September / October 2008
Independent Review Supports Transparency
Transparency is unquestionably one of the most commonly stated words today. In healthcare, the term describes a policy of medical professionals and providers openly sharing with payers and patients facts about their performance and background. In turn, the government, insurers, and consumers are expected to use this information to identify effective, value-based care (Russell, 2006).
With the increased focus on transparency in healthcare, it is now more than ever in a hospital's best interest to have a robust peer review program that aligns with national patient safety efforts.
National Emphasis on Transparency
The Centers for Medicare & Medicaid Services, in conjunction with the Hospital Quality Alliance, has begun publicly reporting 30-day mortality measures for acute myocardial infarction, heart failure, and pneumonia. These measures are intended to focus attention on the patient's outcome of hospitalization. Publicly reporting the mortality measures provides hospitals, patients, and other consumers a tool to recognize quality improvement efforts made by hospitals.
In January 2007, the Joint Commission instituted new standards for monitoring performance and intervening when safety and quality of care concerns are identified. According to the new standards, hospitals of all sizes are required to demonstrate that objective decision-making is employed in the credentialing and privileging of their physicians. The two types of reviews the Joint Commission requires to assure physician competence are ongoing professional practice evaluation and focused professional practice evaluation.
The Institute for Healthcare Improvement's 5 Million Lives Campaign focuses on 12 changes in care that are being implemented in hospitals across the country to save lives and reduce patient injuries. The IHI recommends that all hospital boards conduct intensive case studies when patients are harmed, as well as perform random audits of 20 to 40 medical records per month to help uncover accidents.
Why Independent Peer Review?
Hospitals perform peer review to assure that their physicians are properly credentialed, competent, and adequately trained to safely treat patients, while providing quality care. It is generally accepted that since physicians must measure the competence of other physicians, internal peer review carries the potential for conflict of interest, or the difficulty of holding a colleague accountable, particularly if there are social or professional relationships or too few physicians in a specialty. In-house physicians are at a further disadvantage in performing this critical function simply by having less time to perform the reviews, or they may lack the experience and expertise needed for peer review activities. For any of these situations, independent peer review by an external source is a good option for effective compliance.
External peer review supports the facilities' internal activities by providing hospitals with an impartial third-party evaluation of the care delivered. Objective independent peer review is necessary to evaluate patient care, medical and clinical knowledge, practice-based learning, interpersonal communication skills, professionalism, and systems-based practice (i.e., how well a physician is able to function within the myriad complexities of hospital operation).
With independent peer review, medical records may be reviewed for standard of care, experimental/investigational procedures or treatments, mortalities or sentinel events, physician practice patterns, or medical necessity. A facility may need assistance with coding validation activities. Antibiograms may be reviewed for appropriateness and cost. New programs, such as sleep studies, or new equipment, such as 64-slice CT scanners, may need independent review for certification purposes, and for credentialing purposes for physicians participating in these new programs. A hospital or physician may request an independent opinion during a fair hearing process. Impartial oversight and monitoring of a medical or collaborative practice may be needed. A Critical Access Hospital may need assistance in meeting CAH Federal Conditions of Participation. An individual physician, a group practice, or a facility's entire medical staff may request education on the peer review process to enhance their knowledge base and their internal quality management program.
Examples of reviews in which an independent opinion may be requested include:
A pregnant female undergoes surgery after trauma and the surgeon must decide whether to try to save the life of the mother or baby. Were the indications for surgery appropriate? Did the intraoperative care of the patient meet standard of care?
A pediatric radiologist reads an echocardiogram on a neonate. Did the quality of the echocardiogram meet standard of care (equipment and technologist)? Were the results reported to the requesting physician in a timely and appropriate manner?
A toddler arrives in the emergency department and requires immediate intubation. After successive attempts by the ED physician, an anesthesiologist is summoned and performs the intubation. What level of experience/certification should be required of the ED physician in the care of pediatric patients requiring rapid intubation?
A patient requires return to surgery after laparoscopic gastroplasty. Was the complication (return to surgery) within the range of expected complications? Did the postoperative management of the patient meet standard of care?
A teenage female receives a bilateral oophorectomy during removal of an ovarian cyst. Did the documentation provided in the medical record justify the procedure? Was there adequate documentation that the risk of bilateral oophorectomy was explained to the patient and her family preoperatively? Should there have been documentation of discussion between the surgeon and the patient's family during the surgery and prior to removing the ovaries? Based on the documentation provided, was standard of care met in the care of this patient?
A patient's care is transferred from an attending physician, who is going out of town, to the "covering" physician without written or verbal communication at the time of transfer. Does this meet the standard of care?
A cardiac surgeon begins to perform endoscopic vascular procedures previously only performed by vascular surgeons. Does the preoperative documentation justify the need for the procedures? Is the standard of care being met in the performance of the procedures? Would the patients receiving the procedures benefit from the option of open vascular surgery at the time of the endoscopic procedure, should the need arise?
Peer Review and Transparency
A successful peer review program must be objective and factually based on current standards of practice. It helps ensure that services provided are medically necessary, appropriate, and delivered in a setting best suited to a patient's needs. Peer review assists in assuring that quality of care meets professionally recognized standards. The consequences of not having an effective program may include negative publicity, lawsuits and fines, sanctions and/or loss of accreditation, increased scrutiny by oversight agencies, loss of investor confidence, and damage to a physician's career, even if there was no wrongdoing but there was a perception by the public of "cover up."
Independent peer review augments healthcare quality/risk management programs by providing an unbiased, impartial opinion on care delivery. Not only is it good risk management from a quality perspective, it is good business practice from a financial standpoint. Independent peer review ensures adherence to quality standards; it helps reduce a hospital's liability risk; and it assists with regulatory, credentialing, and accreditation requirements, among other benefits. A well-established peer review program that includes an independent review component enhances response to the healthcare community's expectations for patient safety and accountability, which in turn assists providers in delivery of effective, value-based care.
Judy Kinkelaar Ring has served as CIMRO's manager, quality services and corporate compliance since 2005, was support services coordinator from 1996 to 2005, and began her CIMRO career as quality review analyst in 1995. Ring oversees CIMRO's independent peer review programs, and is responsible for internal quality control and compliance with corporate policies and regulatory/accreditation requirements. She has 18 years supervisory and direct patient care experience in hematology/oncology, medical/surgical, ICU, and intermediate care units in acute care facilities and outpatient clinics. She received her bachelor-of-science degree in nursing from Brokaw Collegiate School of Nursing, Illinois Wesleyan University. She may be contacted at [email protected].
Barry Slotky is board certified in obstetrics and gynecology, and is a Diplomate of the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) and currently serves on the ABQAURP Board of Directors. He has active staff privileges at two Illinois hospitals, and is a former clinical assistant professor at Southern Illinois University School of Medicine and current clinical associate at the University of Illinois. He is a member of the American Medical Association, Illinois State Medical Society, and a Fellow, American College of Obstetricians and Gynecologists. He is chair of the Board of Directors and serves as an OB/GYN Physician Reviewer for CIMRO.
Russell, T. R. (2006). Nothing to hide: Transparency in healthcare. Medscape General Medicine, 8(3), 83.