Following The Right Policies


“We have model policies and procedures, but it seems that chaos and conflict surround our
peer review efforts.”




When great policies and procedures exist amidst conflict, resistance and/or questionable outcomes, it is possible that either P&Ps are not being followed completely or that they are not as good as you think. Some firms like to sell “model” documents or what we refer to as “peer review in a box”. Too often, hospitals fail to avoid the pitfall of buying such a “quick fix” on the grounds that it will solve accreditation deficiencies, save a great deal of time and bring instant credibility to the peer review function. WARNING! While this might feel good in the short run, longer term consequences are inevitable.

Working within accreditation and regulatory standards, hospitals across the country have identified and implemented unique strategies to accomplish what is often perceived as a threatening, daunting task. Successful organizations develop their approach to peer review without seeking short cuts. They know that to have effective, well supported peer review based on trust and mutual respect, policies and procedures must be developed from within and must reflect the culture, structure, and principles of the hospital and its medical staff. Only then can peer review be done with physicians rather than to them.  Where did your peer review P&Ps come from? Were they written or at least endorsed by your medical staff leadership? Are they well understood by the medical staff as a whole? When was the last time they were updated? Are they consistent with and supportive of the bylaws?

Remember that “model” policies and procedures might be exemplary for some hospitals, but highly problematic for others. You might consider using model documents as a starting point. However, skipping the time and effort involved to make them work for your medical staff can leave your peer review failing to live up to the potential it holds for your hospital and those you serve.

Finally, it is critical that your peer review program be well articulated to the medical staff as a whole, that feedback be solicited and taken to heart, and that those leading peer review activities hold themselves accountable to consistently behave in ways that reflect the important principles embodied in your guiding documents.