Everything You Need to Know About Medical Peer Reviews
As a physician, you’ll have to undergo years of medical school and residency, the time-consuming processes of credentialing and privileging and, sometimes, the stressful process of a medical peer review.
Most physicians are highly adept at navigating the many administrative, bureaucratic, and legal regulations that come with the job. Yet, for many physicians, the peer review process is an especially challenging one.
If you’re the subject of a medical peer review or want to arm yourself with information in case one arises later in your career, keep reading.
Here’s everything you need to know about medical peer reviews.
What Is a Medical Peer Review?
A medical peer review is a performance assessment. Through this process, peers evaluate other physicians’ clinical performances. Teams of multiple physicians are assembled, often by administrative committees and ethics committees, to review the patient charts and activities of a particular physician.
The conduct in question may be as the result of a single event or a series of events. Depending on the circumstances, the peer review committee may review everything from patient charts to medical notes to billing procedures.
The purpose of the medical peer review is to improve patient safety and the quality of care. And since physicians know best how to conduct themselves and provide care, it is a group of peers that hold and handle these reviews.
Are All Physicians Subject to Peer Reviews?
Some hospitals may go their entire careers without ever being subject to a medical peer review, particularly those in private practice. Peer reviews are common practice; however, in hospitals, large healthcare groups, and surgical centers.
Depending on your employer, both physicians and nurses may be subject to peer reviews.
Sometimes, peer reviews begin simply because a physician requests more or new privileges. But in other cases, the trigger is a complaint from other members of your staff concerned about your performance or standard of care.
It doesn’t matter what medical association or medical society you belong to or what medical specialty you practice. If you work for a large healthcare provider, you should always be prepared for a hospital peer review.
But there is some good news:
A physician under peer review will know before the start of the process or investigation. Even if you face review due to a complaint or a potential violation of conduct, your employer will inform you.
How Does the Peer Review Process Work?
There are two main subjects in the peer review process. The reviewee (the physician under scrutiny) and the reviewer (the team put in place to conduct the investigation).
Who Performs Peer Reviews?
The reviewer can be one individual physician or a committee of doctors, nurses, and other medical staff. In peer reviews for privileging, the credentials committee may be the reviewer. In other situations, the ethics committee of your hospital board may be the one to conduct the review.
There are also instances where an external peer review committee may be called in to oversee or lead the process.
Steps in the Review Process
Regardless of who the reviewer is, the process always follows these steps:
Step 1: The Trigger Event
Something has to happen for you to fall under medical peer review. In many cases, it means that another physician or staff member has reason to suspect misconduct.
Step 2: Initial Review
The committee of your peers will conduct an initial review. During this phase, the reviewer will gather and review the documents in question.
Step 3: Presentation of the Findings
Once the committee has come to a decision, they give the physician a chance to review those findings. As a physician under peer review, you will know what documents are under investigation and when they reach a conclusion.
Step 4: Physician Responds With Feedback
Depending on what the reviewer finds, you may need to provide detailed explanations or evidence to support your actions. Regardless of the findings, you will get an opportunity to respond with feedback.
Step 5: Assignation of Severity and Intervention Score
Once you’ve responded to the findings in your review, the reviewer will assign it a score based on the level of severity.
The best score you can receive is “no error,” meaning that the review team found you did nothing wrong. The worst score you can receive is “catastrophic error,” which is usually only the case if your conduct resulted in a patient’s death.
Between, there’s a variety of score levels. Some of which are minor and some that may be regarded as moderate or severe. Depending on the score assigned to your peer review, the hospital board or ethics committee may ask for further monitoring. In extreme cases, you could face disciplinary action.
Why Are Medical Peer Reviews So Important?
Medical peer reviews are important for both physicians and hospitals, but for very different reasons. Whether you find yourself a physician under review or as a reviewer, it’s essential to know what the process is and what implications it could have for yourself, the hospital, or the medical group.
Peer Reviews Are Important for Hospitals
Hospitals and health systems follow the standards and abide by the regulations as set forth by The Joint Commission. The Joint Commission is a global healthcare board whose end goal is to provide safe, quality healthcare to all patients.
Hospitals must adhere to a variety of rules to maintain accreditation with the Joint Commission. Performing medical peer reviews is one of the requirements.
Medical peer reviews are a way for hospitals to ensure that they are meeting regulatory standards. They also promote professionalism and promote better behavior in the workplace.
Hospitals also use peer reviews as a way to reduce the potential for malpractice suits. Studies show that in the ten years spanning 2009 to 2019, the United States paid $38.5 billion to malpractice victims. New York State alone paid over $7 billion in that ten year period.
Conducting peer reviews is a cost-effective way for hospitals and large medical groups to help improve conduct, improve patient care, and reduce the possibility of malpractice.
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Peer Reviews Are Important for Physicians
Peer reviews are important to physicians as well. State medical boards often use them for licensing. They provide valuable information in the credentialing and privileging process. They can also be evidence for (or against) you in case of future complaints.
Having negative peer reviews on your record can create trouble for you later in your career. But having a series of positive ones is a great way to prove that you’re meeting or exceeding the standards required of you.
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What Reviewers Need to Know About Peer Reviews
It is not nearly as unnerving to conduct a peer review as it is to be the subject of one. There are some critical things that interviewers should know before they begin the process of reviewing one of their own.
Know the Bylaws
The first thing is to know your hospital and medical staff bylaws. If adverse events, poor physician performance, or disruptive behaviors have triggered the review, be very careful about how you handle your review from start to finish.
Take Good Notes
Reviewers should take detailed notes whenever they’re asked to review actions or review activities. Record any and all concerns, criticisms, and complaints about the physician under review. Be sure to keep track of every document or scenario that you analyze.
If a physician requests a hearing for appeal after a negative review, it will be important to know exactly which member of the committee looked at what portions of the evidence and when.
Your duty as a reviewer is to figure out the truth. The only way to do so is to keep an open mind until you’ve reviewed all the evidence. And allowed the physician to provide feedback and explanations on why certain conduct may look less than ideal.
Physicians deserve the right to a fair hearing, and you should be willing to hear their side of the argument before making any final decisions. Medical peer reviews can have lasting and disastrous consequences on a physician’s career. Those physicians have the right to defend themselves.
Keep It Quiet
While you’re conducting the review, be especially careful not to discuss it with anyone other than the committee members. And when you do have those conversations with your review team, make sure they are not where other people could overhear what you’re saying.
According to the Health Care Quality Improvement Act of 1986 (HCQIA), reviewers have immunity against peer review claims. Talking about a case outside the formal peer review process means you’re putting that immunity at risk.
Confidentiality and professionalism are key throughout every aspect of the physician peer review process.
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What Reviewees Need to Know About Peer Reviews
As a physician under review, the findings and scoring of that review could have lasting effects on your career. So if you’re under scrutiny for anything other than standard credentialing or privileging, prepare yourself for a fight.
Be Aware of a Sham Peer Review
You may have heard fellow physicians complain about the “sham peer review.” This review targets a physician unfairly, without merit by other physicians or board members. Often prompted by personal or non-medical reasons.
It is nearly impossible for a review committee to prove alleged misconduct if there was none, but that doesn’t mean they may not try.
If, for any reason, you believe you are the target of a sham peer review, hire an attorney.
Know Your Rights
You have a right to due process.
Every physician should know their rights when it comes to the review process as well as the hearing and appeals process. All physicians have the right to request an appeal for a hearing, but the time frame for doing so varies from employer to employer.
As soon as you become aware that you are under review, make sure you know your deadline for filing an appeal. You could give up your right to appeal your case if you fail to do so within the time frame specified by your hospital.
If and when you have a hearing, you also have the right to have an attorney present.
Keep a Level Head
No one likes to have their work scrutinized or their conduct judged, but when you’re under review, you need to stay as objective as possible. The review committee is merely doing its job. There is no need to lash out or get angry. Keep a cool head and maintain a level of professionalism at all times.
Do Your Own Review
It is your right (and your responsibility) to conduct your own review while your peers are reviewing your work. Spend as much time as necessary studying the medical records under scrutiny. If you discover something that might raise suspicion or come under question, be ready to back up your actions with data from medical journals.
Remember, you will have a chance to provide feedback, appeal your case, and make your argument for why you did whatever it is they think you did. Compiling journal articles and data from other physicians may make it easier to explain your choices if you need to do so.
Your own evidence can go a long way in the decision-making and final outcome of your review.
If your medical review board does recommend disciplinary action, speak with an attorney to protect yourself.
Medical peer reviews are essential in keeping hospital staff and physicians stringent about patient care and professional conduct.
Demonstrate any sort of misconduct, and you can be certain you’ll find yourself the subject of a peer review. Spot or suspect the misconduct of another physician and say nothing, and you could also find yourself in jeopardy of ethics violations.
State and federal laws regulate medical care. Medical peer reviews are just one of the many methods hospitals and healthcare organizations use to maintain high standards, reduce malpractice claims, and improve upon the quality of patient care they provide.
Like all the other crucial aspects of your employment terms, include the peer review system’s details in your physician employment contract. If you’re getting ready to sign a new physician contract, contact Physicians Thrive now for a full and complete contract review.
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