Peer Review Q&A with Sarah Martin of Meridian Surgical Partners

Sarah Martin, RN, BS, regional vice president of operations for Meridian Surgical Partners, discusses seven of the top ASC peer review and credentialing questions.

Q: What’s the proper number of charts to audit for peer review?

Sarah Martin: A lot of facilities use 5 percent or 30 charts, whichever is the greatest number. You additionally have to do any chart that has a complication — whether it’s an infection, transfer to the hospital, and obviously, if there was a death. Any kind of untoward, unusual chart needs to be audited — those are called fallout charts — in addition to the normal charts you just pull at random.

For one of our smaller centers, the 5 percent or 30 charts didn’t work well, but has worked for us was 10 percent or 12 charts.

Whatever number you use, the goal is to just make sure you are routinely reviewing these charts that you are reviewing an appropriate amount, and you follow the policy and procedures you’ve created.

Q: What kind of tool can I use for auditing; what kind of questions should I ask?

SM: You definitely want to always make sure that, whenever you’re doing peer review for a surgeon, some of the questions you want to answer are:

  • Was the medical necessity there?
  • Were the pathology findings appropriate (if it’s a case where a specimen is involved)?
  • Was there any divergence from the standard of care?

When I’m talking about diverting from the standard of care, we look at whether the event had any adverse effect on the patient and was it appropriately managed. Other outcomes could be medical mismanagement with no adverse effect on the patient. We also have a category that determines if there was medical mismanagement with the potential to harm the patient, but nothing occurred, and a category for medical mismanagement with significant adversity on the patient.

It’s not enough to just say you reviewed the chart. You have to have whoever is reviewing it say that it meets or does not meet surgical review criteria and document what happened.

Q: How do I find time to do these reviews?

SM: I tell my managers and staff that it’s one of those things in life you have to find time for; you have to find a key person to whom to assign it. I like to trade it around with nurses and then in-service all of them on it so that they are bought-in to your QA/peer review process. You just have to set aside the time and allocate time to your nursing staff to complete these reviews.

Q: How often should we conduct peer review?

SM: You can do it quarterly, but I prefer to do it monthly so you don’t have massive stacks of charts to go through. It’s much more manageable if you do it on a monthly basis.

Q: Can I peer review the same charts I audited?


SM: The answer, to me, is yes. I have had accreditation surveyors who have requested that we do not audit the same charts that we peer reviewed; I’ve had other surveyors who say it’s acceptable. Until I’m told otherwise, I think it’s perfectly fine. We don’t just do peer review; we also audit charts to make sure that the nursing orders were signed; that the anesthesia record is complete; that there’s discharge instructions given. We do an administrative review to make sure all of the insurance and other necessary paperwork is on the chart; we do a nursing review; an anesthesia review; and a surgeon review of the charts that we pull. For the most part, we do the 5 percent/30 charts or the 10 percent/12 charts for our chart reviews as well as the peer reviews.

Q: How do you get the doctors’ participation?

SM: You need to find doctors who believe in the QA process and get them involved first and foremost. Peer review is ideally done by a surgeon of the same specialty, but it’s not a requirement. It just needs to be an MD. So, if you have anesthesiologist you are already paying to be your medical director, it seems logical to me that peer review would be part of his responsibilities for receiving his medical director fee.

If no stipend is involved, I would seek support from the head of your governing board and medical director because those are people who have already chosen to devote time and energy to the center. If you’re looking at three charts a month, you can usually get a physician to sit down between cases and review these charts. It’s all about how you approach people. If you approach them in a positive manner and you’re upbeat about it and explain that this process is important, not only for accreditation but to ensure we have quality care for our patients, even the busiest surgeon will assist in the peer review process.

You can outsource it, but it is not a requirement. The only time it’s required is if you’re a single-specialty surgery center and you only have one surgeon working in your facility. You do not want to have a physician review his own charts.

Q: Should we tie peer review credentialing?

SM: Yes. You’re peer reviewing these physicians so that you can use the information gathered during peer review when you’re credentialing your surgeons the next go-around. For example, if you have a physician that has a high infection rate or multiple patient complaints against him, you want to ask yourself if this is somebody you want practicing at your facility. Since credentialing goes to your governing board, it’s important that, as an organization, you make a decision about re-credentialing this physician and is this physician’s skills a benefit to your organization.

Here are seven items you need to peer review for credentialing:

  1. What’s their morbidity/mortality on their patients?
  2. Tissue review
    • Is the pathology appropriate?
  3. Medical record review?
    • Does the physician routinely sign his orders?
    • Is the history and physician adequate?
    • Is treatment consistent with the diagnosis?
  4. Infection review
  5. Incident review
  6. Any complaints — whether regarding patient, nurse or physician.
  7. Surgical case review — using the charts that were peer reviewed, document the appropriateness of the procedures performed by this physician.


Contact Sarah Martin at (615) 301-8140 or at smartin@meridiansurg.com. Learn more about Meridian Surgical Partners.

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