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When should case be sent for external peer review?
Being impartial huge challenge
Imagine being in the position of publicly critiquing a competing hospital's compliance with Joint Commission requirements. Would you be able to be completely objective? Even if you were, would your colleagues really trust your ability to be impartial?
That is the position many physicians find themselves in when asked to review cases of their colleagues or competitors. Trying to do peer review internally is a difficult thing for a number of reasons, says Skip Freedman, MD, executive medical director of AllMed Healthcare Management in Portland, OR. For one thing, the doctors on the committee are very busy with their own practice obligations and lack the time to do a thorough analysis of the facts of the case.
Also, physicians are being asked to decide whether there was a causal relationship between something that might have been done and whatever the outcome was. "That's not necessarily the way doctors think," says Freedman. "First of all, they are not usually given the opportunity to retrospectively look at things and recreate the facts. They are used to making real-time decisions."
Many hospitals have a variety of specialists on their peer review committee — a urologist, an obstetrician, an orthopedist, and a general surgeon, for example. The volume of work might force members to look at cases involving other specialties, which is unfair to the doctor being asked to review the case. "What does an orthopedist know about OB/GYN except in the most general terms?" asks Freedman.
But a more important question is whether a doctor in a practice group should be able to review the work of his partners. "The answer to that is obviously no," says Freedman. Since there is usually one emergency medicine group, one radiology group, and one anesthesia group in any hospital, this poses an obvious problem. "They do their best to give you an honest unbiased answer, but it doesn't take much imagination to understand they might be conflicted in doing this," says Freedman.
The question is where the hospital is going to get an unbiased opinion if all the radiologists, for example, are partners. "I don't just mean they are economically connected. They have to sit in the same room today, tomorrow, and the next day," says Freedman. "So it is emotionally very difficult for them to give honest criticism. It might lead to hard feelings and difficult working conditions."
Other specialties, such as interventional cardiologists, may not be partners, but they may be economic competitors, which poses a different problem. "If I look at the work of a doctor in my specialty who is in a different professional group, he has at least the opportunity to say that I'm just trying to make him look bad for his own economic gain," says Freedman.
Even if the charge is untrue, it puts the reviewing physician in a difficult position and casts doubt on his or her objectivity. "The fact is that if he goes away, I do economically benefit. So the outcome is that I'm more likely to recuse myself, or to just say what he does is OK and not give it a thorough intellectual look," says Freedman.
Resistance to sending out cases
It may be easiest on the hospital and the doctors if these cases are sent for external review, but there is resistance to doing this for several reasons. One is financial.
"Doctors on the hospital staff do it for free — everybody takes a turn and it's sort of a rotating onus of obligation," says Freedman. "If the hospital sends the case out, it costs them something."
The hospital also loses the ability to have any influence over the outcome of the review. "If they're going to ask somebody for an honest opinion, that's what they're going to get," says Freedman. "The external review agent is not going to care if the doctor is the chief of staff of the hospital, or the guy's wife is the publisher of the local newspaper. They're going to call it as they see it."
Many quality professionals are unaware that the option for external review exists, notes Freedman. "They have a difficult job because they may run into resistance for getting outside help from people more politically powerful than they are," he says. "They may be directed to give the external cases to people either who are not very good at it, or who themselves are conflicted."
For example, a quality manager may be told to "find somebody at the tertiary hospital to look at this case." If one of the physicians there is getting referrals from the hospital and is given cases to critique, it's hard for that individual to tell the physicians there that they could be doing better work.
The quality professional would be better served by having a relationship with an external reviewer with all the specialties covered and brief turnaround times, instead of being told to "go find a cancer doctor to look at these cases."
"That's a difficult task for a quality professional," says Freedman.
Which cases should be sent out?
At Sunrise Hospital in Las Vegas, the policy is to offer an internal review first, and then forward the case for external review if needed, says Lila Allen, BSN, quality manager at the hospital. Typically, cases are forwarded for external review when internal peer review cannot reach a conclusion, when there is the determination of a trend with an individual physician, when a limited number of like specialists are on staff to serve as a peer, or when there is no qualified reviewer on staff.
"This occurs mainly in subspecialty areas, including transplant or pediatrics," says Allen. "Finally, external peer review may be requested by the medical executive committee, the chief of staff of a department, or administration."
Recently, a pediatric patient developed cardiac arrest after the administration of a cardiac medication prescribed by a pediatric cardiovascular intensivist. "Our challenge in reviewing the case for appropriate care was two-fold," says Allen. "Our in-house pediatric intensivists did not have training in a cardiac fellowship." Also, other physicians had a close working relationship with the doctor who had prescribed the medication.
Normally, all cases are reviewed internally, so that physicians are given due course via the hospital's established peer review algorithm. "However, in this instance, our in-house pediatric intensivists refused to review the case because they were too close to the practitioner," she says. External peer review was able to not only provide an objective review, but also the expertise of an external pediatric intensivist with similar cardiovascular experience.
The 2007 medical staff standards from The Joint Commission call for both focused and ongoing practice reviews. Since it would be prohibitively expensive to send every case out for external review, Freedman recommends a combination of internal and external review. Different hospitals will have different mixes, based on their own internal ability, how many and what kind of doctors they have.
For example, a focused review for a new doctor joining the medical staff could be handled internally or externally. "Do they have somebody available to proctor the guy while he takes care of the first five or 10 cases? If they do, good, but then again they may not have enough doctors willing to do it," says Freedman.
In that case, outside chart review would be a better solution. Likewise, a hospital may be able to do radiology case reviews with sufficient numbers and good reporting, or they may not. "Do they have 15 radiologists or do they have three? Do they have somebody to look at the quality of CTs or special studies, or do they not? Every hospital will have its own watermark of how much internal and external review combined make the peer review process," says Freedman.
Since internal peer review inevitably involves local interpersonal and professional relationships, objectivity can get lost in the process.
Peer review is supposed to study the quality of care with no consideration to the specific individuals who happen to be involved, says Freedman."It's not supposed to persecute me because I'm a lone wolf and have an ugly personality and everybody hates me. That's irrelevant," he says. "It's also not supposed to excuse me because I'm the most beloved doctor in town and therefore I get a free pass, and I get judged to a different standard than if I were somebody else in that situation."
[For more information on external peer review, contact:
Lila Allen, BSN, Quality Manager, Sunrise Hospital & Medical Center, 3186 South Maryland Parkway, Las Vegas, NV 89109. Phone (702) 892-3697. E-mail: firstname.lastname@example.org
Skip Freedman, MD, Executive Medical Director, AllMed Healthcare Management, 621 SW Alder Street, Suite 740, Portland, OR 97205. Phone: (503) 274-9916. Fax: (503) 223-6244. E-mail: email@example.com.]