Lack Of Adherence To Written Policies And Procedures To Comply With Regulations And Accreditation Requirements
Compliance with regulations and standards is crucial. It is important to involve all stakeholders to design peer review policy and process that can withstand any challenge and to stick to what is written. Policies and procedures must adhere to sound direction set forth in the medical staff bylaws.
No Clear Articulation Of Internal And External
Peer Review Processes
Stakeholders must define the specific criteria for case identification, which might include sentinel events, incident reports or performance trends. They must also define the criteria for sending cases outside the organization for review.
Failure To Document
If you do not document, it did not happen! Documentation provides proof of compliance with statutes and policy. No matter how minor an issue, documentation is critical. Documentation is necessary to establish a pattern over time and provide proof that careful thought has gone into decisions that impact quality and careers.
Failure To Match Specialty And Training Of Reviewer And The Individual Being Reviewed
Any case must be considered in its own context by a similarly credentialed physician.
Failure To Consider Bias Or Conflict, Whether Economic, Professional Or Personal
Partners, competitors, friends or other acquaintances might not provide a fair review. Perceptions must be taken seriously. External review supports objectivity by avoiding potential pitfalls.
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Failure To Communicate With The Physician Involved
The bylaws should establish specific guidelines that would include notifying the physician of the peer review action, inviting them to meetings and setting reasonable timelines for all activities.
Failure To Complete The Process
It is very important to act on any identified issues. The committee must document any planned actions (who, what, when, how) and maintain a good tracking mechanism. It is important to follow through and not leave the process incomplete.
Trying To Address Disruptive Behavior Through
Peer Review Processes
Behavioral issues are not clinical issues. Disruptive behavior is a policy issue. Disruptive behavior should be handled using policies and procedures specifically addressing disruptive behavior.
Misusing The Peer Review Function
Peer review is not a weapon or competitive strategy. A diverse committee must ensure that the process is used fairly, consistently and always with the highest integrity. The driving purpose must always be to maximize safety and quality of care.
Crossing The Line Between Peer Review And Corrective Action
Peers should review only the care rendered in each case and never recommend corrective actions. Response to peer review should be left to medical staff leadership as dictated by bylaws, rules and regulations.
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