Well-run peer review committees are essential to maintaining high-quality performance for physicians and nurses, but recruiting for those committees can be challenging. Physicians and nurses may resist the time commitment or fear legal and professional repercussions from passing judgment on their peers.

Those fears can be dispelled by educating physicians and nurses about the peer review process. Savvy recruiting techniques can help create effective peer review committees.

The overall purpose of peer review committees is to understand objectively what happened in a particular clinical case, compare that to the standard of care or best practice, and look for gaps, says Michael Loftus, MD, chief medical officer (CMO) at Jersey City (NJ) Medical Center.

“When you look for people to staff those types of committees, it is important that they have subject matter expertise about either the specific clinical realm you are reviewing or expertise in peer review and quality assurance,” Loftus says. “Even if the person is not a cardiologist, someone with experience in quality improvement and human factors analysis can provide meaningful contributions to the committee.”

It also is important to recruit physicians and nurses who are known to be open-minded and fair. Peer review hinges on transparent discussions, true identification of root causes and gaps, and using that knowledge to improve.

“That last step, learning from the process, is the key to a safety culture or a just culture,” Loftus says. “You need people on the committee who will identify the system and process issues that lead to individual human error. The peer review part that focuses on an individual error is only the beginning of understanding how a process broke down.”

Loftus says not following through after a review is a common problem with peer review committees. “Often, these committees may do a great job of reviewing cases, they may come to a conclusion about whether there was a gap in care or not, and they may even discuss internally what could be done better,” Loftus explains. “But the dissemination of lessons learned and the actual improvement that can come from it is the part that falls short too often. It’s an extra step, and it takes work beyond the review and conclusion, the regulatory box-checking that must happen.”

Committee members should be able to look beyond the individual error and ascertain what process failures made it possible for an individual’s error to reach the patient and cause harm. The best committees include a mix of backgrounds, training, and titles. A peer review committee that is interdisciplinary within the physician or nursing professions will be most effective.

Seek a Mix of Reviewers

It is common for peer review committees to be populated by the most senior physician and nurse leaders who self-select for peer review as part of leadership commitment. Those members can provide valuable input, but Loftus says it also is important to put frontline caregivers on the committees, not just senior managers and leadership.

“Some committees even have patient family representatives, which has pros and cons, but the idea is that you will have a more effective review and discussion when you have a variety of voices rather than multiple members with the same background and expertise,” Loftus says.

The actual recruiting for service on a peer review committee should be personal and direct. Once one identifies a likely candidate, a phone call or personal conversation with the potential member is best. Explain why that person is a good candidate and what serving on the committee entails. Be prepared to answer questions about the time commitment, confidentiality, and legal liability. With the right culture, Loftus says physicians and nurses will see serving on a peer review committee as an honor.

“They can see it as an opportunity to reflect on and represent the expertise of their peers in a way that benefits them,” he says. “Not as a finger-pointing, ‘I hold your career in the balance’-type of role, but rather as someone who is expected to be fair and hear both sides of a case before objectively deciding where there was a gap in care.”

Time Commitment a Concern

Physicians and nurses often see service on a peer review committee as a thankless job that requires a significant time commitment, says Michael B. Brohman, JD, shareholder with the Roetzel & Andress law firm in Chicago.

“The time required is probably the biggest deterrence to serving on a peer review committee,” he says. “If you have someone who is going to fight the recommended action, then you’re probably going to have to give testimony, deal with lawyers, and spend time showing that what your committee did was the appropriate recommendation.”

Brohman advises appealing to one’s sense of duty to their profession and their peers.

“You can emphasize the good they are doing, how their work will benefit their fellow nurses and physicians, the patients, and the facility,” Brohman offers. “This is probably one of the most important jobs at a hospital. Peer review is being judged by a jury of your peers. It is much more advantageous to be judged by people who are familiar with the issues, and what might be involved in a particular kind of care.”

Recruiting Can Be Difficult

Recruiting people to serve on hospital staff committees can be frustrating and difficult, notes Karen Owens, JD, an attorney with Coppersmith Brockelman in Phoenix. Even with some compensation, many might be leery of committing to work that can be difficult and time-consuming.

Owens notes an Arizona court once ruled, “Review by one’s peers within a hospital is not only time-consuming, unpaid work, it is also likely to generate bad feelings and result in unpopularity.”1

On the other hand, many physicians or nurses could be convinced to participate in staff self-governance for many different reasons, Owens says.

Those motivations can include good citizenship, a leadership personality that makes the physician or nurse want to run things or direct operations, camaraderie, and even curiosity. Based on long years of experience working with hospital and medical staff leadership, Owens says she has learned physicians listen to their colleagues in deciding whether to join committees. “Recruiting medical staff members into leadership roles is not the work of a day,” Owens says. “It has to be a process of ongoing cultivation, over a period of months or even years.”

While the CMO, chief executive officer (CEO), and chief nursing officer (CNO) certainly play important roles in recruiting physicians and nurses into leadership roles, Owens says it has been her observation physicians and nurses listen to their peers in deciding whether to take the plunge. Perhaps the best approach is for leaders to develop physician and nurse champions.

The likely best champions for physicians and nurses are the chief of staff and CNO, respectively. These champions should provide the encouragement and tools to bring other physicians and nurses along to the committee. Similarly, the past chief of staff can be an important recruiter for the medical staff committees.

High-Functioning Staff Attracts Participants

A well-run, efficient peer review committee will attract more participants. “There is nothing worse for a recruiting effort than for a physician [or nurse] to hear that meetings take untold hours, no one really knows who is in charge, or that the administration just steamrolls the process,” Owens says. “Having a process that basically functions and gets the job done, particularly one that is under control with respect to hours devoted to it, is a critical recruiting component.”

There is no magic bullet for achieving that kind of efficiency, but creating good documents that put guardrails around the process can be helpful. Still, even if the medical staff or nursing services are not running smoothly, some physicians or nurses may be drawn to the challenge of fixing the problems.

Recruiting Takes Time

Similar to charitable boards, medical and nursing leadership recruiting seems to work best if it is ongoing, with physicians and nurses brought into relatively low-stress positions and groomed to take on more responsibility.

“Even beyond this, patiently keeping in touch with physicians over time can yield leaders,” Owens says. “Perhaps a physician will become interested in participating once his children are grown, or when her practice has really taken off. It seems to pay not to give up on physicians [or nurses].”

Selecting the right individuals for a peer review committee is similar to selecting the right people for any other team, says Eric Dickerson, managing director of the academic medicine practice for Kaye/Bassman, an executive recruiting firm in Plano, TX. He notes peer review can take many forms, from standing quality improvement peer committees to those formed for the assessment of credentialing or hiring.

The minimum bar would be selecting individuals who are well-rounded in both clinical and academic pursuits in a specific specialty or field. Additional attributes that could help identify quality members of a committee would be good attention to detail, critical thinking skills, and the ability to ascertain complex views.

Dickerson notes peer review committees are about more than investigating bad outcomes and searching for possible dangers to patients. “The focus of a peer review committee is to develop, improve, and help the physician [and the nurse]. If you’ve got a bad apple, you need to separate it from the rest of the bushel, but that’s not necessarily the intention of the committee,” he explains. “It’s about assessing where this person is going in their career, and have they provided the amount of information and clinical outcomes to get where they want to go?”

For instance, someone on a peer review committee must be able to assess a junior colleague in a way that considers his or her level of training and experience, rather than holding the person accountable to the performance one would expect of a more highly trained and experienced physician or nurse. A key concern when recruiting for peer review committees is to look for people who are fair-minded and will approach the committee’s work as a way of helping and supporting peers.

“What you want to avoid is anyone who would approach it from a negative standpoint. Avoid people who have agendas, people who like to gossip, or those who want to be in the know about everything without good reason,” Dickerson says. “Seek out one who is looking to provide a quality peer review but also to learn from others through the peer review process.”

REFERENCE

  1. Scappatura v. Baptist Hospital, 120 Ariz. 204, 584 P. 2d 1194 (1978).

SOURCES

  • Michael B. Brohman, JD, Shareholder, Roetzel & Andress, Chicago. Phone: (312) 582-1682. Email: mbrohman@ralaw.com.
  • Eric Dickerson, Managing Director, Academic Medicine Practice, Kaye/Bassman, Plano, TX. Phone: (972) 265-5245. Email: ericd@kbic.com.
  • Michael Loftus, MD, Chief Medical Officer, Jersey City (NJ) Medical Center. Phone: (201) 915-2215.
  • Karen Owens, JD, Coppersmith Brockelman, Phoenix. Phone: (602) 381-5463. Email: kowens@cblawyers.com.