Preparing New Committee Members


“We lose momentum and take too many steps backward every time the membership of our peer review committee changes.”



The potential adverse impact of changing peer review committee membership over time cannot be underestimated. All the effort put into building your peer review on mutually agreed upon guiding principles (See the ProblemSolved  Medical Staff Support“) and ensuring that these principles are reflected in bylaws, policies, procedures and behaviors, can be easily lost as committee membership changes.

Too often, physicians are asked to take on integrally important committee assignments, but the importance of their role is not reflected in the effort put forth to orient them to their new responsibilities. A sound orientation program for new members is essential for preventing the loss of committee effectiveness over time. This is but one example of how the role of the medical staff director/manager (or management team colleague) can play a vitally important role for the hospital. With longevity and expertise on their side, they can serve as a stabilizing force over time, preserving both the effectiveness of the peer review committee and the support it has garnered among physicians.

Certainly, an argument could be made that just as a physician’s clinical privileges are predicated on proof of competence, so should the privilege to participate as a member of the peer review committee. At a minimum, the new member should be required to partake in a thorough orientation, coordinated by medical staff management and directed by committee leadership, that includes the following:

  • Sections of the medical staff bylaws and rules & regulations that pertain to peer review
  • A presentation on the fundamentals of peer review
  • Relevant rules and regulations
  • Medical staff structure and where the peer review committee fits
  • The roles and responsibilities of the peer review committee as outlined in the bylaws
  • The guiding principles that drive all peer review activities, how they came to be and why
  • The hospital’s OPPE and FPPE process designs
  • Committee meeting format
  • Current and upcoming committee activities

The greater the appreciation for the peer review function and the potential it holds for clinical quality and patient safety, the more obvious becomes the need to embrace such orientation. Making sure that your new peer review committee members are ready to serve consistent with the foundation built by former and existing members optimizes their impact on your hospital and the people it serves.