Peer Review: How 2007 Joint Commission Standards Expand Hospital Peer Review


September / October 2007

Peer Review

How 2007 Joint Commission Standards Expand Hospital Peer Review

The 2007 medical staff standards of The Joint Commission change the peer review process by strengthening and extending it. The standards now call for two kinds of professional practice evaluations: focused and ongoing. In addition, hospitals must make unbiased credentialing and privileging decisions based on physician performance. As a result, the existing methods by which physicians have historically been assessed no longer meet these standards and require revision. These more precise and expanded standards are aimed at attaining and maintaining higher quality hospital peer review, credentialing, and privileging processes.

Focused Professional Practice Evaluation
The Joint Commission defines a “focused evaluation” as an intense assessment of a practitioner’s credentials and current competence. Focused evaluation (MS.4.30) covers credentialing and applies to new applicants for medical staff positions and to practitioners who request new expanded privileges where the hospital has no documented evidence of competence. It also applies to any practitioners with a negative performance or someone lacking the volume of cases needed to assess their competence from practice within the hospital.

When appointing medical staff, the hospital must confirm with primary sources whether a practitioner requesting medical staff membership and privileges has the obligatory current training, knowledge, skills, and abilities. The hospital must also consider the same requirements for practitioners undergoing re-credentialing. The new standards also call for that the granting of privileges to be based partially on the results of peer review and ongoing professional practice evaluations.

Proctoring is another form of “focused evaluation” and involves one-on-one evaluation of a practitioner’s performance by another peer practitioner, or proctor. There are two ways to accomplish proctoring: direct observation and retrospective review. Through direct observation, a second physician observes and gauges the proctoree’s ability to perform a procedure or use a new technology. But having one physician watch another reduces both the physician’s and hospital’s productivity and makes direct observation problematic. When real-time evaluations are not feasible, retrospective focused evaluations of the proctoree’s cases is an alternative. In instances without “same specialty” peer reviewers available internally, external peer review can substitute.

Ongoing Professional Practice Evaluation
Ongoing professional practice evaluation (MS.4.40) goes beyond the traditional case-by-case peer review and peer recommendations and applies to practitioners already granted patient care privileges. These traditional practices must be supplemented by reliable outcome and performance data. This information comes from multiple sources, including aggregate analyses of resource use, practice patterns, and patient outcomes, direct observation, complaints, peer review, and comparative performance measurement projects with large databases, such as the Society for Thoracic Surgery registry.

The Joint Commission provides some guidelines, but leaves the scope of review and information needed for an adequate professional practice evaluation to the discretion of the hospital and its organized medical staff. Information gathered during Joint Commission mandated performance improvement (PI) activities also must be considered. These activities include evaluations of:


  • Medical assessment and treatment
  • Medication use
  • Use of blood and blood components
  • Appropriateness of operative and other procedures
  • Appropriateness of care, including significant departures from generally accepted standards of practice
  • Autopsy findings
  • Adverse events, including sentinel events


The hospital and the organized medical staff must clearly define what additional information is needed to objectively judge a practitioner’s ability to provide safe, effective, and appropriate patient care. This also includes, but is not limited to, information that allows for assessment of a practitioner’s interpersonal and communication skills, professional behaviors, and performance as a team member. The need for practitioner assessments at least every 2 years is implicit in ongoing professional practice.

Credentialing, Re-credentialing, and Granting Privileges
The credentialing of physicians, licensing independent practitioners, and granting of privileges is, strictly speaking, a peer review activity. At least every 2 years, all members of the medical staff must undergo a professional practice evaluation to re-credential them for continued membership and reassign them specific patient care privileges. Due to long-standing personal and professional relationships, staff constraints, limited time, and similar issues, this process often defaults to a “rubber stamp” system in some hospitals. When done correctly, re-credentialing involves evidenced-based validation of a physician’s knowledge, skills, ability, and behavior. As a result, hospitals increasingly view re-credentialing as a peer review process and are putting practices in place to:


  • investigate and assess the professional and personal backgrounds of every practitioner applying for privileges (initial appointment),
  • assign specific privileges appropriate for the practitioner’s training and experience (privilege delineation), and
  • periodically reappoint each member of the medical staff based on performance assessments (reappointment).


Depending on a practitioner’s medical staff status — a new applicant or an existing practitioner requesting new privileges — the peer review process may involve solely a “focused” review or both “focused” and “ongoing” review. For a new applicant, the focused evaluation process qualifies the practitioner for medical staff membership and specific patient care privileges. Conducting a focused evaluation after privileges are granted can confirm competence further. For example, when evaluating a new applicant, a “peer” practitioner currently on the medical staff could review a sampling of the new applicant’s cases from other facilities where the applicant has existing privileges. When no “same specialist” is available to avoid conflict of interest, hospitals could consider using an external peer reviewer to supplement this capability.

Any time current medical staff members request new privileges, hospitals must apply the focused evaluation process to qualify them. The Joint Commission standards expect hospitals to base their decision to grant, limit, or deny requested privileges on clinical performance information. It is common for a current member of the medical staff to request privileges for which the hospital has no documented evidence of the practitioner’s competence. This may be due to a low volume of cases, clinical practice patterns not included in the performance data routinely reviewed by the medical staff, or a lack of physician cases undergoing peer review. Because a hospital must make a decision about privileging based on evidence, when it is faced with practitioners lacking performance information it can randomly select some of their cases to undergo peer review. Through that process the hospital can validate the competence of a requesting practitioner to perform a specific privilege.

Common Peer Review Concerns
Because the 2007 Joint Commission standards now demand knowledgeable, unbiased and objective peer review, some common concerns are emerging. To assure a smooth transition to the new requirements for peer review, hospitals must communicate, recognize issues, and compensate for lack of physician specialties.

Communicate Expectations.
The hospital and medical staff should jointly define what is meant by quality of care, appropriate resource use, patient safety, professionalism, and accountability for active participation as a team member in the care system. Often hospitals do not clearly define what is expected of the members of the medical staff. Without a common set of expectations, peer review decisions may appear arbitrary or capricious. Peer review should not be a subjective process, and practitioners should know how they are being measured. Otherwise they may resist being involved in the peer review process or legally challenge what they perceive as biased or unfair judgments.

Recognize conflicts of interest.
With the expanded role of peer review in hospitals, internal peer review committees must always consider conflict of interest situations among their peer reviewers. Otherwise, cases may be inadvertently sent to ineligible reviewers. Conflicts that may exist can range from a reviewer who is in partnership or competition with another practitioner, to social and personal relationships. In general, committee members should be educated about all potential conflicts of interest. If one exists, the committee chair should be alerted so that another reviewer can be assigned. When one is not available, the committee should choose an external peer reviewer.

Compensate for lack of physician specialties.
Many hospitals do not have the specialist depth of expertise internally to allow for expert and objective peer reviews in all areas. Finding a suitable “peer” or “like specialist” within a hospital group or small community is sometimes impossible. However, when a like specialist does exist, more than likely there are issues surrounding personal or professional relationships, perceived competition for patients, or other conflict of interests. To conduct a legitimate peer review, it’s important for the practitioner under review to be judged by a “true peer” — someone working in a similarly sized hospital with similar capabilities and in exactly the same medical specialty.

Increasingly, hospitals are recognizing the importance of engaging reviewers who are “true peers” and who can make objective, evidence-based decisions grounded on the medical facts involved in the case. Independent Review Organizations can help resolve this concern by exactly matching an external reviewer with the practitioner under review.

Joint Commission 2007 Standards Affecting Hospital Peer Review

  • Two types of reviews — MS.4.30 introduces the concept of “focused professional practice evaluation” and MS.4.40 “ongoing professional practice evaluation.” These standards require review of the practitioner’s knowledge, skills, ability, and behavior. These practice evaluations encompass the more explicitly defined peer review requirements found in the 2007 standards.
  • Standards MS.4.30, MS.4.40, MS.4.45, MS.4.50, MS.4.70 and MS.4.80 address focused and ongoing professional practice evaluations, peer recommendations, fair hearing, and physical health. They look at a physician’s knowledge, behaviors, skills and ability.
  • Standards MS.4.00 – 4.25, MS.4.60 and HR.1.20 deal with credentialing, re-credentialing, and privileging. They ensure all medical staff members are competent and well qualified and move credentialing and privileging processes away from subjective opinions to fact-based decisions.
  • Credentialing, re-credentialing, and privileging — Standards MS.4.00-4.25, MS.4.60, and HR.1.20 explain credentialing, re-credentialing, and privileging of physicians and ensure only qualified and competent practitioners deliver patient care at a hospital. They, too, make the decision toward evidence-based and attempt to remove subjectivity. Selecting and privileging practitioners must be decided on objective assessments of medical knowledge and clinical skills, as well as evaluations of the practitioner’s professionalism and active team member participation in the hospital system.
  • Professional practice evaluation, peer recommendations, fair hearing protocol, and physician health — Standards MS.4.30, MS.4.40, MS.4.45, MS.4.50, MS.4.70, and MS.4.80 address focused and ongoing professional practice evaluation, peer recommendations, fair hearing protocol, and physician health.

Skip Freedman is the medical director at AllMed Healthcare Management, a national independent review organization based in Portland, Oregon. He is a longtime emergency physician and practices at several hospitals in the Portland-Vancouver metropolitan area. He may be contacted at