POLICY and PROCEDURE. TITLE: Quality Improvement Committee Peer Review. TITLE: Quality Improvement Committee Peer Review

POLICY and PROCEDURE TITLE: Quality Improvement Committee Peer Review Number: 10486 Version: 10486.3 Type: Administrative - Medical Staff Author: M...
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POLICY and PROCEDURE TITLE: Quality Improvement Committee Peer Review Number: 10486

Version: 10486.3

Type: Administrative - Medical Staff

Author: Martha Wallace

Effective Date: 3/30/2012

Approval Date: 2/13/2012

Original Date: 6/1/2005

Deactivation Date:

Facility: Banner Churchill Community Hospital Population (Define): Medical Staff Replaces: MS 15 Approved by: Quality Improvement Committee, Medical Executive Committee

TITLE: Quality Improvement Committee Peer Review I.

Purpose/Expected Outcome: A. The purpose of this policy is to guide the Medical Staff through an objective peer review process to maintain quality patient care, facilitate education, and improve performance at Banner Churchill Community Hospital. The peer review process is not a disciplinary process. Disciplinary actions are processed through the Medical Executive Committee in accordance with the Medical Staff Bylaws, professional Review/Corrective Action Plan, Fair Hearing Plan, and medical staff policies.

II.

Definitions: A. Practitioner: A doctor of medicine, osteopathy, podiatry, dental surgery, or medical dentistry legally authorized to practice medicine, osteopathy, podiatry, dental surgery, medical dentistry or Allied Health Professional.. B. Peer Review: the evaluation of the quality of care provided by individual practitioners (including identification of opportunities to improve care) by individuals with appropriate subject matter expertise to make this evaluation. C. Process Improvement: the evaluation and improvement of multi-step processes of care. Examples of process improvement include: the process of blood ordering and administration, safe medication ordering and administration, and established protocols of care. Poorly designed processes hinder all members of the health care team including practitioners. D. Case Review Criteria: criteria established by each medical staff committee and/or service and approved by the Medical Quality Improvement Committee to the utilized in chart reviews to identify quality issues.

III.

Policy: A. Any questionable quality of care issue shall be brought to the attention of the Director of the Quality/Risk Management Department and Quality Improvement Committee for review. B. Medical Records will be screened monthly utilizing criteria pre-established by each Medical Staff Committee/service as approved by the Medical Quality Improvement Committee.

May not be current policy once printed Print Date: 6/28/2012

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Policy Title: Quality Improvement Committee Peer Review

C. Medical Staff Quality Improvement Committee (MSQIC) will assure that all peer review and clinical process improvement activities will be performed: Within the intent and protection of the Healthcare Quality Improvement Act of 1986 and Nevada Revised Statutes NRS 49.265. Actions will be reported to the National Practitioner Data Bank as required. 2. As defined in the Banner Churchill Community Hospital (BCCH) Medical Staff bylaws and appropriately integrated with the BCCH Medical Staff Bylaws Corrective Action/Fair Hearing Plan. 1.

IV.

Procedure/Interventions: A. Screening: 1.

Utilizing pre-selected criteria, charts that fall out, will be reviewed by a Registered Nurse and/or a similarly qualified employed reviewer. A summary of this review will be provided to the Medical Quality Improvement Committee. If further clinical review is required, the medical record(s) will be referred to the Medical Quality Improvement Committee.

B. External Peer Review: 1.

External Peer review will be utilized in the following circumstances: MSQIC cannot reach consensus regarding a practitioner’s performance. Appropriate peer expertise is not available within the BCCH Medical Staff. There exists an inability to reach consensus at any level due to the perception of possible conflicts of interest. d. Mandated by MSQIC or Executive Committee. a. b. c.

2.

This external peer review process shall be conducted according to Banner Health’s peer review process guidelines.

3.

In circumstances where an effective, objective review may not be accomplished through the normal review process outlined in this policy, the Quality Review Committee may appoint a focused review panel to review a case. This review panel shall consist of active members of the medical staff with at least one (1) member having the same specialty as the physician/practitioner being reviewed.

4.

Additionally, a focused review panel may be utilized when a trend is identified in a specific practice pattern of any physician/practitioner. Further intensive review may require further action to improve that physician/practitioner’s performance.

5.

This focused review process involves meeting with practitioner, monitoring, analyzing, and understanding special circumstances of physician/practitioner performance. Relevant information obtained from this review is communicated to the Executive Committee of the medical staff and integrated into the Performance Improvement tracking data for physicians. Outcome of review and any recommendations/actions to improve performance will be discussed with the physician involved and implemented by the Executive Committee.

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Policy Title: Quality Improvement Committee Peer Review

C. Committee Review: 1.

Each case requiring further clinical review will be reviewed by Quality Improvement physician reviewers composed of members from each medical specialty committee. The reviewing physicians shall evaluate each case for compliance with BCCH rules and regulations and local/regional medical standards of care. A QI Committee review sheet (see attached list of the specific criteria for each Medical Staff Committee/Service) will be provided and completed by the committee and is to be used to classify the case as follows:

Score

Action

(0) No Variance (B1) Practitioner Behavior (no effect on pt. care) (B2) Practitioner Behavior (may have affected pt. care) (D1) Documentation (no effect on pt. care) (D2) Documentation (may have affected pt. care) (I) Predictable event within the expected level of care (II) Unpredictable event within the expected level of care (III) Variation from the expected level of care (IV) Significant variation from the expected level of care (SI) System Issue

Closed Committee Chairman discussion with physician Concurrent review of all charts Concurrent review of specified charts Education to be provided to physician Focus Review Implementation of evaluation tools Invitation to next meeting for further discussion No Further Action Other recommendation(s) Phone call to physician Recommendation for performance improvement Refer to additional peer review Refer to Committee for education / discussion Refer to continuing medical education for review Refer to Department / Committee / Service Refer to external peer review Retrospective review of all charts Retrospective review of specified charts Track Trend Type I Letter – For information only Type II Letter – Request for further information

2.

If there are questions or concerns that need to be addressed by the attending or physician involved in the case prior to the QI committee assigning a score, a letter will be sent to that physician asking for a response.

3.

If a score of three (3) or four (4) is considered warranted by the QI Committee after review of the physician’s initial response, , a second letter will be sent to that physician providing him/her with an opportunity to attend the next QI Committee meeting to respond in person or in place of attending they may provide a written response. The QI Committee will assign a score to the case at this time with any recommended actions. If the committee does not receive a response from the physician within 60 days or written notification, the committee may assign the final score at their next scheduled meeting.

4.

If a one (1) or two (2) rating is determined, no action will be warranted. 3

Policy Title: Quality Improvement Committee Peer Review

5.

If a three (3) or four (4) rating is determined, the medical QI committee will send a letter to the attending physician/practitioner involved in the case informing him/her of the score and that there was a deviation from the standard of care. Each case scored will be tracked per physician and reported on the Ongoing Professional Practice Evaluation form. This quality/peer review data sheet shall be available to the Medical Executive Committee whenever needed, whether for reappointment or other Medical Staff action purposes.

D. Timing: 1.

All individuals and committees required to act in the peer review process must do so in a timely and good faith manner. The Peer Review Process should take no longer than one hundred twenty (120) days. This time period, however, is a guideline and does not create any right to have a case processed within a specified number of days. The timing wil stat when the chart enters the Quality Department to the time all the outcomes and actions are followed upon and the case is closed.

E. Non-Medical Reviews: 1.

A significant non-medical issue such as inappropriate management of the medical record will be referred to the Health Information Committee. Non-compliance with Medical Staff Bylaws, Rules and Regulations, or policies will be referred to the Medical Executive Committee. Issues related to disruptive physician behavior will be reported and handled in accordance with the Medical Staff Disruptive Conduct Policy.

F. Availability of Peer Review Data: 1.

All practitioners at BCCH can view their own peer review data at any point during their appointment or reappointment cycle. They can come to the Medical Staff Services office and request their data for reviewing within the Medical Staff office. Hard copies of the peer review data will not be made for individual practitioners.

G. Confidentiality: 1.

V.

Information obtained or prepared for the purpose of coordinating, monitoring, trending, reporting and evaluating all Medical Staff peer review and Medical Staff-driven clinical process improvement activities pursuant to this Peer Review Policy and Procedure shall, to the fullest extent permitted by law, be confidential. Such information shall only be disseminated to the extent necessary for the purposes identified above or except as otherwise specifically authorized by law. Such confidentiality shall also extend to information provided by third parties.

Procedural Documentation: A. N/A

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Policy Title: Quality Improvement Committee Peer Review

VI.

Additional Information: A. N/A

VII. References: A. N/A

VIII. Other Related Policies/Procedures: A. N/A

IX.

Keywords and Keyword Phrases: A. Peer Review B. QI C. Quality Improvement

X.

Appendix: A. N/A

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