| When done properly, peer review is an important | | | | improve the fairness of the process for both |
| process that helps hospitals and their doctors | | | | physicians and the hospital. |
| ensure consistent, high quality patient treatment. | | | | An IRO can match doctors with the right |
| Hospitals can identify at-risk physicians; physicians | | | | specialist expertise to effectively review sensitive |
| can help improve quality of care for patients. Why | | | | cases and reach an unbiased determination. |
| is this process so difficult? It's simple - hospital | | | | Reviews are conducted by board-certified |
| politics, economic advantage and personalities. | | | | physicians in active practice, who are usually |
| The current physician peer review system, | | | | located in a different state than the physician |
| created by Congress in 1986 through HCQIA | | | | being reviewed. Hospitals pay only for the |
| legislation, was intended to promote higher quality | | | | reviewing physician's time at pre-determined |
| patient healthcare. Unfortunately, Congress did not | | | | hourly rates. |
| foresee that hospital peer review actually puts | | | | Because these specialists are already on board, |
| physicians into an environment where political, | | | | reviews can be completed in much less time and |
| economic and personality conflicts can easily | | | | at significantly lower costs. Peer reviews are |
| render the process ineffective. Nor did it foresee | | | | conducted using a standard reporting format, and |
| that hospitals would sanction doctors for speaking | | | | the typical turn-around time is less than 21 days. |
| up on behalf of patients regarding quality of care | | | | Since IROs review thousands of cases annually, |
| concerns. | | | | per case review costs are kept to a minimum. |
| In the hospital environment, peer review is | | | | An IRO can give peer review the high priority and |
| considered an ugly task that is just one more | | | | timely consideration it deserves -- without |
| action item for a busy medical staff and is easily | | | | impacting the hospital staff or tarnishing a |
| pushed to the bottom of the priority list. Often it | | | | hospital's reputation. |
| just doesn't get done. Why? | | | | Using an IRO for objective peer review may be |
| Physicians on peer review or quality management | | | | one of the best solutions for helping hospitals get |
| committees too often find themselves in conflict | | | | back to the intent of the law - improving |
| of interest situations. They compete for the | | | | healthcare quality for patients. An IRO can also |
| same limited geographic pool of patients and for | | | | help reduce costs, avoid expensive litigation, |
| professional recognition within a very narrow | | | | enhance hospital reputation and protect JCAHO |
| specialty. There may also be personality conflicts | | | | certification. |
| with the physician under review or pressure by | | | | Peer Review Best Practices |
| their hospitals not to seriously scrutinize a fellow | | | | To ensure an evidence-based outcome for peer |
| physician who has stature in the medical | | | | reviews, hospitals should consider this nine step |
| community. The tight-knit social and professional | | | | process: |
| relationships found in a hospital environment can | | | | 1. Develop a culture of accountability within the |
| lead to bias and reluctance to pass judgment on | | | | hospital. |
| associates. This reluctance tends to lead to | | | | 2. Make sure that the peer review process is well |
| unusually long delays in resolving critical quality | | | | defined, understood, accepted and adhered to by |
| management issues. By the time a critical situation | | | | all. |
| is actually dealt with, the costs and risks to a | | | | 3. Watch for "sentinel events." Bring patterns of |
| hospital or group can be catastrophic. | | | | recurring or clustered problems to management's |
| Backlash | | | | attention in a timely way. |
| The breakdown in a hospital's quality management | | | | 4. Assure that questions posed during the process |
| system can be very damaging. Inadequate peer | | | | are precise, and that responses are precise as |
| review can result (and has) in negative | | | | well, including the hard questions, with rationale and |
| consequences for hospitals and hospital groups, | | | | associated guidelines. |
| such as: | | | | 5. Make sure that each peer review case is |
| - Negative publicity | | | | reviewed by a "like" specialistwho is unbiased and |
| - High profile lawsuits | | | | has no potential for conflict of interest inrendering |
| - Multi-million dollar fines | | | | an opinion. |
| - Management shake-ups | | | | 6. Make sure the peer review committee meets |
| - Loss of investor confidence | | | | monthly and that cases and replies are distributed, |
| - Damage to physicians' careers and practices | | | | reviewed and responded to in a timely manner. |
| - Joint Commission on Accreditation of Healthcare | | | | 7. Make sure there is a re-review of each case |
| Organizations (JCAHO)sanctions and loss of | | | | after the subject physician input has been |
| accreditation | | | | received. |
| - Scrutiny by state and federal agencies and | | | | 8. As much as possible, conduct all reviews in a |
| other public organizations. | | | | non-accusatory andprofessional format. |
| These negative events, combined with rising | | | | 9. Systematically send your most sensitive peer |
| consumer frustration with the healthcare system, | | | | review cases out to an Independent Review |
| make it increasingly imperative that hospitals pay | | | | Organization. |
| close attention to their quality management and | | | | Choosing the Right IRO |
| adopt best practices whenever possible. | | | | Choosing the right IRO as a partner for hospital |
| Peer Review as a Risk Management Tool | | | | peer review can be as confusing as the process |
| A well-executed peer review process can easily | | | | itself. Here are some simple questions to ask in |
| avoid such negative events by using best | | | | the selection process: |
| practices in risk management. The earlier a | | | | 1. Is the IRO URAC-accredited? - There are |
| physician performance issue is detected and dealt | | | | dozens of companiesthat claim to offer medical |
| with, the lower the costs and potential negative | | | | review services. There are only a fewthat are |
| consequences to the hospital and the physician. | | | | actually accredited by the American Accreditation |
| Basing effective peer review on medical evidence | | | | HealthCare Commission, also known as URAC. By |
| and adhering to the intent of the law -- to | | | | selecting an IROwith URAC accreditation, the |
| improve the quality of patient care -- helps | | | | hospital partner with a standards-based |
| discover, highlight and deal with quality problems | | | | organization can deliver the quality and |
| quickly and efficiently. Issues surrounding internal | | | | objectivityneeded for the peer review process. |
| politics, competition, and personality conflicts | | | | 2. What types of doctors are on staff at the |
| should be considered when setting up a peer | | | | IRO? - It's extremelyimportant to work with an |
| review committee. | | | | IRO that has doctors on staff trained tomake |
| Involving Outside Parties in Peer Review | | | | fast decisions, who are board certified and still in |
| The most effective quality management process | | | | activepractice. |
| involves using a "neutral" outside party in addition | | | | 3. How deep is the IRO specialty panel? - The |
| to the hospital's own peer review committee. This | | | | IRO under considerationshould be able to deliver |
| neutral party can review sensitive cases where | | | | the specialists needed on a moment'snotice. Not |
| there is a potential conflict of interest. Hospitals | | | | only do these physicians need to be in the |
| with the need for an outside case review have | | | | samespecialty, but also from the same type of |
| often turned to affiliated hospitals or searched for | | | | institution. A heartspecialist from Los Angeles may |
| "like" specialists through personal connections. | | | | not be the right physician to reviewa related case |
| While this is an effective method for solving the | | | | coming from a rural hospital in Iowa. |
| problem, it has its own set of challenges: | | | | 4. What are the standard turn-around times? - |
| - How do you quickly locate the right specialist? | | | | The IRO selectedshould have a strong track |
| - How do you convince them to take time to do | | | | record of turning around reviews quicklyand |
| a peer review? | | | | accurately. Find out what the average turn-around |
| - How long do you have to wait to get it done? | | | | times areand what process the IRO offers for |
| Unless you have a well-developed process and | | | | expedited reviews. A standardof 21 days or less |
| pre-arranged agreements with affiliates or | | | | for hospital peer review should be the minimum. |
| physicians to perform peer review, it can be very | | | | 5. How accessible are the IRO physicians? - Many |
| costly and time consuming to arrange for this | | | | IROs offer basicpeer review services. The best |
| each time it's needed. | | | | IROs, however, are the ones thattruly act as |
| IROs: A Cost Effective Solution for Hospital Peer | | | | partners to the hospital peer review committee |
| Review | | | | andmake themselves fully accessible to the |
| Many hospitals, today, are turning to Independent | | | | physicians under review. Bybecoming a part of |
| Review Organizations (IRO) to aid in fixing their | | | | the process, the IRO can truly act as the |
| peer review process. An IRO serves as an | | | | neutralthird-party and help keep the relationships |
| objective third party that can provide hospital | | | | between all parties intact. |
| peer reviews based upon medical evidence and | | | | |