Best Practices For Hospital Peer Review

When done properly, peer review is an importantimprove the fairness of the process for both
process that helps hospitals and their doctorsphysicians and the hospital.
ensure consistent, high quality patient treatment.An IRO can match doctors with the right
Hospitals can identify at-risk physicians; physiciansspecialist expertise to effectively review sensitive
can help improve quality of care for patients. Whycases and reach an unbiased determination.
is this process so difficult? It's simple - hospitalReviews 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 HCQIAbeing reviewed. Hospitals pay only for the
legislation, was intended to promote higher qualityreviewing physician's time at pre-determined
patient healthcare. Unfortunately, Congress did nothourly rates.
foresee that hospital peer review actually putsBecause 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 easilyat significantly lower costs. Peer reviews are
render the process ineffective. Nor did it foreseeconducted using a standard reporting format, and
that hospitals would sanction doctors for speakingthe typical turn-around time is less than 21 days.
up on behalf of patients regarding quality of careSince IROs review thousands of cases annually,
concerns.per case review costs are kept to a minimum.
In the hospital environment, peer review isAn IRO can give peer review the high priority and
considered an ugly task that is just one moretimely consideration it deserves -- without
action item for a busy medical staff and is easilyimpacting the hospital staff or tarnishing a
pushed to the bottom of the priority list. Often ithospital's reputation.
just doesn't get done. Why?Using an IRO for objective peer review may be
Physicians on peer review or quality managementone of the best solutions for helping hospitals get
committees too often find themselves in conflictback to the intent of the law - improving
of interest situations. They compete for thehealthcare quality for patients. An IRO can also
same limited geographic pool of patients and forhelp reduce costs, avoid expensive litigation,
professional recognition within a very narrowenhance hospital reputation and protect JCAHO
specialty. There may also be personality conflictscertification.
with the physician under review or pressure byPeer Review Best Practices
their hospitals not to seriously scrutinize a fellowTo ensure an evidence-based outcome for peer
physician who has stature in the medicalreviews, hospitals should consider this nine step
community. The tight-knit social and professionalprocess:
relationships found in a hospital environment can1. Develop a culture of accountability within the
lead to bias and reluctance to pass judgment onhospital.
associates. This reluctance tends to lead to2. Make sure that the peer review process is well
unusually long delays in resolving critical qualitydefined, understood, accepted and adhered to by
management issues. By the time a critical situationall.
is actually dealt with, the costs and risks to a3. Watch for "sentinel events." Bring patterns of
hospital or group can be catastrophic.recurring or clustered problems to management's
Backlashattention in a timely way.
The breakdown in a hospital's quality management4. Assure that questions posed during the process
system can be very damaging. Inadequate peerare precise, and that responses are precise as
review can result (and has) in negativewell, 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 publicityreviewed by a "like" specialistwho is unbiased and
- High profile lawsuitshas no potential for conflict of interest inrendering
- Multi-million dollar finesan opinion.
- Management shake-ups6. Make sure the peer review committee meets
- Loss of investor confidencemonthly and that cases and replies are distributed,
- Damage to physicians' careers and practicesreviewed and responded to in a timely manner.
- Joint Commission on Accreditation of Healthcare7. Make sure there is a re-review of each case
Organizations (JCAHO)sanctions and loss ofafter the subject physician input has been
accreditationreceived.
- Scrutiny by state and federal agencies and8. As much as possible, conduct all reviews in a
other public organizations.non-accusatory andprofessional format.
These negative events, combined with rising9. 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 payOrganization.
close attention to their quality management andChoosing the Right IRO
adopt best practices whenever possible.Choosing the right IRO as a partner for hospital
Peer Review as a Risk Management Toolpeer review can be as confusing as the process
A well-executed peer review process can easilyitself. Here are some simple questions to ask in
avoid such negative events by using bestthe selection process:
practices in risk management. The earlier a1. Is the IRO URAC-accredited? - There are
physician performance issue is detected and dealtdozens of companiesthat claim to offer medical
with, the lower the costs and potential negativereview 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 evidenceHealthCare Commission, also known as URAC. By
and adhering to the intent of the law -- toselecting an IROwith URAC accreditation, the
improve the quality of patient care -- helpshospital partner with a standards-based
discover, highlight and deal with quality problemsorganization can deliver the quality and
quickly and efficiently. Issues surrounding internalobjectivityneeded for the peer review process.
politics, competition, and personality conflicts2. What types of doctors are on staff at the
should be considered when setting up a peerIRO? - It's extremelyimportant to work with an
review committee.IRO that has doctors on staff trained tomake
Involving Outside Parties in Peer Reviewfast decisions, who are board certified and still in
The most effective quality management processactivepractice.
involves using a "neutral" outside party in addition3. How deep is the IRO specialty panel? - The
to the hospital's own peer review committee. ThisIRO under considerationshould be able to deliver
neutral party can review sensitive cases wherethe specialists needed on a moment'snotice. Not
there is a potential conflict of interest. Hospitalsonly do these physicians need to be in the
with the need for an outside case review havesamespecialty, but also from the same type of
often turned to affiliated hospitals or searched forinstitution. 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 thecoming 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 dorecord 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 andexpedited reviews. A standardof 21 days or less
pre-arranged agreements with affiliates orfor hospital peer review should be the minimum.
physicians to perform peer review, it can be very5. How accessible are the IRO physicians? - Many
costly and time consuming to arrange for thisIROs 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 Peerpartners to the hospital peer review committee
Reviewandmake themselves fully accessible to the
Many hospitals, today, are turning to Independentphysicians under review. Bybecoming a part of
Review Organizations (IRO) to aid in fixing theirthe process, the IRO can truly act as the
peer review process. An IRO serves as anneutralthird-party and help keep the relationships
objective third party that can provide hospitalbetween all parties intact.
peer reviews based upon medical evidence and