QUESTION:     We have an Incident Review Committee which receives all reports generated by our occurrence reporting system. This includes slip and fall injuries and broken equipment, but might also include reports related to the competence or conduct of a Medical Staff member. I’m a little uncomfortable with these physician-specific issues going to the Incident Review Committee, because it’s not designed to deal with them. Ultimately, these issues are referred to our Peer Review Committee anyway. Should our reporting process be revised?

ANSWER:    Yes. We recommend that “reported concerns” about a specific physician (i.e., concerns about clinical competence or conduct) not be referred to as “incident reports” and not be reported initially through the risk management/occurrence reporting process. Instead, we recommend that such physician-specific issues be reported directly to the peer review process.

The rationale for this recommendation is to maximize the protection of these reports under the state peer review protection law. In most states, courts are reluctant to protect risk management reports. As a result, they can often be obtained via subpoena in a malpractice lawsuit. The courts’ rationale is that risk management reports are not “peer review.” Instead, risk management issues involve the financial activities of the hospital, and are not necessarily related to improving care. If reported concerns are initially reported through the risk management/occurrence reporting system, there’s a better chance the malpractice attorney could obtain that report in a lawsuit.

In contrast, if physician-specific concerns are called “reported concerns” and sent directly to the peer review process, it would be easier to argue that the report itself is protected by the peer review privilege. The Joint Commission has done us a favor in this regard, by including the discussion of “reported concerns” in its standards that address peer review.