Peer review: What you can do to avoid lawsuits

Are your organization's conducted in good faith?

Does your organization's peer review committee have any ulterior motives? Are any of the members in competition with physician colleagues who are being investigated? Or are there financial incentives of some sort that could interfere with the objectivity of the committee?

Hospital bylaws must be very clear regarding peer review processes, says Carole La Pine, MSA, CPMSM, CPCS, director of the credentialing department at Saint Joseph Mercy Health System in Ann Arbor, MI. Medical services professionals should work with the bylaws committee or medical executive committee to ensure that peer review hearings are conducted in good faith, she adds.

At Saint Joseph Mercy, the quality committee's role is to conduct or coordinate evaluations and investigations relating to medical staff initial appointments, reappointments, and delineated clinical privileges. But once an investigation results in an adverse action, the fair hearing process needs to be implemented, says LaPine. The organization utilizes access to excellent physician leadership as well as legal counsel, she says. "I believe our medical staff bylaws and policies and procedures are well done and would prevent costly lawsuits," she adds.

The organization's medical staff bylaws require the following:

  • Members of the hearing committee shall not have actively participated in the consideration of the matter involved at any previous level.
  • The committee shall not include any individual who is in direct economic competition with the affected individual or any individual who is professionally associated with or related to the affected individual.
  • The application or member shall have the right to challenge the appointed committee members for cause.

"This makes it clear that competitors will not be involved in the hearing and that the member has the right to know in advance who will be serving on the committee," says LaPine.

Hospitals need to ensure that members of their medical staff are involved in activities to measure, assess, and improve organizationwide performance, says Nilda Conrad, MBA, CPMSM, CPCS, assistant vice president for medical/surgical/pediatrics and professional affairs at North General Hospital in New York City. The goal of peer review is to establish an objective evaluation of medical practice in order to assess a physician's competency, she says.

"Adverse evaluations may have a negative effect on a physician's privileges, their medical staff membership, and would have far-reaching repercussions, not to mention possible loss of their license to practice, malpractice actions, and possible criminal actions brought forth against them," says Conrad. For this reason, hospitals should follow a very specified, consistent, balanced, timely, and ongoing peer review process.

The hospital must be careful that none of the appointed members of a peer review committee are in direct competition or conflict with the practitioner under review, says Conrad. "Those appointed to take part in the review must be seen as objective and with no interest in the matter whatsoever," she says. Peer review must be conducted "in good faith" and without undue influence or pressures. If in doubt as to the biases of members of their own medical staff, hospitals should obtain an external reviewer, says Conrad.

There are other circumstances in which the hospital should seek an external peer review process, such as when a procedure is new to the institution or where there is a conflict of interest with members in a service and the institution seeks an unbiased review. "In this case, external experts must be sought to participate in this process, in order to reduce the risk to the institution," Conrad says.

To ensure that your organization's process is objective, use an internal process for your own committee reviews to improve performance. But for cases with possible conflict with others in the same specialty or competition for the same patients, use an external peer review process of experts from outside your institution who would be better able to remain unbiased and provide their expert findings on a matter, without the possibility of personal gain, says Conrad.

It is the professionals involved in supporting the medical staff leaders — medical staff affairs or quality management staff — who must ensure that the appropriate process is followed, says Conrad. At North General Hospital, medical affairs professionals guide and support the medical staff leaders when external peer review is required, and quality management staff are involved in the internal performance improvement processes. "They are key in ensuring that the appropriate process is followed," says Conrad.

The quality professional's role is to support and guide the various internal committees and assist in the review of the pertinent facts, says Conrad. "They do the legwork for the physicians and, since they are nurses, provide feedback that is reviewed by the appropriate committee to determine their findings and make recommendations for improvement, if necessary," she says.

If an external peer review process is called for, the medical staff professionals assist in obtaining experts in the appropriate specialty with no possible connection to the facility or to the involved practitioner. "The medical staff professional also helps guide the process according to the specified policies," says Conrad.

Conclusions reached through the peer review process must be supported by rationale that specifically addresses the issues for which the review was conducted, adds Conrad. "Such rationale may include reference to specific literature and relevant clinical practice guidelines," she says.

[For more information, contact:

Nilda Conrad, MBA, CPMSM, CPCS, Assistant Vice President, Med-Surg-Peds & Prof Affairs, North General Hospital, 1879 Madison Avenue, New York, NY 10035. Telephone: (212) 423-4774. Fax: (212) 423-4077. Email: nilda.conrad@ngsc.org.

Carole La Pine, MSA, CPMSM, CPCS, Director, Credentialing Department, Saint Joseph Mercy Health System, 2000 Hogback, Ann Arbor, MI 48105. Telephone: (734) 887-0513. Fax: (734) 677-6066. E-mail: lapine@trinity-health.org.