Imagine you have three general surgeons on staff, all competing with each other, and surgeon A has had two patients die within the last year. Or suppose surgeon B performs a procedure on every patient that no other surgeon performs. Do you have a quality problem? Or suppose Dr. C's patients all feel abused by her, but they all have good outcomes. Is there an issue here? Most importantly, can your hospital address these questions without causing ill will and possibly losing a good physician? Can inherent conflicts of interest be avoided in the process of fulfilling the organization's responsibilities related to medical quality?
Unfortunately for many medical staffs, peer review issues are like the elephant in the living room that no one wants to acknowledge. If handled well, however, proactive and effective peer review can be the cornerstone of a strong medical staff. Too often hospitals ignore issues with physician peer review. When a problem is finally recognized, many institutions find themselves scrambling for peer review resources, and uncertain of what to do until a situation is resolved. Making peer review a routine part of hospital Performance Improvement, and not a punitive event, will make physician acceptance much better.
As in any hospital procedure, prior planning prevents poor performance. First, make sure you have strong indicators for key areas, and share successes with everyone. For instance, if surgical site infections are an issue, look at the physicians with the least infections. What are they doing well? What can you learn from them? Routine peer review may reveal areas done well, in addition to what isn't done well.
Next, have a plan for peer review. If you have only one physician in a specialty, you will need outside resources. Two or three physicians in the same specialty might be able to review each other, but not if they're in the same group, or if they are in direct economic competition. If your hospital can't provide peer review internally, you'll need outside help.
Lastly, what do you do with the catastrophic cases? Consider surgeon A above. Are two deaths in one year within the statistical norm, or is it an aberration? Many professional medical societies will have published listings of "acceptable" rates of complications for individual procedures for reference. National organizations, such as the Leapfrog Group, also have reference statistics available. If your hospital's complication rates are excessive, medical staff rules and regulations will often allow for temporary suspension or termination of privileges or procedures. If in doubt, it is always better to err on the side of caution and patient safety than to allow a physician to proceed in dubious circumstances. When this happens, effective quality peer review must be available, given the impact on the physician, his/her patients and the organization.
Most importantly, remember that peer review is a learning experience. Perhaps Surgeon B's procedure is a benefit to his patients, and might be best taught to all physicians. Each peer review issue can reveal strengths and weaknesses, both in the individual physician and in your entire hospital system. Using these lessons wisely can only benefit your entire staff.
Dr. Dan S. Fairman M.D. is an internist in private practice in Sun Valley, ID., and has been active in medical staff leadership for the past 12 years. He is also a Partner of MDReview, a leading provider of external peer review services. He can be reached at dfairman@MD-Review.com
