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PEER REVIEW PROTOCOL Department of Internal Medicine Makati Medical Center V4.2.2008 – PowerPoint PPT presentation

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Title: PEER%20REVIEW%20PROTOCOL


1
PEER REVIEW PROTOCOL
  • Department of Internal Medicine Makati Medical
    Center
  • V4.2.2008

2
The Impaired Physician in Art. 16, Ethical
Guidelines,2. Ethical Issues of the Physicians
Relationship with other Physicians,Part G MMC
Medical Staff By-Laws Rules Regulations,
March 2004 - describes the need for the
institution to create this committee.
  • 4. Equally, it is unethical for a physician not
    to report fraud, professional misconduct,
    incompetence, or abandonment of patient by
    another physician. It is here that professional
    peer review becomes critical in assuring fair
    assessment of physician performance .

3
GOAL of the Departments PEER REVIEW
  • To be an essential component of medical care
  • To provide the department a procedure to examine
    health care, including adverse events and
    injuries, as part of an effort to determine why
    things happen and to improve care in the future

4
GOAL of the Departments PEER REVIEW
  • To provide assistance to member physicians and
    protection to patients should a member
    demonstrate actions/deficiencies perceived as
    detrimental to himself/herself, or to patients or
    organizational processes of high quality and
    efficient care.

5
GOAL of the Departments PEER REVIEW
  • For the Peer Review to become accepted by the
    members of our department and be an impartial
    means of identifying and dealing with errors,
    with emphasis on remediation.

6
Departments Policy Manual Provision
  • Purpose of Departments Peer Review
  • To provide guidelines for effective medical PEER
    Review and to establish a committee for this
    purpose as required by the departments policy
    manual and in compliance to the institutions
    By-Laws.

7
PEER REVIEW PROCESS - GENERAL STANDARDS
  • Triggers that initiate peer review should be
    valid, transparent, and available to all member
    physicians and uniformly applied to all cases and
    physicians
  • Indefensible and vague accusations, personal
    bias, and rumor are to be given no credence and
    shall carefully be excluded from consideration.

8
PEER REVIEW PROCESS - GENERAL STANDARDS
  • It ensures patient confidentiality.
  • It is independent and objective and shall
    consider using outside experts in the field when
    appropriate.
  • The review process shall be well-documented and
    shall yield recommendations

9
PEER REVIEW PROCESS - GENERAL STANDARDS
  • Evidence of physician performance concerns, as
    revealed through the quality improvement process,
    shall be part of the appointment/re-appointment
    criteria for medical staff.
  • It shall use consistent, fair, and equitable
    guidelines, and will employ well-defined criteria
    and encompass all options.

10
from Staff Qualification and Education.doc of our
JCI re Medical Staff (applied to
Doctors-in-training also)
  • SQE.11  Medical staff members participate in the
    organizations quality improvement and patient
    safety activities and, at least annually, there
    is a review of the quality, safety and clinical
    care provided by each medical staff member.

11
PEER REVIEW PROCESS - GENERAL STANDARDS
  • It shall be done in a timely manner.
  • Following the provision of the institution on its
    Staff Qualification and Education, to wit
    SQE.11  Medical staff members participate in the
    organizations quality improvement and patient
    safety activities and, at least annually, there
    is a review of the quality, safety and clinical
    care provided by each medical staff member. ,
    the department will annually report its peer
    review process to the institutions Peer Review
    Committee using standard evaluation Form to
    ensure continued compliance with this policy.

12
PEER REVIEW PROCESS - GENERAL STANDARDS
  • The medical staff member undergoing peer review
    will
  • participate willingly in the peer review process.
  • be provided all information used in peer review
    and have access to each committee or other body
    that deliberates on the analysis and
    recommendations of the peer review
  • to respond to questions and present their
    perspective

13
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14
The Department Peer Review
  • An ad hoc committee shall be convened and is to
    be comprised of Medical Staff Members WITH
    KNOWLEDGE , TRAINING, EXPERIENCE, AND SKILLS in
    the clinical topic(s) under review.

15
A Departmental PEER REVIEW COMMITTEE Its
Functions
  • Proposes to department ExeCom general standards
    for peer review
  • Recommends, when appropriate, the initiation of a
    peer review
  • Assists in creating peer review at the request of
    , for example, a section head
  • Receives summaries and recommendations from
    section heads of all peer reviews that result in
    high level conclusion
  • Regularly reports the results of these gathered
    peer review to the departments ExeCom with
    recommendations for subsequent actions.

16
The Medical Staff PEERS
  • Are defined as those licensed independent
    practitioners with similar training and
    experience who manage similar clinical problems
    as the Medical Staff Member under peer review.
  • Membership on peer review committee is open to
    all physicians of the department staff, both
    Active and Associate Active

17
The PEER REVIEW PROCESS
18
The Peer Review Process -
  • This departments Peer Review Protocol is created
    with procedures and goals of the protocol
    developed , approved by all section chiefs,
    subsequently by the department head and presented
    in a WRITTEN form to the institutions Peer
    Review Committee.
  • It is to be performed within the department
    under the direction of the current Departments
    Vice-Chairman.

19
Peer Review is done at different levels
  • Level 1 - Routine Peer Review
  • Level 2 - Focused /Intensified Peer Review
  • Level 3 - Institutions Peer Review
  • MUSC Policy Manual Jan 2007

20
The ROUTINE Peer Review
  • The timing and nature of routine patient care
    reviews intended for quality assurance is
    described in the peer review of the department
  • MMC existing guide says SQE.11  , at least
    annually, review of the quality, safety and
    clinical care provided by each member.
  • Minutes of the quality review efforts with
    findings and recommendations are reflected in the
    minutes.
  • The names of Medical Staff are not identified
    from the minutes. Instead, hospital ID Number
    shall be utilized in all the reports.

21
Reporting the Conclusion by the Department Peer
Review
  • CONCLUSION 0 - Unable to reach a conclusion due
    to inadequate information
  • CONCLUSION 1 - No concerns
  • CONCLUSION 2 - Minor concerns
  • CONCLUSION 3 - Major concerns
  • CONCLUSION 4 - Serious concerns

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlined in the departmental protocol.
22
Reporting the Conclusion by the Department Peer
Review
  • CONCLUSION 0 - IF committee is Unable to reach
    a conclusion due to inadequate information / Poor
    Documentation.
  • However, Clinical management is appropriate no
    quality issues identified.

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlined in the departmental protocol.
23
Reporting the Conclusion by the Department Peer
Review
  • Conclusion 1 - No concerns / Fallout
    Acceptable.
  • If the case falls into monitoring process, but
    clinical practice is expected and accepted.

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlined in the departmental protocol.
24
Reporting the Conclusion by the Department Peer
Review
  • Conclusion 2 - Minor concerns - Questioned
    Practice.
  • IF the practice is not consistent with accepted
    standard of care, but no potential for
    significant harm exists.

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlined in the departmental protocol.
25
Reporting the Conclusion by the Department Peer
Review
  • Conclusion 3 - Major concerns - Questioned
    Practice Unexpected.
  • IF practice under review is not consistent with
    accepted standard of care and/or potential exists
    for significant harm /- may be error of
    omission.

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlined in the departmental protocol.
26
Reporting the Conclusion by the Department Peer
Review
  • Conclusion 4 - Serious concerns - Questioned
    Practice Very Unexpected.
  • IF practice under review is not consistent with
    accepted standard of care and/or significant harm
    occurred /-error of omission.

The reviewed member will be notified of a planned
peer review to allow the clinician to participate
as outlines in the departmental protocol.
27
The FOCUSED/INTENSIFIED Peer Review - will be
initiated if any one of the following Event
Indicators is/are present
  • Unexpected cardiac or respiratory arrest
  • Neurologic deficit not present on admission
  • Other events designated by the department
  • A recommendation by the VP of MSA , or other
    higher officer of the institution, for a focused
    review requires the department Chair to initiate
    the review process

28
The FOCUSED/INTENSIFIED Peer Review - will be
initiated if any one of the following Event
Indicators is/are present
  • Actions or deficiencies demonstrated by an MD
    that appear detrimental to him/herself, hospital
    employees, patients or organizational processes
    of high quality and efficient care.
  • Sentinel Event
  • Pre-sentinel event or near miss
  • Major Adverse Drug reaction
  • Significant variation from established patterns
    of care, also called trend

29
The FOCUSED/INTENSIFIED Peer Review - A Trend
is defined as when a member receives
  • Two (2) Conclusion 4 evaluations within a
    2-year period
  • Any combination of three (3) Conclusion 3 or
    4 evaluations within a 2-year period
  • Any combination of four (4) Conclusion 2,3 or
    4 evaluations within a 2-year period

30
Elevating Issues to the Institutions Peer Review
Committee
  • The department peer review head will elevate the
    issue to the hospital Peer Review Committee IF
    any of the following is noted within an
    individual member when routine and focused peer
    review have not remedied the practice concerns
  • Persistent problems
  • Deficiency trends
  • Worrisome patterns of practice

31
Elevating Issues to the Institutions Peer Review
Committee
  • Reasons for an institution Peer Review shall also
    include matters that involve
  • Litigation
  • Lack departmental expertise
  • Conflict of interest
  • Strong disagreements within the department as to
    how to proceed

32
Handling Reports and Action Plans
  • Step1 Reports/Conclusions of departmental peer
    review is sent to the Dept Chair
  • Step 2 Chair then creates a WRITTEN ACTION PLAN
  • Step 3 Peer Review team report and Dept Chair
    action plans are filed in the Physicians Quality
    Record WITHIN the dept, and

33
Handling Reports and Action Plans
  • Step 4 A Summary Report is filed with the
    Institutions Peer Review Committee, within a
    prescribed period, i.e., within 45 days of the
    initiation or request for a peer review.

34
Handling Reports and Action Plans
  • Step 5 The Depts peer review head may be asked
    by the institutions Peer Review Committee body
    to present a detailed presentation of the case to
    the institutions full Peer Review Committee -
  • For their review , and
  • To assess the adequacy of response.

35
Handling Reports and Action Plans
  • Step 6 The Reviewed Member will be asked to
    respond in writing within a prescribed period,
    e.g., within 30 days IF the peer review results
    in a class 3 or 4 conclusion.
  • STEP 7 Class 3 or 4 conclusions - need to be
    reported to the institutions PRC Written
    response of reviewed clinician and Dept Chair.
  • Step 8These reports will be placed in the
    reviewed members quality folder secured in the
    Medical Staff office.

36
QUALITY RECORD AND CREDENTIALS COMMITTEE ACTION
  • THE DEPARTMENT shall maintain a Quality Record
    for each Medical Staff member. These records will
    contain any/all of the following
  • ALL written products of peer review
  • Patient satisfaction survey results
  • Patient letters
  • Performance reviews
  • Other materials that profile the physicians
    clinical performance.
  • MEDICAL STAFF OFFICE shall maintain a SEPARATE
    QUALITY RECORD for each member.

37
QUALITY RECORD AND CREDENTIALS COMMITTEE ACTION
  • The Credentials Committee can have the report
    available upon request, in its efforts to
    evaluate an application for reappointment of the
    Medical Staff.
  • ACCESS RESTRICTION ONLY the reviewed member,
    Dept Chair, Institutions Peer Review Committee,
    the department and institutions ExeCom,
    Credentials Committee and the Medical Director -
    can access and review a members Quality folder
    secured in the Medical Staff Office.
  • Other entity including the Office secretariat
    should not have access to the file.

38
This protocol was created by the IM departments
Committee on JCI accreditation after its March
8th, 2008 scheduled meeting in an effort to
address such requirements. It was principally
taken from the Peer Review of Medical University
of South Carolina, St Marys Hospital,
Massachussetts Medical Societys Model Principles
for Incident-related Peer Review , as well as
comments from Gail Weiss of Medical
Economics2/18/2005 and with subsequent inputs
from the committee held during its March 22nd
2008 scheduled meeting, and reviewed by the
departments executive committee in its April 2nd
2008 scheduled meeting.
39
IM COMMITTEE on JCI and its SECTION
REPRESENTATIVES, 2007-2008
  • MANUEL CANLAS, MD Allergology/Immunology
    Section Mobile 63-917-279-8239 CLAVEL
    MACALINTAL MD Cardiology Section Mobile
    63-917-328-0273 GIA WASSMER, MD Endocrinology
    Section Mobile 63-919-555-3557 BENJIE BENITEZ,
    MD Gastroenterology Section Mobile
    63-917-812-4767 PAUL TAN, MD General
    Medicine Mobile 63-918-911-9066
  • JESUS RELOS, MD Hematology Section Mobile
    63-920-945-3787 VILMA CO, MD Infectious
    Diseases Section Mobile 63-920-961-1877 MILAN
    TAMBUNTING, MD Nephrology Section Mobile
    63-917-882-2788 JOEY PARRA, MD Oncology
    Section Mobile 63-917-823-4321 ELIZABETH
    SANTOS, MD Pulmonology Section Mobile
    63-917-792-8542 AUGUSTO VILLARUBIN,
    MD Rheumatology Section Mobile63-917-830-8925

NAZARIO A. MACALINTAL JR.,MD Head
Mobile63-917-894-5979 Email
drjunmac3000_at_yahoo.com
40
Internal Legal Issue that needs to be put in
place.
  • Data acquisition and Review Activities need to be
    protected from discovery, subpoena, or
    introduction into evidence in any civil /criminal
    action.

41
External Legal Issue
  • A law similar to the Health Care Quality
    Improvement Act should give peer reviewers
    near-complete immunity from claims for damages
    arising from peer review actions
  • provided - there are requisites like
  • Peer review was done in the belief that such
    action furthered quality healthcare
  • Addressed in the protocol
  • Those bringing the action made a good-faith
    effort to obtain the facts
  • Addressed in the protocol
  • The physician reviewed was given adequate notice
    and afforded due process
  • Addressed in the protocol
  • The hospital had a reasonable belief that peer
    review action was warranted.
  • Addressed in the protocol
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