Title: FPPE - Peer Review. Section: Administration Number: 104 Pages: 1 of 8. Approval CMO

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1 Title: FPPE - Peer Review Approval CMO Section: Administration Number: 104 Pages: 1 of 8 Date of Origin: 02/09 Reviewed/Revised Date: 03/12 Next Review Date: 03/14 Purpose: To ensure that the hospital, through the activities of its medical staff, assesses the performance of individuals granted clinical privileges and uses the results of such assessments to improve care. Goals: 1. Improve the quality of care provided by individual providers; 2. Monitor the performance of providers who have privileges; 3. Identify opportunities for performance improvement; and 4. Monitor significant trends by analyzing aggregate data. 5. Assure that the process for peer review is clearly defined, fair, defensible, timely, useful, and communicated in a proactive manner. 6. Identify opportunities for recognition of excellence. Definitions: Peer review Peer review is the evaluation of an individual provider s professional performance and includes, but is not limited to, the identification of opportunities to improve care. Peer review differs from other quality improvement processes in that it evaluates the strengths and weaknesses of an individual provider s performance, rather than appraising the quality of care rendered by a group of professionals or a system. Peer review is conducted using multiple sources of information including: 1) the review of individual cases, 2) the review of aggregate data for compliance with general rules of the medical staff and, 3) clinical standards and use of rates in comparison with established benchmarks or norms. The individual s evaluation is based on generally recognized standards of care. Through this process, providers receive feedback for personal improvement or confirmation of personal achievement related to the effectiveness of their professional, technical, and interpersonal skills in providing patient care. Peer A peer is an individual practicing in the same profession and who has expertise in the appropriate subject matter. The level of subject matter expertise required to provide meaningful evaluation of a provider s performance will determine what practicing in the same profession means on a case-by-case basis. For example, for quality issues related to general medical care, a physician (MD or DO) may review the care of another physician. For specialty-specific clinical issues, such as evaluating the technique of a specialized surgical procedure, a peer is an individual who is well-trained and competent in that surgical specialty. The degree of subject matter expertise required for a provider to be considered a peer for all peer reviews performed by or on behalf of the hospital will be determined by the Medical Staff Quality Improvement Committee (MSQIC) unless otherwise designated for specific circumstances by the Medical Executive Committee (MEC). Conflict of Interest A conflict of interest may exist if a member of the medical staff is not able to render an unbiased opinion. Automatic conflict of interest would result if the physician is the one under review. Relative conflicts of interest are due to either involvement in the patient s care or because of a relationship with the provider involved as a direct competitor or partner. It is the obligation of the individual reviewer to disclose to the peer review committee the potential conflict. The responsibility of the peer review body is to determine if the conflict would prevent the individual from participating and the extent of that participation. Individuals determined to have a conflict may not be present during peer review body discussions or decisions other than to provide information if requested. Policy:

2 FPPE - Peer Review 104 Page 2 of 8 1. All peer review information is privileged and confidential in accordance with medical staff and hospital bylaws, state and federal laws, and regulations pertaining to confidentiality and non-discoverability. 2. The involved provider will receive provider specific feedback on a routine basis. 3. The hospital will use the provider-specific peer review results in its credentialing and privileging process and, as appropriate, in its ongoing professional practice evaluation. 4. The hospital will keep provider-specific peer review and other quality information concerning a provider in a secure file. Provider specific peer review information consists of information related to: performance data for all dimensions of performance measured for that individual provider, the individual provider s role in sentinel events, significant incidents or near misses, correspondence to the provider regarding commendations, comments regarding practice performance, or corrective action. 5. Peer review information is available only to authorized individuals who have a legitimate need to know this information based upon their responsibilities as a medical staff leader or hospital employee. However, they shall have access to the information only to the extent necessary to carry out their assigned responsibilities. Only the following individuals shall have access to provider-specific peer review information and only for purposes of quality improvement: Medical staff officers, Members of the MEC (includes Department Chairs), Credentials Committee, and MSQIC; Risk Management Director; Peer Review Coordinator; Quality Management Director; Medical staff services professionals to the extent that access to this information is necessary for the recredentialing process or formal corrective action; Individuals surveying for accrediting bodies with appropriate jurisdiction, e.g. The Joint Commission or state/federal regulatory bodies; and Individuals with a legitimate purpose for access as determined by the hospital board of directors. The hospital Chief Executive Officer (CEO), or their designee, when information is needed to take immediate formal corrective action for purposes of summary or precautionary suspension by the CEO. 6. No copies of peer review documents will be created and distributed unless authorized by hospital management or policy. Circumstances requiring peer review: Peer review is conducted on an ongoing basis and reported to the appropriate committee for review and action. The procedure for conducting peer review is described in the process and timeframes document. Upon initial appointment the medical staff will review provider performance based on random selection of cases either through chart review or by observation. Additional evaluation will be conducted when there is: A sentinel event or near miss identified during concurrent or retrospective review; or An unusual individual case or clinical pattern of care identified during a quality review. Circumstances requiring external peer review: The MSQIC will make recommendations on the need for external peer review to the MEC. External peer review will take place under the following circumstances if deemed appropriate by the MEC or by the Board of Directors. No provider can require the hospital to obtain external peer review if it is not deemed appropriate by the MEC or Board of Directors. Circumstances requiring external peer review include: Litigation - as directed by legal counsel. Ambiguity - when dealing with vague or conflicting recommendations from internal reviewers or medical staff committees and conclusions from this review will directly impact a provider s membership or privileges. Lack of internal expertise When no one on the medical staff has adequate clinical expertise in the case under review as determined by the MSQIC; or when the only providers on the medical staff with that expertise are determined to have a conflict of interest regarding the provider under review as describe above. External peer review will take place if this potential for conflict of interest cannot be appropriately resolved by the MEC or Board of Directors.

3 FPPE - Peer Review 104 Page 3 of 8 Miscellaneous issues - when the medical staff needs an expert witness for a fair hearing, for evaluation of a credential file, or for assistance in developing a benchmark for quality monitoring. In addition, the MEC or Board of Directors may require external peer review in any circumstances deemed appropriate by either of these bodies. Participants in the review process: Participants in the review process will be selected according to the medical staff policies and procedures. The work of all providers granted privileges will be reviewed through the peer review process. Clinical support staff will participate in the review process if deemed appropriate. Additional support staff will participate if such participation is included in their job responsibilities. The MSQIC will consider and record the views of the provider whose care is under review prior to making a final determination. In the event of a conflict of interest or circumstances that would suggest a biased review, the MSQIC or the MEC will determine who will participate in the process. Participants with a conflict of interest may provide information as requested but may not be present during the final discussion and vote. Thresholds for intensive review: If the results of individual case reviews for a provider exceed thresholds established by the Medical Staff described below, the MSQIC will review the findings to determine if further intensive review is needed to identify a potential pattern of care. Thresholds: o Any single egregious case o Within any 12 month period of time, any one of the following criteria: o 2 cases rated provider care inappropriate o 3 cases rated either provider care controversial or inappropriate o 3 cases rated as having documentation issues regardless of care rating Peer review for specific circumstances: In the event a decision is made by the Board of Directors to investigate a provider s performance or circumstances warrant the evaluation of one or more providers with privileges, the MEC or its designee shall appoint a panel of appropriate medical professionals to perform the necessary peer review activities. Peer Review Time Frames Peer review will be conducted by the medical staff in a timely manner. The goal is for routine cases to be completed within 90 days from the date the chart is reviewed by Peer Review Coordinator and complex cases to be completed within 120 days. The timelines for this process are described in this policy. Oversight and Reporting Direct oversight of the peer review process is delegated by the MEC to the MSQIC. The responsibilities of the MSQIC related to peer review are described in this policy. The MSQIC will report to the Board of Directors through the MEC at least quarterly. Statutory Authority The above policy is based on the statutory authority of the Health Care Quality Improvement Act of U.S.C , et seq., Section , et seq., MCA, and Section , et seq., MCA, and Montana State law.

4 FPPE - Peer Review 104 Page 4 of 8 Case Identification Case Screening Physician Review Additional Review Needed Completed Case Review Reviews Rated Care Appropriate or Exemplary Reviews Rated Controversial or Inappropriate Care Patient case review work lists screened for indicators by the quality database system. (pending availability) Cases identified by incident reports or other referrals with adequate information for review available Peer Review Coordinator reviews case to determine if physician review is required. Chart assigned to physician reviewer per the Peer Review policy. Peer Review Coordinator provides the physician reviewer a case summary and identifies key issues. Physician reviewer reviews case and completes review section of peer review form. When concerns are identified primary reviewer will contact involved provider prior to presentation at MSQIC. If additional expertise is required (either internal or external), initial reviewer will contact the MSQIC Chair or designee to determine 2nd reviewer. Completed reviews will be submitted to the Peer Review Coordinator by the physician reviewer immediately upon completion to enter into the case review tracking system. Reviews indicating appropriate or exemplary provider care are reported to the MSQIC for summary approval. Reviews indicating controversial or inappropriate provider care or needing more information are discussed with the involved provider by the reviewer before discussion at the MSQIC meeting. The cases are then presented to the MSQIC for discussion and confirmation or change in Peer Review Coordinator informed about the case when the issue is identified. Cases referred to Peer Review Coordinator must be submitted to the peer review process within 2 working days. Peer Review Coordinator will perform the initial screen and refer the case for physician review within 1 week of receiving the chart. Review will be completed within 1 week of assigning chart. Second review to be completed within 1week of assigning chart unless difficulty is encountered obtaining 2 nd reviewer or external review required. Completed reviews must be submitted to the Peer Review Coordinator at least 5 days prior to the MSQIC meeting to be included in the agenda. Appropriate or exemplary care reviews are approved at next meeting after the review is submitted. Once the involved provider has been notified regarding the case and the reviewer had received the provider s input, the case will be presented at the MSQIC meeting.

5 FPPE - Peer Review 104 Page 5 of 8 Communicating Findings to Physicians Tracking Review Findings Improvement Plan Process Improvement plan development Referrals to Hospital Committees preliminary scoring. If care is determined to be appropriate, the provider will be informed as described below. For cases determined as appropriate or exemplary provider care, involved providers are informed of the decision by routine letter with a copy placed in the peer review file. For cases of inappropriate or controversial care, involved providers are informed of the decision by certified letter with copies sent to the Department chair and peer review file. The Peer Review Coordinator will enter the results of all final review findings into the database for tracking. If the results of either case reviews or analysis of rate or rule indicator trends indicate a need for individual provider performance improvement, the issue will be referred to the appropriate Department Chair. The reviewed provider and the Department Chair or designee as determined by the chair of the MSQIC will work together to create and implement the improvement action plan. For cases with potential opportunities for improving system performance or potential issues with nursing care, the MSQIC will communicate the issue to the appropriate Hospital Committee. Decision letters sent to provider(s) under review within 30 days of the MSQIC meeting. Results will be entered in the database within 1 week of the MSQIC meeting finalizing the rating. The department chair in collaboration with the reviewed provider will create and implement the improvement plan within 30 days. The plan will be approved by the President of the Medical Staff and the Chair of the MSQIC. The Peer Review Coordinator will track the data related to the improvement plan and will report back to the MSQIC. The hospital committee receiving the referral will discuss the issue and communicate action plan to the MSQIC. High -risk case time lines: For high-risk cases, timely processing of provider-specific information is necessary to ensure patient safety. For sentinel events requiring peer review, immediate review by the MSQIC Chair or designee will be performed within 72 hours of identification, with committee action/decision within 45 days of event. Additional information (such as a literature search, second opinion, or external peer review) may be necessary before making a decision on action. Under these circumstances, the timelines may be extended after approval from the Board of Directors or its designee or the MEC. The processes and time frames in this document do not apply to precautionary suspensions or summary suspensions under the Medical Staff Bylaws and Rules.

6 FPPE - Peer Review 104 Page 6 of 8 Medical Staff Quality Improvement Committee Charter Goals The establishment of a centralized committee for improving provider performance on an individual and aggregate level is to accomplish the following goals: 1. Improve patient outcomes. 2. Encourage the pursuit of excellence. 3. Increase efficiency of the provider performance evaluation. 4. Support medical staff educational goals. 5. Efficient use of provider and quality staff measurement resources. Scope The MSQIC will be responsible for evaluating and improving provider performance in the following areas: Technical Quality: Skill and judgment related to effectiveness and appropriateness in performing the clinical privileges granted Service Quality: Ability to meet the customer service needs of patients and other care caregivers Patient Safety/Patient Rights: Cooperation with patient safety and rights, rules and procedures Resource Use: Effective and efficient use of hospital clinical resources Relations: Interpersonal interactions with colleagues, hospital staff and patients. Citizenship: Participation and cooperation with medical staff responsibilities The following areas are considered within the Committee s scope or will be delegated as noted: Behavior o Individual provider behavior incidents within the scope of the Disruptive Behavior/Sexual Harassment and the Medical Staff Policy issues will be the responsibility of MSQIC. Adverse patterns and trends of provider behavior will be identified by the MSQIC and findings will be referred to the President of the Medical Staff or his/her designee. Resource o Routine concurrent aspects of provider resource use will be monitored through the Utilization Review Committee. Patterns and trends data will be addressed by the MSQIC. The MSQIC will address clinical resource use related to retrospective review of unusual or complex specific cases effecting patient care. Safety/Blood Use o Policies requiring medical staff approval for Blood Use will be referred to the MEC for approval. The MSQIC will perform peer review relating to the use of blood or blood products. Pharmacy o Formulary and medication policy issues requiring medical staff approval will be addressed by the P & T Committee and referred to the MEC for approval. The MSQIC will perform peer review of cases referred to it relating to use of medications with an adverse patient outcome potentially related to provider care. Medical Records o Health Information Management systems issues will be addressed by the Utilization Review Committee. Issues related to provider compliance will be addressed by the MSQIC. Credentials o Credentialing/privileging is the responsibility of the clinical departments through the Credentials Committee and the MEC. Proctoring o Proctoring during the initial year of medical staff membership is the responsibility of the individual departments by procedures determined by the MEC. If an adverse event is identified through the proctoring process, the case event will be forwarded to the MSQIC for review. Responsibilities Evaluation of Individual Cases 1. Initial review will be performed for all cases identified using the screening criteria or by referral. 2. Obtain reviews and recommendations from specialists on staff when required. 3. Communicate with the provider involved with the case to obtain input prior to making determinations when opportunities for improvement may exist. 4. Make determinations regarding opportunities for individual and/or system improvements based on individual case review. 5. Identify cases of exemplary provider performance.

7 FPPE - Peer Review 104 Page 7 of 8 Provider Performance Measurement o Generic screens o Blood product appropriateness screening o Drug use evaluation o Surgical and invasive procedure pathologic findings o Performance Improvement o Care management staff for quality issues or for unusual or complex cases o Risk management o Department or specialty specific criteria o Referrals regarding provider service d Rule Indicators Regular review of adverse patterns, trends and outlier status from aggregate results of rate and rule indicators relevant to all dimensions of provider performance within the scope of the committee. The purpose of this review is to identify individual or system opportunities for improvement and determine if additional analysis or focused chart reviews are needed. Set targets for acceptable and excellent performance for rate and rule indicators. Make final determination regarding opportunities for individual or system improvements based on the results of rate or rule indicators. Review of diagnostic images (e.g. radiology, pathology, cardiac, etc.) will be performed by the specific specialty for quality control and general review. The aggregate results of the reviews are then sent to the committee. Improvement Opportunities The role of the MSQIC is to assure when opportunities for improvement are identified, the appropriate individuals are notified of the issues and a reasonable improvement plan is developed. This will be accomplished through the following: Communicating individual improvement opportunities to the appropriate department chair, who, in conjunction with the appropriate medical staff leader develops an improvement plan if necessary. Communicating system improvement opportunities to the appropriate hospital committee Holding providers responsible through requests for improvement Reviewing the improvement plan and tracking responses for requests for improvement. Reporting to the MEC regularly regarding actions taken to improve care. Any cases where action was not taken when requested or actions are perceived to be inadequate, will also be reported to the MEC Performance Improvement System Management Approve requests to the Performance Excellence team for additions or deletions to indicators, criteria or focused studies for evaluating provider performance. At least annually review the indicators, screening tools and referral systems for effectiveness in collaboration with the medical staff/department chairs and recommend changes to the MEC. In coordination with the Credentials Committee, the Utilization Review Committee and the medical staff department chairs, define the appropriate content and format for provider performance feedback reports. Changes to the MSQIC s policies, charter, supporting documents, and case review tools are to be requested and then approved by the MEC. Membership The MSQIC will be comprised of a representative member from each of the following specialties: General Medicine, a Medical Subspecialty, Pediatrics, Orthopedics, Family Practice, Surgery, OB/GYN, Emergency Medicine, and Anesthesiology. Physicians from other specialties may be invited to the meeting as needed. The President of the Medical Staff is an ex-officio member with a vote. Family practice residents, third year residents, will rotate through the committee for educational purposes only and are a non-voting member. The MSQIC members will be appointed by the Chairperson of the committee with the approval of the President of the Medical Staff. Members will serve for a three year term except for initial committee members. The initial committee will have staggered representative terms with a third of the representative members assigned initial terms of one year, a third assigned initial terms of two years and a third assigned initial terms of three years. Committee members may serve an unlimited number of consecutive terms.

8 FPPE - Peer Review 104 Page 8 of 8 The Chair of the MSQIC will be appointed by the President of the Medical Staff, and approved by the MEC, from the members of the committee for a term of three years. To be eligible for appointment as Chair, the member must have served on the committee at some point in time for at least one year, except for the first Chair of the committee. The Chair may serve an unlimited number of consecutive terms. Committee members will be expected to attend at least two thirds of the committee meetings over a twelve month period to maintain membership. Committee members will be expected to participate in appropriate educational programs provided by the Hospital or Medical Staff to increase their knowledge and skills in performing the Committee s responsibilities. Meetings The committee will meet monthly. The presence of five voting committee members will constitute a quorum at a regularly scheduled meeting for purposes of making case determinations. A majority will consist of a majority of voting members present. The Committee will report monthly to MEC. Reporting

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