Introduction

The following is a reproduction of the actual survey instrument that was used for data collection for the National Peer Review Practices Survey from October 25 to December 18, 2007.  It is no longer possible to contribute a response.

BayState Health letterhead

Welcome to the National Peer Review Practices Survey and thank you for joining us in this groundbreaking effort. This anonymous survey applies only to acute care hospitals. It should take 10-15 minutes to complete.

Note that the survey asks for best estimates of Peer Review program support staff FTEs, turn-around-time for review, reviewed cases as a percent of screened cases, the proportion of cases sent for external review, and case review volume in relation to hospital volume. If these data are not available, it’s okay. Complete the survey and select “Unknown” for your response.

In the unlikely event you require technical assistance to complete the survey, please contact Deborah Naglieri Prescod at (413) 794-8832 or deborah.prescod@bhs.org

Answers to Frequently Asked Questions are available online. For other questions regarding the survey, please contact the investigators: Dr. Evan Benjamin, at (413) 794-2527 or evan.benjamin@bhs.org, or Dr. Marc Edwards, at (860) 521-8484 or marc@QAtoQI.com.

We greatly appreciate your participation.

Peer Review Practices Survey

Peer Review Program Organization, Scope and Process

In answering the following questions, think primarily of the Peer Review process as it applies to members of the medical staff who provide direct patient care. If your hospital is part of a multi-hospital system, answer only for your facility.

Medical Staff Peer Review Activity (e.g., physician case review, case adjudication/scoring, etc.) is best described as:

  • Centralized (e.g., a single committee for the entire organization)
  • De-centralized, primarily under the clinical department structure (e.g.., independent committees or reviewers for most departments)
  • De-centralized, primarily under interdepartmental/service line structures
  • Partially centralized, partially de-centralized
  • Not formally organized

Administrative support for Peer Review activity (e.g., case identification, pre-review screening, data entry, reporting, etc.) is best described as:

  • Centralized (e.g., a single department for the entire organization)
  • De-centralized, primarily under the clinical department structure
  • De-centralized, primarily under interdepartmental/service line structures
  • Partially centralized, partially de-centralized
  • Not formally organized

How many Committees conduct Peer Review activity?

(If none, enter 0)_________

What is the relationship of Peer Review to the hospital’s Performance Improvement (Quality/Safety Improvement) process?

  • Highly interdependent
  • Fairly well-coordinated
  • Somewhat connected
  • Minimally connected
  • Disconnected

What is the relationship of Peer Review to the hospital’s Risk Management process?

  • Highly interdependent
  • Fairly well-coordinated
  • Somewhat connected
  • Minimally connected
  • Disconnected

Approximately how many Full-Time Equivalent (FTE) paid staff provide administrative support for your entire Peer Review Program?

(Check “Unknown” if unable to answer)

Include an estimate of the allocated time of those not specifically assigned to the program organizational chart or budget

Do not count Peer Reviewers

  • Unknown
  • _________Administrative assistant
  • _________Technical analyst
  • _________Information systems programmer/specialist
  • _________Non-physician clinician (RN, PA, etc.)
  • _________Physician (MD/DO)

What is the Title of the individual (or individuals, if de-centralized) who manages the administrative support of the Peer Review Program?

_____________________________________

To whom does this individual report (What Title)?

_____________________________________

Comments on peer review organization, support and relationships:

____________________________________

Are Reviewers compensated in any way for their activity?

  • Yes
  • No

If yes, how are the Reviewers compensated?

  • Check all that apply
  • Salary
  • Hourly fee
  • Per case (per review) fee
  • Per meeting fee
  • Offset to medical staff dues or other fees
  • Other non-cash awards or indirect compensation

Are Advanced Practice Nurses (CRNA, Nurse Mid-wife, etc.) or Physician Assistants credentialed to provide care at your facility?

  • Yes
  • No

If yes, is their clinical activity subject to:

  • The same peer review process as physicians (MD/DO)
  • A separate peer review process

If APRNs or PAs are subject to the same peer review process as physicians, do they serve on Peer Review Committees (or as Reviewers if there are no committees)?

  • Yes
  • No

To what extent is the Peer Review process standardized across the organization?

  • Highly Standardized (e.g., well-defined by a policy which is followed in practice, variation from which is formally approved by whatever committee provides oversight)
  • Greatly standardized (e.g., there is a defined process with some variation that has not been formally approved)
  • Standardized (e.g., Whether or not the process has not been formally defined, there is significant commonality in approach across the organization, despite the presence of significant variation)
  • Somewhat Standardized (e.g., There is some commonality in approach across the organization, but variation is substantial)
  • Minimally Standardized (e.g., Regardless of whether or not there is a formal peer review policy or a common overall rating scale, autonomous behavior dominates)

What methods are generally used to identify cases for Peer Review?

Check all that apply

  • Generic screens for problematic cases (e.g., mortality, readmission, operative complication)
  • Clinically “interesting” cases
  • Patient complaints
  • Hospital staff concerns
  • Physician concerns
  • Risk management events
  • Referrals from other committees
  • Focused review of new privileges
  • Quality improvement studies
  • Unexplained deviation from protocols, pathways or other standards
  • Statistical monitoring of process or/outcomes measures
  • Random selection
  • Other (Please specify)_______________________________________________

What process, if any, is used to further screen identified cases prior to Peer Review assignment

Check all that apply

  • We don’t pre-screen
  • Chart review by a non-physician clinician (RN, PA, etc.)
  • Chart review by a physician
  • Chart review by non-clinical staff
  • Review of ancillary data from hospital information systems
  • Other (Please specify)_______________________________________________

If you do secondary screening of identified cases, what percent proceed to formal Peer Review?

  • Unknown
  • <20%
  • 20-39%
  • 40-59%
  • 60-79%
  • 80% or more

What is the annual volume of all Peer Reviews as a percent of hospital admissions?

  • Unknown
  • <1%
  • 1-1.9%
  • 2-2.9%
  • 3-3.9%
  • 4-4.9%
  • 5% or more

What percentage of total case volume involves External Review?

  • Unknown
  • <1%
  • 1-4%
  • 5-9%
  • 10-19%
  • 20-39%
  • 40-59%
  • 60-79%
  • 80% or more

What is the average Turn-Around-Time for Peer Review, as measured from the time of the event which gave rise to the review process until the completion of the adjudication of that case?

  • Unknown
  • Less than 30 days
  • Less than 60 days
  • Less than 90 days
  • Less than 180 days
  • At least 180 days

What types of activities are included within the scope of your Peer Review Program?

Check all that apply

  • Retrospective medical record review
  • Concurrent medical record review
  • Morbidity & Mortality case conference
  • Proctoring for new privileges
  • Other forms of direct observation
  • Comparative evaluation of performance measures (e.g., complication rates, core measures, patient satisfaction)
  • Comparative evaluation of aggregate data from Peer Review
  • Root cause analysis
  • Conducting performance improvement projects
  • Producing educational programs for groups of clinicians
  • Physician Health Program administration
  • Other interventions to improve individual performance
  • Other (Please specify)_______________________________________________

What documents do Peer Reviewers commonly examine?

Check all that apply

  • Formally prepared case abstracts
  • Case screening notes
  • Medical records
  • Pertinent diagnostics (X-ray, ultrasound, etc.)
  • Pertinent operative video recordings
  • Other pertinent operative images
  • Other (Please specify)_______________________________________________

What data is systematically captured and retained in the Peer Review process?

Check all that apply

  • Overall quality of care rating for an individual clinician
  • Categorization of an event type (e.g., morality, readmission, etc.)
  • Rating of whether an untoward event was preventable
  • Rating of whether an individual clinician could have prevented an event
  • Identification of contributory factors (e.g., high risk patient or procedure)
  • Rating of the degree of deviation form the standard of care
  • Recommendations for improved performance of an individual clinician
  • Other recommendations (referrals for additional review, group education, etc.)
  • Written case analysis
  • Structured ratings of specific elements of individual performance (legibility, quality of history & physical exam, etc.)
  • Identification of process of care issues involving other disciplines, information systems, organizational policy/procedures, etc.
  • Identification of clinician to clinician issues (gaps in communication, call coverage, supervision, coordination among clinicians, etc.)
  • Patient harm
  • None of the above
  • Other (Please specify)_____________________________________

Which sample rating scale best reflects the approach used in your organization?

  • We don’t use a rating scale
  • Quality concerns?     Yes    No
  • Acceptable    Minor Deviation    Major Deviation
  • Excellent    Very Good    Good     Poor    Very Poor
  • Multi-faceted scale such as the following table:
Score Description
0 No Quality Issue Present
1a Outcome Acceptable - Management Appropriate
1b Documentation Issue - Management Appropriate
1c Common Occurrence - Management Appropriate
1d High Risk - Management Appropriate
1e Unexpected Outcome - Management Appropriate
1f Technical Issue - Management Appropriate
2 Management Varied from Standard of Care
3 Unexpected Outcome - Quality Issue Raised
4 Management Unacceptable

When individual clinical performance may benefit from improvement, what best reflects the manner in which Peer Review decisions are generally made?

  • Group discussion to consensus
  • Majority
  • Minority
  • Peer Review Committee Chair
  • Department Chair
  • Independent opinion of a single reviewer
  • The average of multiple independent reviews

To what extent is individual Peer Review data aggregated and analyzed?

  • On a regular basis (e.g., quarterly, semi-annually)
  • Sporadically
  • Whenever there is a significant deviation and/or at the time of reappointment
  • Rarely
  • Not at all

How often do clinicians receive feedback regarding the results of Peer Review of their performance?

  • Following every review
  • On a regular basis (e.g., quarterly, semi-annually)
  • Sporadically
  • Whenever there is a significant deviation and/or at the time of reappointment
  • Rarely
  • Not at all

To what extent does your Peer Review program provide recognition for outstanding clinical performance?

  • Frequently
  • Occasionally
  • Seldom
  • Rarely
  • Not at all

The Peer Review process is primarily governed by:

  • Medical Executive Committee (or it’s equivalent in your organization)
  • A specially designated Peer Review oversight committee (of whatever name)
  • The organization’s Performance Improvement Committee or equivalent
  • Other (Please specify)_______________________________________________

In what manner is the Peer Review process governed?

  • Regular review of data involving the process and outcomes from peer review activity, with meaningful discussion related to ongoing improvement of the process (irrespective of discussions about individual performance issues)
  • Regular review of data involving the process and its outcomes, with little or no discussion
  • Irregular review of data involving the process and outcomes
  • Attention to Peer Review process rarely and/or only when problems arise
  • No attention to process, only attention to individual performance issues

What process or outcome measures from Peer Review activity are tracked and reviewed either by individual committees/departments/service lines or the governance committee?

Check all that apply

  • Case review volume
  • Turn-around-time for case review
  • Case review backlog
  • Counts and/or patterns of recommendations for improved performance of clinicians
  • Counts of clinicians recognized for excellent performance
  • Counts and/or topics of recommendations for group educational events
  • Counts and/or patterns of process of care improvement opportunities identified
  • Trends in targeted clinical performance measures
  • Trends in adverse event rates (either globally or by event type)
  • Trends in individual or group performance on specific elements of care evaluated through the peer review process
  • None of the above: we do not track and review any process or outcome measures in relation to our Peer Review Program
  • Other (Please specify)_______________________________________________

What information regarding Peer Review is routinely shared with the hospital’s Board of Trustees beyond that which might surface in relation to an adverse action?

Check all that apply

  • High-level aggregate data
  • Physician-specific aggregate data
  • Case-specific summary information
  • Case-specific detailed information
  • None of the above
  • Other (Please specify)_______________________________________________

Which statement best describes the level of participation by Reviewers in the Peer Review process?

  • Excellent
  • Very Good
  • Good
  • Fair
  • Poor
  • Very Poor

Which statement best describes how your medical staff perceives the Peer Review process?

  • Excellent
  • Very Good
  • Good
  • Fair
  • Poor
  • Very Poor

What is the likelihood that your Peer Review Program makes a significant ongoing contribution to the quality and safety of patient care at the hospital?

  • Very likely
  • Likely
  • Somewhat likely
  • Somewhat unlikely
  • Unlikely
  • Very Unlikely

What is the likelihood that your medical staff will make significant changes in the Peer Review Program structure, processes or governance in the coming year?

  • Very likely
  • Likely
  • Somewhat likely
  • Somewhat unlikely
  • Unlikely
  • Very Unlikely

Title of individual completing the survey

  • CMO/VPMA/Medical Director or equivalent
  • Chief of Staff or other elected medical staff leader
  • VP/Director/Manger of Quality/Safety or Performance Improvement
  • Risk Manager
  • Medical Staff Services head (of whatever rank)
  • Other (Please specify)___________________________________________

Comments on any aspect of this survey or elaboration on any specific survey item:

__________________________________________________

Hospital Demographics

Almost done: Just a few more quick items that are needed to put your responses in context.

Staffed Acute Care Beds

  • 25
  • 25-49
  • 50-99
  • 100-199
  • 200-299
  • 300-399
  • 400-499
  • 500 or more

Approximate percent of total admissions primarily attended by employed/contracted physicians (e.g., Hospitalists)

  • <20%
  • 20-39%
  • 40-59%
  • 60-79%
  • 80% or more

Post-Graduate Training

  • Major Teaching (member of Council of Teaching Hospitals – COTH)
  • Minor Teaching
  • Non-Teaching

Ownership/Control

  • Non-Government/Non-Profit
  • Investor-owned/For Profit
  • Government/Non-Federal
  • Government/Federal

Census Division

  • New England (CT, MA, ME, NH, RI, VT)
  • Mid Atlantic (NJ, NY, PA)
  • South Atlantic (DC, DE, FL, GA, MD, NC, SC, VA, WV)
  • East North Central (IL, IN, MI, OH, WI)
  • East South Central (AL, KY, MS, TN)
  • West North Central (IA, KS, MN, MO, ND, NE, SD)
  • West South Central (AR, LA, OK, TX)
  • Mountain (AZ, CO, ID, MT, NM, NV, UT, WY)
  • Pacific (AK, CA, HI, OR, WA)

Setting

  • Urban (including all Metropolitan Statistical Areas – MSA)
  • Rural (all other locations)

Optional Contact Information

If you provide contact information for your organization, it will be held confidential and used only for the purpose of follow up for clarification of responses.

Phone:_____________________

email:____________________

Thank you for sharing your responses with us.

Answers to Frequently Asked Questions are available online. If you have any further comments or if you would like further information, please contact:

Evan Benjamin, MD

Chief Quality Officer, Baystate Medical Center

Associate Professor, Tufts University School of Medicine

via email (evan.benjamin@bhs.org)

(413) 794-2527

OR

Marc T. Edwards, MD, MBA

Principal

Wilson-Edwards Consulting

via email (marc@wilson-edwards.com)

(860) 521-8484

Please click "DONE" to complete the survey and permanently record your responses.

12/18/07 Addendum (via e-mail):

Thank you for having responded to the National Peer Review Practices Survey. We received nearly 350 valid replies and hope to submit our manuscript for publication within the next few months. We’ll alert you when it has been accepted.

We have additional questions for you about participation of those under review (the Reviewees) in your typical peer review process scenario.

Please hit reply first, then fill out the form included in this message and send it back to me. If you have trouble entering data into the form, simply type your numeric response to the four questions in order.

Best Regards,

Marc T. Edwards, MD, MBA

860 655 4640

In answering, think of case review in general, (not a Morbidity & Mortality Case Conference or a Serious Occurrence investigation):

Input Request Likelihood

When a specific case is reviewed, how likely is it that one or more clinicians involved in that patient’s care will be solicited for input to the review process?

1=Frequently; 2=Occasionally; 3=Seldom; 4=Rarely; 5=Not at all

Input Provision Likelihood

When input is requested, how likely is it to be provided by the clinician?

1=Frequently; 2=Occasionally; 3=Seldom; 4=Rarely; 5=Not at all

Input Stage

When input is requested, at what stage in the review process is the information considered?

1=Before initial review; 2=During initial review; 3=Following initial review, before final scoring/disposition; 4=Following final scoring/disposition

Input Form

When input is provided, in what manner is it most likely to come?

1=In person; 2=In writing; 3=Equally likely in person or in writing