THE QUALITY CO$T CONNECTION

Fortifying individual case review activities

Screening cases for peer review

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Joint Commission standards require ongoing professional practice evaluations of physicians and licensed independent practitioners (LIPs). One aspect of this evaluation involves collection and evaluation of performance results — using process measures and outcome measures. This component of The Joint Commission standards was covered in last month's column. In the second part of this two-part peer review series, individual case review is covered.

Case review involves analysis of the circumstances surrounding an individual case to determine if the practitioners involved met the standard of care. The review is conducted for the purpose of judging the competence and professional conduct of practitioners. To ensure the review is objective and fact-based, a peer physician or LIP should do it.

Peers are individuals who share the same profession and have similar training and privileges. When general medical management issues or professional behaviors are being evaluated, a peer with comparable skills can often objectively examine the facts of the case and render a knowledgeable judgment. If the judgment requires the peer reviewer have specialized expertise or skills, then someone considered competent in that specialty should evaluate the case. For instance, it may not be appropriate for a cardiac surgeon to evaluate a case involving pediatric heart surgery unless the surgeon has pediatric surgery training.

All physicians and LIPs should have some of their cases reviewed. It is not sufficient to evaluate individual competence solely based on aggregated performance measurement data. While performance data are useful, there are many professional performance factors that cannot be adequately evaluated based on numbers alone.

The number of cases that need to undergo review for each practitioner is dependent on the volume of patients seen. The medical staff should establish a minimum case review requirement, such as 10%, and apply that requirement uniformly across all disciplines. The Joint Commission standards are silent on this issue — stating only that the medical staff define the circumstances that require evaluation of a practitioner's performance and the methods that will be used. Surveyors judge compliance with the standards by comparing what is actually occurring with the stated case review policies of the medical staff.

The medical staff should establish criteria for selecting cases that will undergo peer review. Some cases will be reviewed for appropriateness of blood and medication use, utilization practices, and surgical appropriateness. Other cases will be selected to evaluate general issues related to medical assessment and treatment of patients. These cases are commonly selected for review after a particular event occurs. The common types of events that prompt case review are listed in Figure 1. Each medical staff department or subspecialty may identify additional events requiring peer review that are unique to particular patient populations or interventions. In Figure 2 are examples of events that undergo peer review in one hospital's radiology service.

Screening cases for peer review is often a multi-step process. Events may be identified concurrently, while the patient is hospitalized, and retrospectively, during chart review by staff in the QM or health information management department. A referral from infection control, risk management or another clinical department may cause a case to be flagged for peer review.

In some hospitals, all events undergo some type of peer evaluation. However, it is common for professional staff in the quality department to conduct a first-level review using criteria approved by the medical staff. For instance, in the case of a patient's death, the medical staff may elect to review the case only if one of the following circumstances is present:

  • Lack of documentation of patient's deterioration during 48 hours preceding death.
  • Change in patient's condition with no action taken during 48 hours preceding death.
  • Lack of agreement between the patient's pre-mortem and post-mortem diagnoses.
  • Death appears to be related to a communication failure among practitioners.
  • Lack of documentation explaining the death.
  • Lack of documentation that the death was expected.
  • Death appears related to an incident or a complication of treatment.
  • Death within 24 hours of admission (except in cases in which death is anticipated and clearly documented).
  • Death within 72 hours of transfer out of a special care unit (unless the transfer was made because death expected).
  • Death during a surgical procedure or death is suspected to be related to a surgical procedure.
  • Death appears to be related to treatment choice, including medication.
  • There is reason to think death may have been preventable.

Once a case has been identified as needing peer review, the flow of the review process varies among hospitals. In some hospitals cases selected for review are assigned to a multi-specialty medical review oversight committee comprised of physicians and LIPs from each department. Senior administrative leaders may also sit on this committee. Cases determined by the oversight committee to need further investigation go to the relevant medical staff departments for general and specialty-specific medical review. In other hospitals, the flow is reversed with cases first being reviewed at the department level and questionable cases sent to a multi-specialty medical review oversight group for broader evaluation. Some hospitals have only one level of review; either by an oversight committee or by peer review committees within each medical staff department. Regardless of the flow of the review process, if the case needs to be evaluated by a peer with specialized expertise or skills and there no practitioner at the hospital that meets these criteria, arrangements should be made for external peer review.

To meet the intent of the Joint Commission standards, peers should review some cases of every physician and LIP. If no cases are identified through routine event screening activities, then a random sample of the practitioner's cases must undergo review. Don't want until right before the practitioner's reappointment to review these cases. At least semi-annually identify practitioners that have not had some type of case review during the previous six months and select a representative sample to undergo peer review. To prevent the need for this periodic analysis, some hospitals routinely conduct peer review for one or two randomly selected cases for every practitioner. These reviews are done in addition to the cases identified through the event screening system.

The objective of case review is to validate that physicians and LIPs are competent to perform the patient care privileges granted to them by the hospital. At the same time, case review should be viewed as an educational process. Information derived from the evaluations should be used to educate individuals about how to improve their skills and reduce errors. Punitive action for misconduct or practice irregularities is a last resort – taken only in egregious situations or when other interventions have failed. Properly designed, case review is outcome based with the process used to:

  • identify events that present improvement opportunities;
  • recommend actions to lessen future occurrences of the event; and
  • implement those recommendations with the individuals involved.

The ultimate goal is to continually assess and improve the quality of care provided by physicians and LIPs and minimize the system factors that impact professional practice. How to review cases so this goal can be achieved will be covered next month in part 3 of this series.