The real deal on holding successful case reviews
Keep in mind the purpose and critical questions
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Unfortunately, the term "peer review" has negative connotations — it is generally associated with disciplining practitioners. The Joint Commission's medical staff standards stress the importance of viewing peer review as educational but this can be difficult to do when review outcomes are used only for credentialing and privileging purposes. To be truly accepted as an educational process, the primary purpose of peer review must be quality and patient safety improvement with individual competence assessments merely a byproduct.
It is common to find peer review policies that begin by stating the primary purpose is quality improvement. Except for that one statement, however, the policy focuses on the fact finding and disciplinary elements. How case reviews are conducted affects how practitioners view the peer review process. If, for example, reviewers are only asked to judge the appropriateness of other physicians' decisions, it is no wonder the review process is felt to be punitive. The disciplinary nature of review is further reinforced if physicians are only made aware of case review results when their decisions are being questioned.
The goal of peer review of individual cases is quality improvement, and corrective actions are important to this goal. In only rare instances will a practitioner need to be disciplined or sanctioned. In most situations, the case evaluation results provide a learning opportunity for those involved as well as those who care for similar types of patients. To further maximize the improvement value, the review process should extend beyond one practitioner's performance to include an assessment of the operational environment in which all practitioners function.
In this last installment of the three-part series on physician peer review, the case review process is described. The elements required by Joint Commission standards are covered, as well as techniques for transforming peer review into a more positive learning experience.
Practitioners serving on peer review committees should receive training in how to evaluate cases and how to complete whatever documentation is required by the medical staff. The aim of the training is to provide reviewers with an understanding of the techniques required for peer review assessment and the underpinning philosophy. Without such training there is no way to ensure consistency of case reviews throughout all medical staff departments.
Peer review evaluations should be based on appropriateness, medical necessity, and efficiency of services to assure quality medical care. But what standard of care should reviewers apply? Is the assessment to be based on the reviewer's own medical judgment and expertise? Are reviewers expected to consider community standards or are the generally recognized national levels of quality to be considered? These questions need to be addressed during reviewer training. To provide objective and consistent medical opinions, reviewers in all medical staff departments should have a similar basis for making case review decisions.
Often reviewers are expected to answer several questions about each case, such as:
- Does the care represent a deviation from accepted standards?
- Was practitioner judgment/decision making adequate?
- Could this incident have been prevented?
These questions may be easier to answer in retrospect. During reviewer training discuss the influence of hindsight bias on evaluation decisions — knowing the patient's outcome can influence how past events are assessed. Practitioners involved in the case did not know the patient's outcome at the time treatment decisions were being made. Thus, what may seem obvious to reviewers may not have been apparent to the practitioners involved. Reviewers should be cautioned to guard against hindsight bias as much as possible.
Reviewers also should be introduced to the logics of the medical staff's peer review process. For example:
- what cases are selected for review;
- the first-level screening process by the quality department (if done);
- questions on the review forms;
- how quickly reviews are to be completed;
- what happens to a case if the reviewer discovers a possible quality-of-care problem;
- how additional information, if needed for the review, is obtained from the involved practitioners;
- what happens if a quality-of-care problem is confirmed;
- the types of cases selected for morbidity and mortality conferences;
- how practitioners are informed of peer review results;
- peer review confidentiality policies.
New reviewers should receive this training before they are assigned cases to evaluate. By staggering the membership on peer review committees, the medical staff will always have a core group of trained reviewers that can complete case evaluations while new recruits are being trained.
Dual purpose reviews
To reinforce the quality improvement goals of peer review, evaluations should go beyond determining if the care meets acceptable standards and is appropriate for the patient's condition. Although this judgment is needed for eventual use in the credentialing/privileging process, it should not be the only conclusion solicited from reviewers; it is just as important to identify the structures and processes responsible for adverse events or suboptimal outcomes. When peer review is focused solely on individual performance, the organization misses opportunities to make changes in problematic systems over which individual practitioners have little control.
Examples of systems problems are:
- information systems that delay or lose key elements of patient care, such as physician orders, patient records, lab results, etc.
- defective procedures that impede communication among caregivers or delay delivery of services to patients.
- scheduling systems that inhibit timely access to services and personnel.
Along with evaluating individual practitioners' performance, reviewers should be encouraged to also identify problems in the support systems that may have contributed to suboptimal patient outcomes. For example, consider the case described below:
An orthopedic surgeon discharges his patient without noticing the patient's abnormally low platelet count. The patient is readmitted in just one day for treatment of thrombocytopenia secondary to an adverse medication reaction. Clearly the surgeon was responsible for reviewing lab results prior to discharging the patient, and the physician reviewing the case classified it as not meeting the standard of care. However, the reviewer also identified some system problems related to timely communication of abnormal lab results to physicians. The peer review committee referred these issues to the hospital's quality council for resolution.
Practitioners still have the responsibility to comply with acceptable standards. However, by also evaluating practitioner errors in the context in which they occur, it's possible to determine whether changes in the system of care can reduce the risk of future errors. Encourage reviewers to ask, "What must be done to make it more difficult for practitioners to make a similar mistake in the future?" This questioning process will lead to system improvements that can benefit all caregivers.
At the conclusion of a case review, the involved practitioners should receive feedback. In most situations, this simply will be a confirmation of the effectiveness of the practitioner's professional, technical, and interpersonal skills. If opportunities for improvement are identified, the involved practitioner should receive a written report detailing the issues and peer recommendations. The Massachusetts Medical Society's "Model Principles for Incident-Based Peer Review for Health Care Facilities" recommend the following information be provided to the involved practitioner1:
- The identified deviation (act or omission) in the process of care from the "standard of care."
- The "standard of care" from which the deviation occurred.
- The source for the above "standard of care."
- What specific steps of care should have been taken or not taken to meet the "standard of care."
- What specific remediation, if any, is recommended for the physician.
The feedback process closes the quality improvement loop and further reinforces the primary focus of peer review. The goal of case review should be to affirm the quality of professional practices and discover ways of improving both practitioner and system performance.
1. Massachusetts Medical Society. Model Principles for Incident-Based Peer Review for Health Care Facilities. June 2005. Web site: www.massmed.org.