External Peer Review (EPR) typically is thought of as the review of a medical record for individual cases in which concerns have been raised regarding the quality or appropriateness of care. This review can be based on concerns regarding adverse outcomes, the appropriateness of procedures or treatments, or the use of resources.
The implementation of EPR for case reviews should be driven by a clear medical staff policy that has been reviewed by legal counsel. A good EPR policy should address the following six questions:
- What circumstances typically require EPR?
- The hospital peer review policy must make it transparent when EPR will be used. Typically, EPR is recommended under the following circumstances:
- Lack of internal expertise
- Legal concerns
- Lack of internal resources
- Who determines when EPR is needed?
- Typically, recommendations for EPR arise from peer review committees that are faced with issues they can’t resolve for the reasons cited above, from medical staff and hospital leaders dealing with potential legal or credibility issues, and from medical staffs and quality directors wishing to validate their internal peer review findings. The board also should have the right to decide whether it needs EPR to answer concerns or protect itself legally, even if the medical staff believes it can, or has, conducted a fair review. Because EPR often will require the use of extra financial resources, the hospital or medical staff leadership should approve the need for EPR.
- Who will select the reviewer?
- Typically, the body with authority to determine whether a review is necessary also selects the reviewer. This is important because there needs to be up-front buy-in regarding the credibility of the reviewer. Although the MEC or quality committee may delegate the preliminary selection of the reviewer to an administrator, the choice should be brought back to that group, or at least to the chair, for final approval.
- How will the cases be selected?
- If EPR is needed to make determinations for specific cases, case selection is not an issue. However, if the need is to obtain an in-depth understanding of a physician’s practice, then case selection is critical to interpreting and using the findings. A good peer review policy does not need to have a detailed description of case selection methods. Rather, it should acknowledge the types of approaches that may be used (e.g., single cases, 100% review, random sampling) and who will determine the selection method appropriate for the question at hand. The latter should be done utilizing the same procedure used for reviewer selection. A good EPR organization should be able to provide assistance with case selection.
- Who will review the EPR report findings?
- Prior to contemplating a corrective action, an EPR report should not be treated any differently than an internal review. The results should be reported to the group that made the initial recommendation—the same group that would be considering the results of an internal review. This is typically the medical staff peer review committee or department chair. A good EPR policy also designates a time frame for reviewing the report. This makes the process fairer for the individual under review. Typically, reports should be reviewed within 30 days of receipt or at the next regularly scheduled committee meeting.Unlike an internal review, in which the committee can query the physician about concerns before coming to a conclusion, an external reviewer must base findings on medical documentation and image studies provided by the organization. If the report identifies any concerns or improvement opportunities, the physician under review should be given an opportunity to review the report and respond in a defined time frame. However, as this is prior to any corrective action process, the physician should not be allowed to have personal legal counsel involved at this stage.If a corrective action process is being contemplated, the report may go directly to the MEC or its designee. The physician under review and members of any hearing panel (if there is the potential for an adverse action) must have the opportunity to review the results of the evaluation with the individual who conducted the review. They also should be allowed to question the methodology, the outside consultant’s qualifications, and the findings in the consultant’s report.
- How will the results be used?
- A good EPR policy should provide guidance on how the results will be interpreted prior to obtaining an external review and define the next steps if the review should be adverse. Although a committee should not be constrained regarding its recommendation for improvement or corrective action, it often is helpful to decide whether the findings of the reviewer will be considered definitive. This can be done on a case-by-case basis, based on the nature of the review, the expertise of the reviewer, and the issues under review.When considering a recommendation for improvement or action, the medical staff leadership and the MEC should consider the results of the external review, along with what they already know about the physician being reviewed. This includes the willingness of the physician to address improvement opportunities. An EPR should not be the only criterion used to take action against a medical staff member.
The above was excerpted from The Greeley Company’s eight-page white paper, External Peer Review: When and How. Click here to download the full white paper for more detail and discussion of how to establish an effective external peer review policy and process.