Recognition of Excellence
We have a method to identify and regularly provide recognition for outstanding clinical performance
We occasionally recognize outstanding performance
Seldom or rarely, if ever, do we recognize outstanding performance
Governance of Process
The medical staff leadership gives little or no attention to governance of the peer review process and its aggregate outcomes
There is regular review of data involving the process and its aggregate outcomes, with little or no discussion
There is regular review of data involving the peer review process and its outcomes, with meaningful discussion directed toward ongoing improvement of the
process (irrespective of discussions about individual performance issues)
Rating Scales for Case Review (see examples above)
We don't use rating scales
We rate elements of clinical performance primarily on Yes or No type scales (e.g., a check box for documentation issues)
We rate elements of clinical performance on scales that have at most three or four intervals from best to worst (Example A)
We rate elements of clinical performance on scales that have five or six intervals from best to worst (Example B)
We rate elements of clinical performance on scales that have seven or more intervals from best to worst
Which statement best describes the level of participation by Reviewers in the Peer Review process?
Fair or worse
Relationship to Performance Improvement Activity
Peer review is highly interdependent with the hospital’s Performance Improvement (Quality/Safety Improvement) process
Peer review is at least fairly well-connected to the hospital’s PI process
At best, peer review is only somewhat connected to the hospital’s PI process
In each case review, we look for process improvement opportunities including clinician to clinician issues, in addition to evaluating individual clinical
In each case review, we do little more than ask, "Was the standard of care met?"
Trustees periodically receive information about peer review activity beyond that which would be reported in relation to an adverse action
Trustees are only provided information in relation to adverse actions
Cases are reviewed and opportunities for improvement are communicated on average within 3 months of the episode of care
On average, more than 3 months is required
Case Review Volume
The total annual volume of cases reviewed is at least 1% of hospital inpatient volume
The total annual volume is less than 1% of hospital inpatient volume
Documents Examined During Case Review
Pertinent diagnostic images or recordings (e.g., CT, MRI, ultrasound, fetal heart tracings, etc.) are routinely examined along with the medical record
Only the medical record and the reports of pertinent diagnostic studies are examined
Peer Review Program Goals
Peer review activity may serve many aims, some of which are achieved by primary intent and others as means to those ends or as indirect benefits.
To what extent does the primary aim and purpose of your peer review program target improved quality and safety of care?
Not at all
Medical staff members frequently report adverse events, near misses and/or hazardous conditions affecting their own patients for peer review.
Group Discussion of Case Reviews
What proportion of case reviews are presented and discussed by a group or committee prior to final decision-making?
75% or more
Quality of Case Review
Rate the general quality of case review activity on the following scale:
Relatively superficial and lax
Extremely thorough and rigorous
Peer Review vs. Credentialing
Which statement best describes the relationship between peer review and credentialing at your hospital?
The peer review program is completely separate from credentialing
The peer review program is independent of credentialing, but the results of peer review may be used in credentialing decisions including OPPE
Peer review program activity is partially mixed with credentialing activity
The peer review program encompasses the credentialing program
The credentialing program encompasses the peer review program
Reviewed Clinician Input
Thinking of case review in general, (not a Morbidity & Mortality Case Conference or a Serious Occurrence investigation),
how likely is it that one or more clinicians involved in that patient’s care will be solicited for input to the review process?
Rarely or not at all
Almost every time
While peer review methods are widely applied, not all such use is locally defined as being within the scope of the medical staff’s peer review program.
Prior study has shown wide variation in program scope.
Check all that apply to your program
Concurrent medical record review
Case-specific, individually-targeted recommendations to improve performance
Peer Review Process and Outcome Measures
Hospital leaders commonly follow a "dashboard" of key performance measures relevant to their area of responsibility.
Here, we are interested in learning only about those that are tracked specifically to monitor or improve peer review program performance,
whether or not such measures are used for other purposes.
What process or outcome measures of peer review activity are tracked and reviewed either by individual committees/departments/service lines,
the governance committee or the Board?
Turn-around-time for case review
Counts of clinicians recognized for excellent performance
Counts/patterns of system or process of care improvement opportunities identified