Common Peer Review Pitfalls: Low Hanging Fruit

Problem:

“We are working to improve trust in our peer review program.  What are the common pitfalls we should avoid to ensure our peer review processes don’t fail?”

Solution:

That’s a loaded question!  We have seen so many pitfalls—many on a consistent basis.  This question is probably best addressed in a series of ProblemSolved editions.  For this edition, let me outline some of the more common pitfalls, “low hanging fruit”:

Using peer review to address policy-related issues:  Allocating resources to review physician practice, especially if by an outside reviewer, makes little sense if the primary question relates to whether or not an internal policy has been violated.  Such determinations typically don’t require an expert peer.  Further, such application of peer review consumes unnecessary time and money.

Not including the physician in the process:  Doing peer review to physicians rather than with physicians can be more damaging to trust and peer review effectiveness than anything—for the entire peer review program.  Include the physician whose care is the subject of review in the process at the earliest possible time.

Cutting corners on process or quality to save money or effort:  Leaving out parts of records to save time; using non-physicians to extract data from a record for a physician’s interpretation and review; not making the effort to include office records in the review when relevant; shipping the records for expedited external review using standard ground shipping; using the most willing rather than the most capable and credible reviewers…the list of corner cutting mistakes is a long one.  The key is to remain vigilant and make sure that every action reflects appreciation for both process integrity and the cost of mistakes.

Going off script and deviating from review processes and procedures:  Never waiver from your bylaws and policies.  Review your controlling documents from time to time to make sure they are appropriate and will work—that they are worthy of being followed.  If you haven’t looked at these documents in a while, there is a good chance that at least parts aren’t adequate any longer.

Failure to engage the right legal counsel at the right time:  Legal counsel can be expensive and sometimes slow the process.  However, the expertise can be invaluable.  Getting legal counsel involved to minimize the damage that the same counsel could have prevented is senseless.  If ever in doubt, involve legal counsel at the earliest time.

Allowing peer review to leak outside the medical staff:  Keep the medical staff and, if appropriate, it’s legal counsel in command and control.  Reports, letters, deliberations or any other communications or decisions must not escape the oversight and control of the medical staff.  This will not only help maintain process integrity, but also ensure that discoverability and immunity protections remain intact.

Turning aspects of the process over to disinterested staff or to staff that does not appreciate the significance of each step, big or small:  A committed, knowledgeable member of the team has to remain the quarterback and ensure everyone is working from the same playbook.  We have seen great peer review efforts fail in medical records, the loading dock, information systems…you name it.  Everyone involved is a link in a chain that can’t be broken.  Someone has to assume responsibility for vigilant oversight of every step.

Using a reviewer that is not qualified, creditable, willing and interested:  You must be confident that the reviewer is not only a credible peer, but also motivated and qualified to review the cases with the utmost integrity.

Providing the reviewer with incomplete records:  It is true: garbage in, garbage out!  Go through the rigors of making sure all appropriate documentation is included for review, including imaging.  (Whether for internal or external review, MDReview’s Medical Records Checklist can be very helpful.)  Leave it to the reviewer to determine what is important.

Assuming peer review is limited to the hospital’s walls:  Balanced and thorough peer review often warrants inclusion of office records.  It is in no one’s best interest to exclude office records when relevant to the care under review.  Failure to consider the importance of office records and to make every effort to include them in the review can be a fatal mistake.  You are never darned if you do…but you can certainly be darned if you don’t!

Peer reviewers recommending corrective action:  It is not the reviewer’s job to recommend any corrective action.  In fact, by recommending corrective action, the reviewer can do more to interfere with the process than support it.  Corrective action is leadership’s responsibility.

Treating peer review as a report rather than a process:  The peer review report is not the end; it’s often the beginning.  Even after submission of the report, all remaining questions should be answered, concerns addressed, challenges considered, clarification provided…whatever is necessary to ensure that the results of the peer review are understood by leadership.  The eve of a fair hearing is no time to start turning over stones.

Unfortunately, I could go on with many other common pitfalls.  And in future editions of ProblemSolved, I will!  In peer review, mistakes come at a high price.  The above mistakes are common and can cause so much damage.  Through thoughtful process design and effective, vigilant oversight, they can all be avoided.