3)
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
4)
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)
5)
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
6)
Reviewer Participation
Which statement best describes the level of participation by Reviewers in the Peer Review process?
Excellent
Very Good
Good
Fair
Poor
Very Poor
7)
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
8)
Improvement Opportunities
In each case review, we look for process improvement
opportunities including clinician to clinician issues, in addition to evaluating individual
clinical performance
In each case review, we do little more than ask, "Was
the standard of care met?"
9)
Board Involvement
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
Unknown
10)
Performance Feedback
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
Unknown
11)
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
Unknown
12)
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
13)
Adverse Events
Trends in adverse event rates (either globally
or by event type) are monitored in the context of peer review outcomes by committees,
departments or governance
Adverse event rates are measured, but trends are not monitored
in the context of peer review outcomes
Adverse event rates are not measured
14)
Self-Reporting
Medical staff members frequently report adverse events, near misses and/or hazardous conditions affecting their own patients for peer review.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
15)
Committee Discussion of Case Reviews
What proportion of case reviews are presented and discussed in a committee prior to final decision-making?
<25%
25-49%
50-74%
75% or more
Unknown
16)
Quality of Case Review
Rate the general quality of case review activity on the following scale:
Relatively superficial and lax
..
...
....
.....
Extremely thorough and rigorous