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    Is peer review worth saving?

    An increasingly vocal group of physicians says the hospital peer review process is misused to strike down competitors and outliers.

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    In fact, peer review and other quality assurance efforts are so inadequate, says a malpractice claims specialist who requested anonymity, that more bad doctors are identified by insurance companies after claims are filed than are identified by their peers. "Hospital-based peer review is an ineffective way of dealing with bad doctors or questionable medical care. Physicians are more likely to be sheltered by peer review than to have it used as a weapon against them."

    Toward a more effective peer review system Many observers who say that the peer review system is broken contend that the process needs, above all, to be made more objective. "If we're going to conduct peer review," says Linda Peeno, "an outside body should do it." This is difficult in small communities, where everyone knows everyone else, but one way to surmount that problem is to form reciprocal agreements with neighboring communities: We'll review your cases and you can review ours. Or a specialty board can hear the case.

    Also, critics say, because peer review focuses on individual behavior, it misses systemic problems. "Healthcare is so complicated and accountability needs to be much more public, but I don't think peer review is an effective tool," says Martin Hatlie, president of the Partnership for Patient Safety in Chicago. "We need organizational accountability, not just the accountability of people in the organization."

    Along those lines, Nancy Foster, senior associate director of health policy for the American Hospital Association in Chicago, would like to see the Patient Safety and Quality Improvement Act of 2003 become law. The bill, which has passed both houses of Congress, would, among other things, enable hospitals to share data garnered from peer review. "Not clinician names," Foster points out, "but information on occurrences so that we can learn from each other."

    The measure would require shielding the peer review process from discovery in civil proceedings—something federal and state courts have long endorsed. "Otherwise peer review would be the inexpensive gathering of evidence for a lawsuit," says James Hilliard, a healthcare attorney in Walpole, MA. "The plaintiffs would just sit back, let the peer reviewers do their thing, then discover what peer review has done and they'd have their case."

    That shield has begun to crack, however. In November the Florida electorate endorsed a constitutional amendment—touted as a patient-safety measure—that would eliminate confidentiality from the peer review process. In response, the AMA, at its interim House of Delegates meeting in December voted to seek federal legislation to prohibit discovery of records, information, and documents obtained during the course of professional peer review proceedings.

    The AMA also has taken steps toward adopting a set of peer review principles based on the Massachusetts Medical Society's Model Principles for Incident-Based Peer Review. This is one of the few sets of guidelines, according to Hilliard, that stresses remediation over punishment and aims to limit the likelihood that hospital insiders or a physician's competitors will co-opt the process.

    Among the model principles:

    • Triggers that initiate a peer review within a healthcare facility should be valid, transparent, and available to all member physicians and uniformly applied to all cases and physicians.
    • Summary suspension or restriction of clinical privileges may only be used to prevent "imminent danger to the health of any individual."
    • A peer review committee, engaged in a formal peer review or disciplinary proceeding, may not include the subject physician's direct economic competitors and should include a fair representation of specialists/subspecialists from the physician's specialty/subspecialty whenever feasible.
    • Membership on the peer review committee must be open to all physicians on the medical staff.
    • Whenever a peer review committee adequately representing the subject physician's specialty/subspecialty can't effectively be constituted by physicians from within the institution (excluding direct economic competitors), qualified external consultants or an external peer review panel through another appropriate institution should be appointed.
    • Any conclusion reached or action recommended or taken should be based upon the information presented to the peer review committee and made available to the subject physician. Indefensible and vague accusations, personal bias, and rumor should be given no credence and should be carefully excluded from consideration. Any conclusion reached should be defensible under a "reasonably prudent person" standard.
    • A healthcare facility's conclusion and recommended action should emphasize steps for remediation, as needed, for the subject physician and the system.
    • A process should be available to appeal any disciplinary finding, and the requirements and procedures for all existing appeal mechanisms should be made available to the subject physician.

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