Posted on by hortyspringer

QUESTION:        We’ve taken steps in the last year to change the perception of peer review from punitive to educational.  We’ve eliminated scoring, increased the use of educational sessions to share lessons learned from the review process, and created accountability for fixing system/process concerns that are identified during the review process.  Overall, our physicians feel the process is much improved.  However, there are occasional holdouts who refuse to provide input when their cases are under review, and who seem intent on simply delaying the review process.  What can we do?

ANSWER:            Obtaining timely and meaningful input from the physician under review is an essential element of an effective and fair professional practice evaluation (“PPE”) process.  Giving the physician an opportunity to provide input enhances the credibility of the process and encourages everyone involved to think critically about a case.

There are several fundamental rules to obtaining input.  Most importantly, PPE policies should state that no “intervention” (such as an educational letter or a performance improvement plan) will occur until a physician has been given the opportunity to provide input.  Also, physicians should be given the opportunity to provide both written and verbal input by meeting with those conducting a review.  Input can be obtained at any point in the process, and multiple requests for input may be made.

If a reviewer has questions about a case, the physician should be notified of the concerns.  Any letter to the physician must be carefully drafted to avoid giving the impression that a decision about the case has already been made.

The PPE policy should also make clear that a physician cannot stop the review process by not providing input.  PPE policies should state that individuals who fail to provide input when requested by the PPEC can be deemed to have temporarily and voluntarily relinquished their clinical privileges until the input is provided.  Such relinquishments do not entitle the physician to a Medical Staff hearing or appeal, nor are they reportable to any federal or state government agency.  Instead, they are merely an administrative “time-out” until the physician provides the requested information.

To learn more about PPE best practices, join Paul Verardi and Phil Zarone by dialing in for the upcoming audio conference: Professional Practice Evaluation Policy — Special Topics on July 11.