5 key thoughts on peer review for ASCs

Peer review can be a daunting task for ambulatory surgery center staff, but its findings can help the center proactively identify and address shortcomings.

In a presentation at Becker's ASC 23rd Annual Meeting: The Business and Operations of ASCs, four experts on business and legal issues spoke on how ASCs can excel in the peer review process.

Here's what they had to share:

1. Focus on quality. "Peer review is not a medical chart audit," said Ann Geier, RN, chief nursing officer at Birmingham, Ala.-based SourceMed.

Ms. Geier noted that, as a surveyor, she frequently sees physicians "basically checking that everything has been signed on the chart," rather than providing meaningful feedback about their colleagues' work. Another common issue is peer reviewers tackling each physician assessment on a case-by-case basis, rather than considering these individual actions in conjunction with trends across the entire facility.

"Oftentimes, there's a myopic view, where you look at peer review and quality for a particular surgeon, and then silo that away and move on to the next one," said Nathan A. Kottkamp, JD, a partner at the Richmond, Va., office of McGuireWoods. "But sometimes, the peer review process will reveal trends across the board. You want to be sure you're taking enough of a global view."

2. Establish proactive policy. One of the primary goals of peer review is to identify any problems before they escalate.

"Oftentimes, if a problem is identified early on, it can be addressed and resolved in a low-key, cost-effective manner," said Thomas Stallings, JD, a partner at the Richmond, Va., office of McGuireWoods. "But I can't tell you how many times I've been contacted by a center that's gone pretty far down the path — at that point, you sort of 'cross the bridge,' legally speaking, and your options are more limited."

Because peer review can provide this protective element, it's an important task, regardless of an ASC's physician or patient volume. Although centers with physicians who only perform a few cases a year might have trouble identifying a critical mass of cases to review, and centers with physicians who see many patients might feel overwhelmed by the undertaking, Mr. Stallings emphasized that performing peer reviews will help ASCs be successful in the long-run.

3. Ensure policy compliance. "You want to avoid, wherever possible, having a disconnect between what your written policies say — and what your medical staff bylaws say — and what you actually do," Mr. Stallings said.

As an example, Benita Tapia, RN, administrator at 90210 Surgery Medical Center and Precision Ambulatory Surgery Center in Beverly Hills, Calif., discussed her peer review process. The process included pulling either 30 cases or 5 percent of cases — whichever is larger — from each surgeon, anesthetist and nurse at the center, which are reviewed by peer colleagues within their field.

"As a surveyor, I'm looking for compliance with your policy," Ms. Geier said. "If you have 5 percent or 30 charts, whichever is greater, then I'm going to look at that."

Issues with compliance often arise when an ASC adopts the policies and bylaws of an affiliated healthcare facility, but does not review the documents to confirm they match the day-to-day practice of the center. "Either change your practice to fit your policies or change your policies to fit your practice," Mr. Stallings said. "But you want to avoid that disconnect."

4. Protect the reviewers. To achieve honest feedback from peer reviewers, it is integral to assure physicians of their confidentiality and immunity.

A successful ASC can discuss peer review privilege with their physicians doing peer review. Peer review privilege ensures that the physician's review documents will be kept confidential; however, how this privilege is established and defined varies by state. "What you want to do at your center is to take full advantage of your state's peer review privilege," Mr. Stallings said.

Similarly, peer review immunity laws vary by state, as well. Peer review immunity laws, in most states, protect peer reviewers from personal liability, should a provider attempt to sue them based on their statements. Another area to research involves insurance, since many malpractice insurance policies protect individuals who participate in peer review, according to Mr. Stallings.

5. Cultivate staff trust. Again, a goal for peer review is to avoid patient harm by addressing it as early as possible; however, to accomplish this mission, medical staff must feel comfortable voicing their concerns, even outside of the peer review process.

"You cannot underestimate the power of the hierarchy within the facility," Mr. Kottkamp said. "You need to do everything you possibly can to ensure the nurses, the anesthesiologists, anybody else who's in that room knows that if they have a concern, they can raise that concern, because it's about patient care."

For Ms. Tapia, ensuring her medical staff knows she will take their concerns seriously has proven an effective strategy.

"I'm not always in the room with the patient, but they are," she said. "When they come to you and tell you there's an issue, it's not about 'yes, we do peer review when we have an event,' or 'yes, we do peer review for infection, transfer' — our whole goal is to be proactive, not reactive."

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