Multidisciplinary peer review 'more objective'

Responsibilities laid out

Review of physician performance by peers is effective when done properly, but the process is time-consuming and often very subjective. Often, the criteria for determining judgments are not expressly stated, so reviewers often use their own criteria to assess the quality of care, says Charlotte Jefferies, a consultant with Pittsburgh-based Horty, Springer & Mattern.

"This often occurs in departmental reviews," says Jefferies. "A retrospective, subjective peer review process by a group of direct economic competitors does not work and is very risky. And simply changing the scoring system or paying stipends to a quality reviewer does not change a bad design."

Establishing a multidisciplinary committee that focuses solely on peer review matters can be helpful in structuring a more objective, criteria-based process.

"To the extent that it can be done, quality must be defined in advance. Then the work of the medical staff leadership is to help practitioners achieve that quality," Jefferies says.

An effective peer review committee can comprise the vice president of medical affairs or medical director, the director of quality/performance improvement, and at least one physician from each clinical service/department.

"In order to avoid the problems of the past, the duties of this committee should clearly demonstrate that the goal of peer review is performance improvement when possible," says Jefferies.

The responsibilities of a multidisciplinary peer review committee should include:

  • Oversight of the implementation of the medical staff peer review policy;
  • Review and approval of the quality indicators developed by the clinical departments and the quality/performance improvement department;
  • Review and familiarity with patient care protocols and guidelines developed by national organizations;
  • Identification of those quality indicators which do not require focused physician review but do require educational letters to the practitioner being reviewed;
  • Review of cases referred to it, as outlined in the peer review policy;
  • Development of performance improvement plans for practitioners when appropriate;
  • Regular reports to the medical staff leadership regarding peer review activities;
  • Review of the effectiveness of the peer review policy, and recommendations for revisions or modifications, as necessary.

The multidisciplinary peer review committee should be established as a subcommittee of the Medical Executive Committee, and should mandate a uniform method by which peer review is performed, says Douglas L. Elden, chairman of the Northbrook, IL-based National Peer Review Corp.

Without a centralized multidisciplinary peer review system, cases requiring multidisciplinary peer review are often sent from one department to another, with each department blaming the other, says Elden.

For example, in a case involving questions about surgery and anesthesia, the department of surgery peer review committee may determine that the deviation from the standard of care occurred due to the anesthesiologist, and terminate the peer review without action or recommendation. At the same time, the department of anesthesiology peer review committee may determine that the deviation occurred due to the surgeon, and terminate the peer review without action or recommendation.

"Without a centralized peer review infrastructure to track the case and a multidisciplinary peer review committee to enforce the appropriate analysis, the peer review of the case will be unresolved, and the issues forgotten," says Elden.

The multidisciplinary peer review committee should have the power to assign cases to the following, says Elden:

  • Individual or multiple peer reviewers working together on a case for reporting to the committee, such as anesthesiologist and a surgeon reviewing a surgery case;
  • Subcommittees, such as a group of anesthesiologists and surgeons reviewing a surgery case;
  • Clinical services, divisions and sections, such as a case assigned to the department of anesthesiology and the department of surgery, with a time requirement for returning the report to the multidisciplinary peer review committee;
  • External peer review, in accordance with the organization's policy.

At Riverside Methodist Hospital in Columbus, OH, a multidisciplinary peer review committee functions as an oversight committee for other peer review committees. As a larger institution, Riverside has too much peer review activity to do it all in a single committee, says Robert L. Thompson, MD, chair of the multidisciplinary peer review committee.

The committee handles cases being litigated, professional conduct peer review, complex cases referred from department or section peer review, and cases where department or section peer review committees have conflicting opinions.

An individual department or section peer review committee may not have the expertise to complete a determination for a complex case — an ideal setting for multidisciplinary peer review to occur. "However, much of peer review is less about super special expertise and more about meeting the accepted standards of care," says Thompson. "That is the arena in which multiple practitioners of different disciplines can function well, and determine if the care delivered was appropriate or not."

Difficulties will arise

Sometimes, findings and assessments made by the various specialties represented on the peer review committee contain disparities, or may even dispute the findings or conclusions reached by other members of the committee.

"In those cases, coordination of the peer review reports and process is necessary to resolve issues and to prevent gridlock," says Jefferies.

Sometimes the committee may find it prudent to send the matter under review back to the department chair or to the medical staff leadership with specific questions or concerns, or refer the matter to another medical staff committee for review. "The findings must be reconciled," says Jefferies. "The goal must be to achieve a final peer review report, which contains the coordinated findings of the committee and an action plan to improve the practitioner's performance."

The key to effective peer review is early detection, prompt action, and education. "Each member must be experienced and respected, and have a clear understanding of the duties to be performed," says Jefferies. "Individuals serving on the committee should receive information and training in the elements and essentials of peer review."

One criticism of multidisciplinary peer review committees is that the practitioner being reviewed has expertise that very few have, and therefore, cannot be reviewed by other specialists or even generalists.

"However, much of the less-than-optimal care delivered is not in this super expertise category, and is more about the daily need for compulsive attention to detail in the care of the patient," says Thompson. "Being caught up in the argument of 'only a similar expert with my training can review my case' leads to frustration and delay."

A medical peer review committee is only as good as the physicians who sit on the committee, says Thompson. "Poorly informed, disinterested practitioners will not provide the type of product that the modern peer review process should — fair, evidence-based, objective determinations," he says.

[For more information, contact:

Douglas L. Elden, Chairman, National Peer Review Corp., 1033 Skokie Blvd., Suite 640, Northbrook, IL 60062. Phone: (847) 480-8800. Fax: (707) 988-8800. E-mail: douglas.elden@nationalpeerreview.com. Web: www.nationalpeerreview.com.

Charlotte Jefferies, Horty, Springer & Mattern, 4614 Fifth Ave., Pittsburgh, PA 15213. Phone: (412) 687-7677. Fax: (412) 687-7692. E-mail: cjefferies@hortyspringer.com.

Robert L. Thompson, MD, Chair, Multidisciplinary Peer Review Committee, Riverside Methodist Hospital, 3535 Olentangy River Rd., Columbus, OH 43214-3998. Phone: (614) 566-3755. E-mail: rthompso@ohiohealth.com.]