Peer Review

POLICY:  Leadership of the organization as well as the 
members of the provider Staff recognize the importance of an 
ongoing system of peer review or focused review to the 
quality assessment, quality of care and performance 
improvement.  Peer review consists of a review of the 
practices of the on-staff provider(s), including anesthesia 
providers, relating to quality of care and documentation of 
patient interaction. Peer shall be defined as of the same 
specialty or sub-specialty or expertise.  The individual 
whose performance is being reviewed shall participate in the 
review process either in person or by conference call. When 
conference calling is utilized, each individual participating 
in the review shall be reviewing duplicate documents. 
Peer review is conducted every 2 yrs. The Medical Director may request an 
individual's peer review be conducted more often based on 
occurrences of special circumstances.
Cases for review can be selected on any one of the following bases:
1. Surgical or Procedural Peer Review:  5- 10 random charts are reviewed for selected criterion. 
    Anesthesia Peer Review: 5-10 random charts are reviewed for selected criterion. 
2. Special circumstances: All cases involving trauma 
   suffered at the organization (e.g., falls), infections 
   (health care acquired, follow- up, elevated temp), major complications (e.g., perforation, 
   return to procedure, unplanned transfer to acute care). 
3.  The more complicated patient, i.e. patients with co-morbidities, multiple medications, prolonged recovery/delayed discharge, patients deemed unfit for anesthesia based on comorbidities.

Participation in the peer review process and successful 
completion of peer review activities are necessary for 
continuation of medical staff privileges.  Failure to allow 
peer review of one's activities is grounds for immediate 
termination of clinical privileges.  Results of Peer Review 
will be reported within 2 weeks of the review, to the Medical 
Unsatisfactory peer review results will be discussed with the
subject staff member and placed in writing in that provider's 
file. A staff member identified as having unsatisfactory peer 
review results will have the opportunity to discuss the 
review with the Medical Director. 
A program will be developed if this happens; i.e. mentor or preceptorship, 
educational courses, etc to help the individual in question 
improve performance.  This program(s) will be communicated in 
writing to the individual and will include the goal(s) or 
area of performance to improve.
Upon the next clinical review, attention will be focused on 
the unsatisfactory issues from the previous peer review.  If 
the same issues remain unsatisfactory, the Staff member will 
have one month to improve performance in the problematic area 
after which time a peer review will be performed.  If 
substantial compliance with the quality of care requirements 
is not observed at the special peer review, staff privileges 
are subject to immediate termination.
This organization has a fair hearing and appeal process and allows adverse decisions to be 
appealed.  The hearing committee for this organization 
consists of  the Medical Director.  Should any staff member request a 
hearing the following process will occur : A written request should be requested for the same and a hearing will be scheduled within a two week time frame of the request or as soon as possible. 
1.  The agreed-upon number of charts will be reviewed by the
    peer reviewer, in the presence of the Staff member 
    being reviewed.  
2.  Following completion of the chart review, the reviewer
    will prepare a summary of findings.
3.  Subsequent to the chart review, the provider being
    reviewed  will receive a copy of the review along with
    any comments from their particular review. 
1.  There should be  written documentation between both parties.  
2.  Documentation that each party was available to one another if 
    questions arose in review process (i.e. conference 
    call).  All communication via the two parties should be
    documented.  This can be noted on a peer review form.
3. Documentation that both parties were examining the same documents.  

This will be documented in patients progress notes that the entire chart was sent for review.
4. If this happens against the Medical Director, all the above steps from 1 to 3 will still be the same, but then another physician in the same specialty from outside the practice must be present during the tele -review.  
This peer review can be accomplished 
within the organization.  However, should any individual 
being reviewed request to have a reviewer from outside of the 
organization, the request will be honored. 
If the Medical Director wishes to convene a 
special committee for peer/focused review from outside of the 
organization this will also occur with provision that the 
individual being reviewed is made aware of such committee.

Approved By Governing Board
Control #6.14