There are so many ways the peer review process can go off the rails. Some are obvious, but some may not seem risky until they result in a disgruntled physician suing the hospital.

Poor documentation from peer review meetings also is a common factor in litigation, says Christopher Metzler, PhD, chief growth officer and CEO of FHWFit, a global healthcare conglomerate in Washington, DC. Too often, hospitals create brief, incomplete notes and use cryptic references that only make sense in the moment, he says. Then, months later, the participants are expected to remember details of the peer review and explain the references that no one understands, he says.

“If there are detailed notes, counsel can use those to refresh someone’s memory much later when there is litigation,” he says. “You should have someone taking notes who is experienced in recording minutes of a formal proceeding, rather than just having the physicians there make some notes. The physicians are there to do the technical review and they shouldn’t be charged with taking notes because they’re not going to do a good job.”

Peer review committees also must have a solid process for preserving documentation, he says. Especially in any peer review meeting in which adverse action against a physician was even discussed, even if no action was taken, all patient charts pertaining to that review should be photocopied immediately and preserved as part of the review documentation, he says.

Physicians also must be careful about discussing peer review, Metzler says. People can let their guard down in the doctors’ lounge and chat about what they’ve seen in records or what the peer review committee is considering. That’s a very bad move, Metzler says.

“As a member of the peer review committee, you are an agent of the hospital and if you have conversations in the doctors’ lounge or anywhere else that is inappropriate, you can lose immunity,” he says. “It’s very important that physicians under the strict confidentiality of peer review matters.”

Even small slips can give the appearance of impropriety in peer review, Metzler says. He once worked with a peer review committee in which one of the physician reviewers was using her personal stationery to communicate peer review business.

“I had to explain that in peer review you are acting as the agent of the hospital in monitoring quality of care, and so any communication must be on the hospital’s or medical committee’s stationery. She said it was OK because everyone knew she was on the peer review committee,” Metzler says. “No, that doesn’t matter. You cannot do that. It gives the wrong impression about who this information is coming from, and puts you at risk.”

Physicians in the peer review process also should have a clear understanding of their focus and not wander into areas that are not of their concern, Metzler says.

“If they are addressing one topic and come across something else, they may wish to raise that with an administrator at some point, but the peer review process is not the place,” Metzler says. “Stick to the charge that you have and the patient records under review. Understand the scope of the committee’s purpose and its powers.”

Metzler also cautions against appearing to have prejudged the results of peer review. Those involved in the peer review process should never say things like, “Hypothetically, if it happened this way then we should do this.”

“They should be concerned only with getting the facts and not appear to have come even to a preliminary conclusion about anything,” Metzler says.

“I once had a physician say, ‘Hypothetically, if the physician did these things…’ and he thought it was okay because he says ‘hypothetically.’ But I said, ‘We’re all sitting here and saw you use air quotes when you said that, so we know you have prejudged this case and we have to reconstitute an entirely new committee.’”