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Patient Safety Nov 20, 2023

Everything You Need to Know About Improving Medical Peer Review

This guide will help explain everything you need to know about improving Medical Peer Review.

Medical Peer Review is the process that all hospitals are mandated to use to measure the clinical compliance of their care providers to ensure patient safety by ensuring a standardized level of care is provided by all practicing physicians.

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Introduction

Patient safety and patient-centered care are the pinnacle of modern healthcare, but how do you measure the quality of the care your staff provides? When hospitals and accrediting bodies asked this question in the 1950's, they came up with the idea of medical peer review. As medical peer review evolved into what it is today, the focus is on patient safety as well as ensuring a standard of care that is upheld across all hospitals in the United States.

Under the supervision of patient safety committees, providers evaluate each other's clinical performance, professionalism, and decision-making process. Clinical peer review is the closest thing to a standard procedure for assessing hospital patient safety.

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1. The Role of Peer Review in Patient Safety

Medical peer review is one of the ways hospitals evaluate the competency and safety of their providers. So, how does this translate to safer care environments? The answer depends on the facility it takes place in and how its leaders conduct the process.

At its best, peer review looks like an ongoing learning experience shared by a hospital's staff. Providers willingly report unsafe events without fear of negative consequences. All specialties participate in the hospital's peer review committee and administrators follow-up with review results to address gaps in patient safety. However, keeping peer review internal places providers at risk of potential bias, and reform is overdue. Fortunately, there are companies such as Medplace that can provide a streamlined platform and remove the risk of potential bias by keeping medical peer review internal.

When discussing the improvements required in the conduction of medical peer reviews, it is important to identify the shortcomings. The early methods of peer review was exactly that, coworkers conducting evaluations of each other. Clinicians may be hesitant to review their peers, especially if they are close colleagues or suspect peer review fraud, which may be present in up to 10 percent of cases. This is especially dangerous as legislation has passed laws to give immunity to reviewers which has further resulted in abuse and reviewers utilizing the peer review process for their own personal gain. The alternative is they may give short, unactionable feedback to avoid the review leading to workplace conflict. And providers may not speak out after near-misses for fear of penalization. Even worse, hospital leadership often lacks follow-up in their process, leaving potential gaps in patient safety. Across the country, hospitals need help finding reviewers to build a consistent approach, and their patient safety suffers.

In this guide, you will learn best practices from top healthcare organizations in order to improve patient safety at your hospital. Alternatively, click here to schedule a demo with the Medplace team and see how our platform can streamline your existing process in less than 6 days.

 

2. How Peer Review Helps Elevate Your Quality of Care

In a legal setting, you would expect a trial by your peers, so it makes sense that doctors and nurses undergo evaluation by other medical professionals. This is the case with peer review. So, at its core, medical peer review evaluates a provider's performance using two standard sets of requirements. 

An Ongoing Professional Practice Evaluation (OPPE) is a routine review hospitals must conduct at a minimum of once every 12 months and is utilized to identify trends in practice impacting the quality and safety of patient care and is applicable to all providers that maintain privileges for that facility. The goals behind this process are to collect data to identify trends in a provider's performance that may require intervention and to establish objectives that are driven by data when the decision to renew privileges arise. Hospital committees must create a process to standardize the conditions needed to initiate a review, who assesses in what setting, and the resulting procedure. Since accrediting bodies do not provide hospitals with a standard process, here are some tips to serve as a starting point for your organization.

Design: When developing an OPPE for your organization, the process should be clearly defined and include responsibilities of the medical staff department in the review process, frequency of review, process for data usage in decision making, and the process for decisions resulting from the review.

Data: Ensure you gather data from various sources, including qualitative and quantitative data, as described in your research. This could include chart reviews, patient outcomes, complaints, and peer recommendations. Expanding data sources provides a more holistic view of your staff’s performance.

Benchmarking: Compare individual practitioner performance with department or hospital-wide benchmarks to effectively identify outliers and areas for improvement.

Risk Stratification: Develop a risk stratification system to prioritize which practitioners require more frequent and in-depth reviews. For instance, practitioners with a history of performance issues or those with high-risk responsibilities should undergo more frequent evaluations.

In contrast, a Focused Professional Practice Evaluation (FPPE) is a type of review conducted to evaluate the competence of medical staff specific to their privileges. Hospitals perform FPPEs when a practitioner's quality of care is called into question, either by an unexpected adverse patient outcome or a lack of documentation for a requested privilege.  

Both types of reviews seek to address whether the physician under review met the standard of care based on your organization's clinical guidelines, so it is vital that you choose these guidelines carefully. Click here to learn more about selecting clinical guidelines that streamline peer review.

Various reputable sources offer recommendations, such as Healthcare Effectiveness Data and Information Set (HEDIS) guidelines from the National Committee for Quality Assurance (NCQA) or the Agency for Healthcare Research and Quality (AHRQ). But rather than adopt these sets in full, you can opt for a more tailored approach by selecting guidelines relevant to high-risk or high-volume areas in your hospital and then filling in the gaps with a more complete selection. 

With these considerations in mind, guidelines can be built tailored to your organization's needs and risks. Many top hospitals routinely add improvements as needed, so it is appropriate to add or remove guidelines, increase or decrease the frequency of reviews, or any other alterations your organization finds necessary.

 

3. How to Systematize Your Peer Review Process 

While many hospitals may conduct reviews as needed, top healthcare organizations approach peer reviews systematically. Through this method, providers do not feel singled out or punished when under review, and the hospital can continuously find areas for improvement.  

The next step to standardizing a peer review process is to create a review committee. You will need to gather a group of medical professionals across various specialties with differing perspectives. Aim to have most, if not all, specialties represented in your peer review committee. Most hospitals involve senior staff leaders, but consider including frontline caregivers, such as nurses. They may bring a perspective that top-level staffers cannot. ReliasMedia also recommends adding staff with quality improvement experience to the committee. 

Lastly, you'll need to find committee members who will keep an open mind and learn from mistakes when presented with evidence contrary to their initial opinion. This will reduce egos from clouding the results and muddying the process with workplace politics.  

Finding the appropriate experts for your peer review process can be time-consuming and can take months if you do not already have them on your staff. Alternatively, find a practicing medical expert for your peer review committee in less than 24 hours using the Medplace platform. 

Once your hospital has outlined who will be conducting the evaluations, you'll need to set a peer review cadence. Many hospitals determine a need for peer review via chart review. Therefore, creating a schedule of who will perform chart reviews and how often would be a good place to start. The frequency will depend on what kind of care facility you are in. For example, FQHC providers may review charts once a week, if not more often. Regular hospitals may not need such an aggressive approach, but more reviews translate to more oversight. For more information about how hospitals determine peer review needs, check out Medplace's Peer Review Whitepaper. Click here to download.      

 

4. How to Navigate Medical Peer Review 

Peer review is a time-consuming, often stressful process that most, if not all, providers must experience at some point. As a provider being reviewed, be mindful of your response to constructive criticism and remember that the basis of peer review is to improve patient safety. First, some medical cases require extra in-depth analysis, especially if they lack documentation. Additionally, peer reviews directly impact the livelihood of the reviewee and the patients they care for. They may also cover complex topics, like patient mortality. Many practitioners feel uncomfortable with the high stakes involved in conducting peer reviews. But by following a simple set of guidelines, doctors and nurses can effectively navigate the process and improve healthcare.  

  • Be confident and empowered to lead the review discussion.
  • Review the medical record beforehand and arrive prepared with your own notes and be an active listener and take notes during the discussion.
  • Consider the setting involved and the available resources in this setting.
  • Investigate any missing information that could change the outcome of the case.
  • Be transparent with the reviewee about what you see in the case.
  • If there is a lawsuit involved, figure out what it may focus on

 Remember that current federal law and accrediting guidelines require confidentiality so you can confidently give feedback to your peer without fear of retaliation. You are evaluating their process, not their character.  

 If you are a risk leader tasked with conducting the review, keep the following in mind:

  • To combat defensive behavior from providers subject to review, emphasize that the review is a learning opportunity.
  • Seek out top practicing experts or recruit a third party expert to ensure the reviewee feels they are being evaluated fairly by the patient safety committee
  • Blind the outcomes to prevent hindsight bias from impacting the reports

Still trying to figure out how to conduct your peer review? Medplace thoroughly trains its network of 700 experts across all specialties in best reviewing practices and professionalism. So whether you are a risk management expert, patient safety leader, or a practitioner interested in helping peers improve care, Medplace has an easy way to get started

 

5. Mitigating Legal Risks with Peer Review 


Peer review is vital for mitigating legal risks in healthcare because it offers an impartial assessment of patient care and helps organizations identify deviations from established standards. This proactive commitment to evaluating and improving care quality creates a solid legal defense by demonstrating accountability and adherence to best practices – which can translate to lower legal costs. But simply conducting a review may not be enough.  

Prompt reviews are essential to signal transparency and patient safety commitment. Delayed reviews can raise doubts and lead to increased legal exposure. Hospitals can get the necessary insights to make early decisions and prevent further harm by conducting reviews as soon as possible. Ideally, conduct focused peer reviews within 60 days. While many hospitals take up to 6 months to complete this, Medplace customers only wait 6 days, leading to safer care.    

Matching reviewer specialties is crucial for credibility and effectiveness. For example, an OBGYN's review of another OB will hold much more weight to legal counsel than a nurse's. This targeted approach strengthens the organization's defense by showcasing specialized knowledge, ultimately enhancing the quality of peer reviews and their legal standing. Check out this guide for finding a medical expert for your peer review with Adrienne Fugett, RN, or search the Medplace platform for expert matching in less than 24 hours.  

With a robust process for peer review, as outlined in the previous sections, you'll minimize adverse events in your hospital and be well prepared for any potential litigation your organization may face.

 

6. Peer Review and Risk by the Specialty

Your hospital's team is unique, so reviewing staff should not be a one-size-fits-all model. Certain specialties need more oversight, and others require different types of reviews. As a result, creating your hospital's peer review process requires factoring in the kinds of reviews, resources, and expertise at your facility. Keep in mind that the following specialties get sued at a higher-than-average rate:  

  • General Surgeons
  • Obstetrics/Gynecology
  • Orthopedic Surgery,
  • Radiologists
  • Emergency Medicine Physicians

If your hospital has multiple of the same specialty, ensure you have a review process and experts to evaluate them frequently to mitigate risk. Nurses also need special review considerations. Notably, some nurse peer reviews are not anonymous. The Just Culture model prioritizes learning opportunities over placing blame when medical errors occur. Underreporting is severe in healthcare work environments where blame and punishment come before opportunity for improvement.

Creating a peer review process that is right for your facility's staff can be a significant undertaking, but now more than ever, there are resources from top organizations that have solved common problems already. Some hospitals, like HaysMed, expedited the process using Medplace's platform.

 

7. Peer Review Bias and How to Account for It 

 

Congratulations on implementing a peer review process in your healthcare facility! Unfortunately, there's more work to ensure you get the most actionable information possible.  

Did you know that up to 36% of physicians feel like their peer review process is biased? It makes sense. Peer review relies on difficult conversations between caregivers, and although they may try their best to be professional, personal experiences, workplace tensions, and more can get in the way.  

Bias can creep into the peer review process in a variety of ways. Professional bias can occur between specialty groups. For example, physicians are trained to approach cases differently than nurses. Group biases become a concern when a group, like a review committee, fall into patterned thinking that rejects outside opinions. Additionally, hindsight bias skews peer review reports when the outcome is known.  

Bias at any point in the quality improvement process introduces unnecessary risk. While some bias is unavoidable due to human error, hospitals can take steps to reduce their role in the process significantly. For example, providing questions specific to the case with the process in mind instead of the outcome can prevent outcome bias, and conducting external reviews prevent group biases. Click here to learn more about reducing bias in your hospital.

Bias can jeopardize the quality of care, so by considering these tendencies when building your process, you can prevent it from reducing the quality of your hospital's peer reviews.

 

8. The Value of Getting a Third-Party Perspective with External Peer Review

Risk and patient safety leaders at top hospitals realize that there is only so much you can do to mitigate bias in internal review processes. So, for healthcare's most critical review cases, like patient mortalities, admins will opt for an external review from an expert outside of their facility. External reviews benefit from more specialized expertise, a more comprehensive selection of experts, and increased objectivity. However, coordinating them may take longer and require sharing sensitive medical documents outside the facility.  

Hospital leadership typically requires an external review at some point, so you should create a policy to determine what kind of review is required on a case-by-case basis. The Credentialing Resource Center for hospitals recommends a protection clause, set circumstances for requesting an external review, and a policy for what should happen if the assessment determines that the standard of care was not met, among other items. 

Conduction of more reviews means more data collected, and ultimately, more insight into the quality of care delivered. Therefore, hospitals determined to see continuous improvement choose frequent external reviews. For instance, FQHCs must review physicians quarterly. Since these facilities secure federal funding by showing significant quality improvement metrics, they may methodically review a set amount of patient encounters instead of incidents. 

Ultimately, external peer reviews are the most objective form of feedback providers can receive. While recruiting an external expert can take up to 6 months, Medplace helps hospitals secure a practicing medical expert in less than 24 hours. Click here to learn more.

 

9. I Got My Peer Review, Now What?

A quality peer review process is an excellent start, but hospitals need to put these insights into action to protect patients. This means directing resources towards improving gaps in care and proactively searching for risk using peer review. This can reveal preventable errors in care, allowing hospitals to address them.  

Caregivers rely on peer review feedback to prevent future adverse outcomes. It is paramount that the process not be punitive or risk staff feeling singled out by reviews or that they are subject to sham review. Doctors and nurses on the defensive are not likely to take peer evaluations in earnest. However, standardization helps ease the process, as well as a focus on performance improvement through identification of opportunities for education rather than blame. You can further reduce the stigma by giving kudos to providers who go above and beyond to deliver excellent care.

After the review committee has conducted the review, the resulting report is added to the doctor's credentialing and privilege file. Healthcare professionals can review the feedback, address any concerns, and provide their own insights or explanations for the clinical decisions made. This collaborative approach fosters a culture of learning and accountability within the medical community. 

Following the initial communication with the healthcare providers, the medical facility's quality assurance or peer review committee performs a comprehensive analysis of the peer review findings. This committee is pivotal in identifying trends, patterns, and systemic issues that may have contributed to the clinical situation under review. They may recommend changes in protocols, additional training, or process improvements to prevent similar incidents in the future. Moreover, the follow-up process may involve ongoing monitoring and periodic reevaluation to ensure that the recommended changes are effectively implemented, and the quality of care continues to improve.  

By adequately following up with peer review, hospitals confirm that peer reviews lead to safer care and make the most of their available resources.

 

10. From Peer Review to Peer Learning

Unfortunately, medical peer review still faces a negative stigma in most hospitals. Thus, a shift from peer review segued into peer learning. In a peer learning model, the focus shifts from a punitive or judgmental perspective to one focused on mutual learning. Healthcare providers engage in reflective discussions, sharing their clinical experiences and decisions in a non-threatening environment. 

This approach encourages self-reflection, empathy, and mutual understanding among peers, fostering a culture where staff view mistakes as opportunities for learning rather than reasons for punitive action. Peer learning promotes trust and openness, allowing healthcare professionals to learn from one another's experiences and insights, ultimately leading to improved patient care. 

Here are some ways to encourage a peer review culture based on professional development rather than blame: 

 

  • Develop a Robust Peer Learning Framework: Start by establishing a comprehensive peer learning framework that focuses on education and improvement rather than punitive measures. This framework should precisely categorize peer learning events, such as perception errors, great calls, cognition errors, communication errors, and reporting errors. 
  • Encourage Active Participation: Encourage active participation in the peer learning process by setting achievable monthly targets for peer reviews and providing opportunities for providers to learn from each other. Emphasize the educational aspect of the process to alleviate concerns about performance evaluation. 
  • Regular Educational Conferences: Integrate peer learning events into regular educational conferences, such as morbidity and mortality (M&M) meetings. Consider including multiple specialties for multiple perspectives. This allows for the presentation and discussion of interesting cases, promoting a culture of continuous learning and improvement. 
  • Maintain Transparency and Anonymity: Ensure transparency while maintaining anonymity between reviewers and reviewees. Implement measures to protect the confidentiality of peer reviews per relevant legal and regulatory requirements. 

Additionally, doctors and nurses under review report heightened rates of burnout, depression, and feelings of meaninglessness. You can reduce turnover while protecting staff and patients by improving your hospital's peer review culture. Click here to learn to move about the relationship between hospital reviews and staff well-being.

 

11. The Future of Peer Review

Transforming your hospital's patient safety doesn't have to be a resource-intensive undertaking. With increasing nuclear verdicts, hospitals and partner organizations have invested in strategies to reduce adverse events. Technology platforms have played a significant part in this process. Studies have shown that several technology tools effectively mitigate many adverse events, especially medication errors.  

One of these tools, Medplace, was born out of a need to bring efficiency to the peer and case review process using technology. As technology advances, healthcare companies are turning to companies, such as Medplace, who collaborates with top insurers and hospitals. Medplace has created a cloud-based platform of experts to expedite the review process with higher quality.

Now, top hospitals nationwide are bringing technology to their peer review process. Since medical records, finding experts, and handling invoices delay peer review by weeks or months, tech-based solutions like Medplace have stepped in to fill the gap. Medplace has helped hospitals of all sizes streamline their peer review and enhance patient safety without needing any training or IT integration. Schedule a demo to learn more about how Medplace can help your facility.

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References

 

Kirsten Gonzalez MSN, APRN, ACNPC-AG has worked in the nursing profession for ten years and is currently a Cardiothoracic Surgery Nurse Practitioner specializing in the care of patients with Left Ventricular Assist Devices (LVADs). Her previous bedside experience was in the Medical/Cardiac Intensive Care Unit and she was also a Clinical Instructor for BSN students for a year before transitioning into the Advanced Practice Provider Role. When she is not providing patient care, she enjoys traveling and spending time with her family.

 

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