Peer Review: 10 Things to Know

Nancy Jo Vinson, RN, BA, CASC, of NJM Consulting recently joined the consulting team of Healthcare Consultants International, a subsidiary of the Accreditation Association for Ambulatory Health Care.


She discusses 10 things ambulatory surgery centers should know about peer review.


1. More than just retrospective clinical review. The most common misconception about peer review is that it's just a retrospective clinical review. "It's really a process that's an interrelated series of actions, events and steps," says Ms. Vinson. "It has to be goal-directed to evaluate the provider."


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2. Needs to involve the medical staff in the establishment of peer review activities. When developing a peer review policy and procedure, physicians must look and provide feedback on the criteria that will be used for peer review. "They need to be involved in the establishment of the process," Ms. Vinson says. "They have to identify acceptable or unacceptable occurrences that effect patient outcomes."


3. Many elements should be considered as criteria. ASCs should consider many different elements during the peer review process. Ms. Vinson says these can include the following:

  • Post-op infections
  • Adverse drug utilizations
  • Improper drug utilizations
  • Surgical and unplanned outcomes
  • Hospital transfers or admissions within 24 hours
  • Sentinel events
  • Malpractice claims
  • Patient/staff complaints
  • Cancellations on day of surgery (an excessive number might show inappropriate scheduling of patients)
  • Unplanned returns to the OR


"These all could be included in peer review," she says. "That's why the medical staff has to identify what they want to look at to be comfortable with their peers to continue to have privileges at their center.


"Clinical record review is one element that is important because it can show if [the reviewed physician] is complying with the requirements of documentation," she says. "But it's important to remember that this is just one element and too many people look at that as the only element."


4. Criteria are tracked on a consistent basis. For effective peer review, ASCs must track the elements included in the peer review process on a consistent basis. "Being consistent means it is ongoing and not just at the time of reappointment to try to get just a recommendation," Ms. Vinson says. "Whether it's a risk management issue or you're tracking to see if a physician is complying with policies and procedures, you must be able to gather all of this together at the time of reappointment. You want to look at everything that affects how the healthcare professional is functioning."


5. Not just for physicians. For example, an RN who is giving conscious sedation should undergo peer review for that competency, Ms. Vinson says. "Peer review should be done for anyone involved in specific privileges outside of a normal job description, such as conscious sedation," she says. "Peer review is utilized for appointment or reappointment for anyone who's privileged." Peer review for personnel may be included in their competencies or performance review.


6. Does not require same-specialty review. Ms. Vinson says there is a common misconception that peer review of a physician must be performed by someone in the same specialty as the reviewed physician. "That would be the optimal goal from a standpoint of familiarity, knowledge and the type of cases being reviewed," she says. "But if an ASC has just one physician in each specialty, then that's probably not going to be possible unless they incur a cost to hire someone and that is not a requirement. I know some centers have incurred those costs because they thought it was a mandate."


7. Understand requirements. ASCs should review their state regulations to see how peer review is protected and how it should be reported if there are issues, Ms. Vinson says. ASCs should also check their accreditation and licensure requirements concerning peer review.


8. Must be communicated to the governing body. CMS and the accreditation bodies check to make sure the ASC's governing body is included in the peer review process. "The governing body needs to review [the peer review results] and make decisions if necessary for them to give final approval for reappointment of privileges," Ms. Vinson says. "For example, the governing body must decide if somebody is approved for knee arthroscopies. If that surgeon hasn't done one for three years, should that surgeon maintain those privileges?"


9. Documentation is critical. ASCs must document peer review and do so according to their state requirements, Ms. Vinson says. "ASCs are at-risk because of exposure and confidentiality," she says. "Sometimes it's required — or at least worthwhile — to get a legal opinion for how and when to document and how much documentation to provide at a meeting."


10. Should be a positive experience. "Peer review is looking at how well a physician performs," Ms. Vinson says. "Peer review, at any level for a healthcare professional, is a positive input into the qualities the center is providing and one of the important ways to maintain that quality. The end to all of this is continuation of the provision of quality care."


Learn more about Healthcare Consultants International.


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