Normative Clinical Peer Review Database Project


Hospital-wide medical staff peer review activity


Pathology and Diagnostic Radiology reviews


Active Medical Staff
The number of members in the medical staff category representing the majority of physicians with active hospital practices. In many hospitals, this is termed the "Active" category and is often distinguished from Courtesy, Consulting, Emeritus, etc.
Pre-Review Case Screening
A process to determine whether to send a question related to one specified patient episode of care for peer review
Case Review
A peer review of one specified patient episode of care by one committee or department. If the same patient episode of care is independently reviewed by a separate committee or department, count it as a separate case. Count a readmission review as 1 case review.
Learning Opportunity
A broad view of the potential for improvement, both individual and organizational, to be gained from the peer review process.
More than 1 learning opportunity may be identified in any single case review.
Reason for Review
Whatever criteria or screens are used in your organization to identify cases for peer review. They may differ across departments or committees. A comprehensive taxonomy is available on request.

Data Collection Periods

  • Annual according to either the calendar year or the Federal Fiscal Year (FFY) October 1 – September 30

Note: All measures apply to the time period being reported.

Primary Data

  1. Total Staffed Beds
  2. Total Active Medical Staff
  3. Total hospital admissions
  4. Total ED visits
  5. Total number of cases identified/referred for review
  6. Total case review volume
  7. Total count of instances of recognition of excellent performance by a member of the medical staff
  8. Total count of Learning Opportunities discovered in peer review (sum of a-c)
    1. System issues
    2. Group education
    3. Individual education

Additional Program Data as Available

  1. Breakdown of Total number of cases identified/referred for review
    1. Number of cases self-referred for peer review
    2. Number of cases identified/referred by medical staff involving other clinicians
    3. Number of cases identified/referred by other clinical staff (do not include referrals by those whose defined role is to identify cases for peer review)
    4. Number of cases identified by all other means
  2. Breakdown of Total number of cases reviewed by committee or service. For example,
    1. Total number of Medical cases reviewed
    2. Total number of Surgical cases reviewed
    3. Total number of Other cases reviewed
  3. Breakdown of Total hospital admissions corresponding to #2. For example,
    1. Medical admissions
    2. Surgical admissions
    3. Other admissions
  4. Number of cases identified/referred by reason for review
  5. Number of cases closed via pre-review screening process (sum of a-c)
    1. Number screened by a physician
    2. Number screened by non-physician clinicians
    3. Number screened by non-clinicians
  6. Number of cases reviewed by reason for review
  7. Average turn-around-time for case review, measured in days, from date of the event which ultimately gave rise to the review until the date of final decision on the case, for cases in which the final decision is made during the period
  8. Reviewer meeting attendance – average percent attendance for the time period
  9. Average cases reviewed per reviewer per meeting
  10. Breakdown of System issues identified in the peer review process
    1. Clinician to Clinician or Interdepartmental issues
    2. Other system issues
  11. Learning opportunities discovered by type vs. reason for review – a pivot table with Excellence and the 4 types of learning opportunities as columns (Excellence, Clinician to Clinician Issue, Other System Issue, Group Education, Individual Education) and the Reasons for Review as rows.

Have Questions or Need Clarifications?

Contact Marc T. Edwards, MD, MBA: or 860 521-8484