PEC Orientation

1. St. Luke’s Regional Medical Center PEC Orientation

2. Why do we do peer review? The Bottom Line Physicians are mutually accountable to each other for the quality of care they provide

3. Dimensions of physician performance • Technical Quality of Care • Service Quality • Patient Safety/Patient Rights • Resource Utilization • Relationships • Citizenship

4. Greeley = 2008 JCAHO Six Competencies Starting in January 2008, every medical staff in the United States will have to collect physician specific data regarding the six core competencies as defined by the Joint Commission. These are the same six competencies that we are already using to rate every physician. • Patient care • Medical/clinical knowledge • Practice based learning and improvement • Interpersonal and communication skills • Professionalism • Systems-based practices

5. The FACE of effective peer review • Fairness (minimize bias) • Personal bias • Group bias • Accuracy (the right data for the right physician) • Consistency (good inter-rater reliability) • Efficiency (don’t waste physician and staff time)

6. Four steps to make peer review effective • Simplify the committee structure • Select the right indicators and targets • Standardize the case review process • Provide useful and timely feedback

7. Three types of physician performance indicators • Review: Identifies individual cases potentially requiring physician review due to case complexity or significance • Rule: Identifies individual instances of non-compliance with administrative or clinical processes complied with by most physicians • Rate: Identifies potential performance differences among physicians using aggregated outcomes or processes of care

8. Examples of Clinical Indicators • Review • Unexpected Mortalities • Readmission within 14 days • Rule • Completion of medical records • Do not use abbreviations • Rate • 3rd/4th degree lacerations with delivery • Frequency of expected complications

9. Opportunities for routine feedback • Case Review • Exemplary Care • Appropriate Care • Controversial or Inappropriate Care • Rule Indicator Occurrences • Aggregate Data • Reappointment profile vs performance feedback report

10. What has changed? • Single medical staff multi-specialty quality committee • Rotating Case Assignment • Oversight of measurement • Continuity of membership • Use of review, rule and rate indicators • Case review screening support by RN • Database designed for individual performance measurement • Prospective Targets • More productive committee discussion • Defined reviewer input • Defined performance expectations • Culture of positive feedback • Case Review • Excellence Targets

11. Pre-review Process The goal of the pre-review process is to focus the physician reviewer on the key issues of the case. The pre-review process should assure the following: • Qualifies as a review case and is not a rate or rule indicator event. • Identify the issues that need review based on primarily whether the right things were done or not done, not just on the patient outcome. • Issues are potentially physician related and aren’t solely a system or process issue.

12. Physician Reviewer General Approach The primary question the physician reviewer is trying to answer is whether a physician’s actions and decisions were appropriate independent of the outcome of care.

13. Four Steps to Excellent Case Review • Step 1: Issue Identification • Step 2: Physician Rationale • Step 3: Preliminary Rating • Step 4: Committee Presentation

14. Step 1: Issue Identification • Review the issues identified in pre-review • Briefly review the entire course of care: • Confirm the issues identified in pre-preview are the right issues and add any other issues. • Make sure the issues are potentially physician related and aren’t solely a system or process issue. • Define any potential system or process issues that need to be addressed by the hospital • Determine the patient outcome and effect on patient care

15. Guide to physician care issue identification • Was an important diagnosis not considered? • Was an important procedure, medical treatment, or test not indicated or not appropriate at the time performed? • Was an important procedure, medical treatment, consultation or diagnostic test not performed that should have been? • Was there a delay in diagnosis, evaluation, consultation, intervention, or decision-making that affected the patient’s clinical condition? • Was there a lack of follow through of the treatment plan or monitoring of the patient’s condition? • Was there a communication that was not timely, unclear or inadequate for an important clinical need? • Was the response to a change in patient condition or complication not timely or inappropriate?

16. Guide to physician care issue identificationcontinued • If no issues are identified through these questions, it is unlikely that there are physician care issues with the case. • If issues are identified, the next step is to look at the physician’s rationale for the actions or lack of action.

17. Step 2: Physician Rationale • Track the issues throughout the case by reviewing the specific record documentation to the extent necessary to understand the physician’s rationale. • If multiple physicians are involved in the case, determine which physicians’ care raises a concern. • If there are any technical issues beyond your expertise, determine what additional reviewer expertise is needed.

18. Guide to understanding the physician’s rationale • Was the documentation sufficient to understand the rationale for the actions or decisions? • Did the rationale make good clinical sense at the time? • Was it consistent with evidence-based medicine or good practice? • Was it consistent with medical staff expectations? If there is no clear expectation, does the medical staff need to create one? • Are there technical issues beyond your expertise?

19. Step 3: Preliminary Rating • Appropriateness of physician care • Exemplary • Appropriate • Controversial • Inappropriate • Uncertain • Potential physician cause (e.g. judgment, skill, knowledge, follow-up, etc) • Basis for preliminary rating • Pre-review issues • Physician reviewer issues

20. Peer Review Committee • Multidisciplinary membership • Monthly meetings • Review sheets and reports • Combine with technology • Acknowledge excellence • Use in credentialing process • “Why are you different?”

21. Step 4: Committee Presentation • If care is rated less than appropriate or uncertain, determine what questions should be asked of the physician in a collegial manner • Present the review to the Committee for discussion

22. St. Luke’s Boise/Meridian Goals • Single committee, providing consistent and objective peer review • Used for meaningful reappointment process • Engage the Medical Staff around quality within the organization • Physician Satisfaction • Utilize physician expertise to evaluate system/process issues

23. Questions?