CRYSTAL RUN HEALTHCARE LLP
Policy / Procedure
MANUAL: ADMINISTRATIVE
SECTION: Human Resources ~ Credentialing and Assignment of Clinical Responsibilities of LIP’s
POLICY STATEMENT: Peer Review Policy and ProcedureIMPLEMENTATION: 07/01/06 / CONCURRENCES:
Administration
Human Resources
Provider Resources
REVIEWS: 10/28/11
REVISIONS: 07/02/07
INITIATOR:
Michelle A. Koury, MD, COO
APPROVAL: Chief Operating Officer/Chief Medical Officer
PURPOSE:
To ensure that the quality of the medical staff is reviewed in an organized, systematic fashion and that prompt response to deviation from accepted standards is identified and acted upon accordingly.
DEFINITIONS:
Practitioner: Medical Doctor (MD or DO), Nurse Practitioner (NP), or Physician’s Assistant (PA) with staff appointment privileges and licensed in the State of New York
Peer: Any of the above not related by marriage and whenever possible of like specialty
Peer Review: Process by which a practitioner’s clinical activity is evaluated by his/her peers on a routine or scheduled basis or in cases where the expected outcome was not achieved necessitating an analysis to determine cause, effect, severity, and opportunity for improvement for the furtherance of health care quality
Focused Review: Monitoring of a specific process performed by members of the medical staff or the monitoring of a particular member of the medical staff in relation to a specific issue. Determination of need for focused review may come as the result of regular peer review or external investigation; focused review will occur whenever the practitioner has the credentials but competence needs to be confirmed, or whenever there are questions regarding a practitioner’s performance
PROCEDURE:
Circumstances of Peer Review:
1. Peer review will occur under the following circumstances, including but not limited to:
a. Wrong patient, wrong site surgical procedure
b. Incorrect procedure or treatment: invasive
c. Unintentional retained foreign body due to break in surgical technique or inaccurate surgical count
2. Peer review will occur when any unexpected adverse occurrence not directly related to the natural course of the patient’s illness or underlying condition results is:
a. Brain Death
b. Cardiac or respiratory arrest requiring ACLS/BLS intervention
c. Loss of limb or organ
d. Impairment of limb (limb unable to function at same level prior to occurrence) excluding
positioning paresthesias and newborn occurrence
e. Loss or impairment of bodily functions (sensory, motor, communication, or physiologic function diminished from prior level)
3. Peer Review will occur when:
a. Errors of OMISSION/DELAY result in death or serious injury RELATED to the underlying condition
b. Crime resulting in death or serious injury, as defined in 2 (a-e).
c. Suicides and attempted suicides with serious injury, as defined in 2 (a-e.)
d. Elopement from the facility which results in death or serious injury as defined in 2 (a-e.)
e. Malfunction of equipment during treatment or diagnosis or a defective product which resulted in death or serious injury as described in 2 (a-e.)
f. Infant/child abduction or discharge to wrong family.
g. Sexual assault by another patient or staff.
h. Routine review for established indicators which are department or service specific
4. Proceedings described below and records relating to the Peer Review Process shall be subject to discovery as per the NY Public Health Law Section 2805-m.
5. Additionally, participants in the Peer Review Process are afforded all the protections available under the state and federal law, including but not limited to: New York Public Health Law Section 2805, Education Law Section 6527, and the Federal Health Quality Improvement Act.
REFERRAL AND REVIEW PROCESS:
1. A request for peer review may come from:
a. Medical Staff
b. Clinical and non-clinical administrative staff
c. Facility personnel
d. Patients
e. Patient Representatives or Family members
f. Fallouts from routine reviews or as recommended by PI committees
2. The request will be forwarded to the Chief Medical Officer.
3. The Chief Medical Officer will then assign a physician approved by the Management Committee to perform the review.
4. The reviewing physician will review the case in detail and complete a Peer Review case Scoring Sheet.
5. He/She will be notified by the Chief Medical Officer if there are unresolved issues, and participation if desired by the practitioner will be arranged.
6. An external review may need to occur if:
a. There is no “like specialist” in the group to perform the review
b. The practitioner reviewed is a partner
c. The Review committee cannot arrive at consensus regarding standard of care and/or recommended course of action
7. The period of time from the request for peer review to assignment to the Management Committee for action is not to exceed 21 days.
ROLE OF MANAGEMENT COMMITTEE IN THE PEER REVIEW PROCESS:
1. The Management Committee will designate members to perform peer review upon demand. Consideration will be given to specialty and nature of the case being reviewed.
2. The Management Committee will discuss all peer review activity at each meeting, minimally quarterly, but likely monthly.
3. The Management Committee will review and approve the quality rating for each practitioner under review as determined by the reviewer.
4. The Management Committee reserves the right to call the involved practitioner to a Management Committee meeting to discuss unresolved issues. This is not to be considered a fair hearing.
5. The involved practitioner has the right to participate in the review process separate and distinct from a fair hearing. His/her participation will be directed by the Chief Medical Officer.
6. The Management Committee, based on its review and interviews will then take one or more of the following actions:
a. Peer Review Process resulted in desired outcome: no further action necessary.
b. Retrospective medical record review for a defined period or predetermined number of cases.
c. Formal education of the involved practitioner(s) in the form of a journal article, completing a CME review with a post-test, attendance at a CME offering, and/or formal course work.
d. Complete literature review and presentation to the Medical Staff.
e. Concurrent medical record review for a defined period or predetermined number of cases.
f. Mentoring of a predetermined number of cases.
g. A letter of reprimand to the practitioner’s file.
h. Privileging action, to be determined by the Executive Committee.
i. Any and all other actions deemed appropriate, up to and including termination of employment for cause.
7. The period of time from receipt of the issue by the Management Committee to recommended action is 21 days. If the review is done externally, this time frame can be extended to 35 days.
ROLE OF EXECUTIVE COMMITTEE IN THE PEER REVIEW PROCESS:
1. The Executive Committee will review all recommendations by the Management Committee and must concur with any privileging action or action which will result in termination.
2. If Peer Review involves a member of the Management Committee, the Managing Partner/Designee will assign the Executive Committee to function as the Management Committee in the above process.
3. If a member of the Executive Committee is the subject of peer review, then the Managing Partner/Designee will assign an ad hoc committee to function as the Management Committee in the above process.
4. If and when a conflict is identified by any member of the Management or Executive Committees, the Chief Medical Officer, Chief Operating Officer or the managing Partner, the Peer Review Process will be performed by an External Peer Review Consultant.
5. Additionally, inability to arrive at consensus regarding peer review, or upon the recommendation of counsel, cases may be referred to an External Peer Review Consultant for resolution.
IN ANY EVENT, THE CONTENTS OF THE EMPLOYMENT AGREEEMENT SUPERCEDE THE ABOVE, THE TERMS OF WHICH SPEAK FOR THEMSELVES.
REFERENCES
CROSS REFERENCES:
Fair Hearing and Appeals Policy
ATTACHMENTS:
Attachment A: Peer Review Case Scoring