Ongoing review: Change of mindset is now needed

No more 'bad apple' approach

The traditional "bad apple" approach to peer review is changing to a new emphasis on performance improvement, says Nancy J. Auer, MD, FACEP, chief medical officer of Seattle-based Swedish Health Services. "To reflect this change in our organization, we have changed the name to 'medical staff peer review/performance improvement,'" she reports.

The ability to perform effective physician performance improvement depends on a hospital's ability to gather accurate, credible, physician-specific data. "In fact, that is our major problem," Auer says. "For years, we collected only aggregate data on physicians, believing that they would not participate in PI activities if they thought we were collecting data on individuals. Now physicians are saying, 'If you want me to change, show me my data.'"

The organization is currently building physician-specific databases. "Some are very robust and some are sparse," says Auer. "A good database will provide information that is more independent of physician bias." If physicians can agree on indicators and what data will be collected in advance, the data will speak for themselves, adds Auer.

To ensure that quality care is provided, and guarantee competencies, use a variety of methods. Observations, interviews with coworkers, and validation of the entries in documents are a few methods, recommends Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Charlotte, NC-based Presbyterian Healthcare.

"Recently, I heard a Joint Commission surveyor describe the performance evaluation requirements of the medical staff as an extension of what nursing has been doing for years," Swain says. "Why is this scrutiny reserved for the hospital staff? The medical staff has as much at stake as anyone."

To make the new process seem less difficult, take the approach of using what is already done in other parts of the health care arena and extend it to the medical staff, says Swain. "These next two years will do much to bring the medical staff into the process of patient care delivery review, with a spotlight on how systems operate and how the medical staff operate within those systems," she predicts.

Here are effective strategies to comply with the ongoing review requirements:

• Enlist the help of a champion.

"After shock and awe amongst the ranks of the medical leaders, a medical champion must declare the absolute necessity of this for organizational operations," says Swain. The champion could be the chief of staff, the credentials committee chairman, or the vice president of medical affairs, says Swain.

• Design a plan that will provide medical staff leaders with valuable information.

"Medical staffs that have from 50 to 2,000 members will need to examine what's doable," she says.

• Consider adding in subjective data to your results.

Administrations in every type of facility will need to closely examine the sources of data as they fold them into performance evaluations, says Swain.

"There will need to be at least an Excel database managing this," says Swain. Volume statistics on admissions, discharges, surgeries, births, and procedures are useful, but adding more subjective data that may have been provided through peer review statements reported as meeting best practice brings another level of complexity, she says.

"Physicians have been afraid of 'numbers reporting,' 'economic credentialing,' and other accountabilities for years," says Swain. "This may be well founded in light of the poor data mining under way in many databases. However, with pay for performance at the door, there is little relief from the use of numbers identified by providers."

• Involve others when interpreting data.

The data for each provider will be put before peer review committees, who will need to deal with the nuances of multiple types of data, says Swain. "There should be questions from the committee requiring more drill-down questions, and involvement of nurses, ancillary staff, and cross-service physicians when looking for answers to twists found in data," she says.

The old peer review response of "acceptable exception" by a peer review committee will not be useful in the performance evaluation of the future, says Swain. "Conscientious review, referral to outside agencies, and longer credentialing committee meetings will be trends of the future."

Physicians and allied health professionals will need to be involved with what is going into their files, says Swain. Share stories of success through education sessions, such as grand round sessions and general medical staff meetings, she recommends. "Throughout the transition process, they should be taught that this is the expected standard for all."

[For more information, contact:

Nancy J. Auer, MD, FACEP, Chief Medical Officer, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Phone: (206) 386-6071. E-mail:

Paula Swain, MSN, CPHQ, FNAHQ, Director of Clinical and Regulatory Review, Presbyterian Healthcare, 200 Hawthorne Lane, Charlotte, NC 28204. Phone: (704) 384-8856. E-mail:]