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PEER REVIEW PROTOCOL

PEER REVIEW PROTOCOL. Department of Internal Medicine Makati Medical Center V4.2.2008.

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PEER REVIEW PROTOCOL

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  1. PEER REVIEW PROTOCOL Department of Internal MedicineMakati Medical Center V4.2.2008

  2. “The Impaired Physician” in Art. 16, Ethical Guidelines,2. Ethical Issues of the Physicians’ Relationship[ with other Physicians,Part G MMC Medical Staff By-Laws & Rules & Regulations, March 2004 - describes the need for the institution to create this committee. • … • “4. Equally, it is unethical for a physician not to report fraud, professional misconduct, incompetence, or abandonment of patient by another physician. It is here that professional peer review becomes critical in assuring fair assessment of physician performance ….”

  3. GOAL of the Department’s PEER REVIEW • To be an essential component of medical care • To provide the department a procedure to examine health care, including adverse events and injuries, as part of an effort to determine why things happenand to improve care in the future

  4. GOAL of the Department’s PEER REVIEW • To provideassistance to member physicians and protection to patientsshould a member demonstrate actions/deficiencies perceived as detrimentalto himself/herself, or to patients or organizational processes of high quality and efficient care.

  5. GOAL of the Department’s PEER REVIEW • For the Peer Review to become accepted by the members of our department and be an impartial means of identifying and dealing with errors, with emphasis on remediation.

  6. Department’s Policy Manual Provision • Purpose of Department’s Peer Review • To provide guidelines for effective medical PEER Review and to establish a committee for this purpose as required by the department’s policy manual and in compliance to the institution’s By-Laws.

  7. PEER REVIEW PROCESS - GENERAL STANDARDS • Triggers that initiate peer review should be valid, transparent, and available to all member physicians and uniformly applied to all cases and physicians; • Indefensible and vague accusations, personal bias, and rumor are to be given no credence and shall carefully be excluded from consideration.

  8. PEER REVIEW PROCESS - GENERAL STANDARDS • It ensures patient confidentiality. • It is independent and objective and shall consider using outside experts in the field when appropriate. • The review process shall be well-documented and shall yield recommendations

  9. PEER REVIEW PROCESS - GENERAL STANDARDS • Evidence of physician performance concerns, as revealed through the quality improvement process, shall be part of the appointment/re-appointment criteria for medical staff. • It shall use consistent, fair, and equitable guidelines, and will employ well-defined criteria and encompass all options.

  10. from Staff Qualification and Education.doc of our JCI …re: Medical Staff (applied to Doctors’-in-training also) … “SQE.11  Medical staff members participatein the organization’s quality improvement and patient safety activities and, at least annually, there is a review of the quality, safety and clinical care provided by each medical staff member.”

  11. PEER REVIEW PROCESS - GENERAL STANDARDS • It shall be done in a timely manner. • Following the provision of the institution on its Staff Qualification and Education, to wit: “SQE.11  Medical staff members participatein the organization’s quality improvement and patient safety activities and, at least annually, there is a review of the quality, safety and clinical care provided by each medical staff member.”, the department will annually report its peer review process to the institution’s Peer Review Committee using standard evaluation Form to ensure continued compliance with this policy.

  12. PEER REVIEW PROCESS - GENERAL STANDARDS • The medical staff member undergoing peer review will : • participate willingly in the peer review process. • be provided all information used in peer review and have access to each committee or other body that deliberates on the analysis and recommendations of the peer review • to respond to questions and presenttheir perspective

  13. The Department Peer Review • An ad hoc committee** shall be convened and is to be comprised of Medical Staff Members WITH KNOWLEDGE , TRAINING, EXPERIENCE, AND SKILLS in the clinical topic(s) under review.

  14. A Departmental PEER REVIEW COMMITTEE & Its Functions • Proposes to department ExeCom general standards for peer review; • Recommends, when appropriate, the initiation of a peer review; • Assists in creating peer review at the request of , for example, a section head • Receives summaries and recommendations from section heads of all peer reviews that result in high* level conclusion • Regularly reports the results of these gathered peer reviewto the department’s ExeComwith recommendations for subsequent actions.

  15. The Medical Staff PEERS • Are defined as those licensed independent* practitioners with similar training and experience who manage similar clinical problems as the Medical Staff Member under peer review. • Membership on peer review committee is open to all physicians of the department staff, both Active and Associate Active;

  16. The PEER REVIEW PROCESS

  17. The Peer Review Process - • This department’s Peer Review Protocol is created with procedures and goals of the protocol developed , approved by all section chiefs, subsequently by the department head and presented in a WRITTEN form to the institution’s Peer Review Committee. • It is to be performed within the department under the direction of the current Department’s Vice-Chairman.

  18. Peer Review is done at different levels: • Level 1 - Routine Peer Review • Level 2 - Focused /Intensified Peer Review • Level 3 - Institution’s Peer Review • MUSC Policy Manual Jan 2007

  19. The ROUTINE Peer Review • The timing and nature of routine patient care reviewsintended for quality assurance is described in the peer review of the department • MMC existing guide says “SQE.11  …, at least annually, … review of the quality, safety and clinical care provided by each … member.” • Minutes of the quality review efforts with findings and recommendations are reflected in the minutes. • The namesof Medical Staff are not identified from the minutes. Instead, hospital ID Number shall be utilized in all the reports.

  20. Reporting the Conclusionby the Department Peer Review • CONCLUSION “0” - Unable to reach a conclusion due to inadequate information • CONCLUSION “1” - No concerns • CONCLUSION “2” - Minor concerns • CONCLUSION “3” - Major concerns • CONCLUSION “4” - Serious concerns The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlined in the departmental protocol.

  21. Reporting the Conclusionby the Department Peer Review • CONCLUSION “0” - IF committee is Unable to reach a conclusion due to inadequate information / Poor Documentation. • However, Clinical management is appropriate; no quality issues identified. The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlined in the departmental protocol.

  22. Reporting the Conclusionby the Department Peer Review • Conclusion “1” - No concerns / Fallout Acceptable. • If the case falls into monitoring process, but clinical practice is expected and accepted. The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlined in the departmental protocol.

  23. Reporting the Conclusionby the Department Peer Review • Conclusion “2” - Minor concerns - Questioned Practice. • IF the practice is not consistent with accepted standard of care, but no potential for significant harm exists. The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlined in the departmental protocol.

  24. Reporting the Conclusionby the Department Peer Review • Conclusion “3” - Major concerns - Questioned Practice Unexpected. • IF practice under review is not consistent with accepted standard of care and/or potential exists for significant harm +/- may be error of omission. The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlined in the departmental protocol.

  25. Reporting the Conclusionby the Department Peer Review • Conclusion “4” - Serious concerns - Questioned Practice Very Unexpected. • IF practice under review is not consistent with accepted standard of care and/or significant harm occurred +/-error of omission. The reviewed member will be notified of a planned peer review to allow the clinician to participate as outlines in the departmental protocol.

  26. The FOCUSED/INTENSIFIED Peer Review - will be initiated if any one of the following Event Indicators is/are present: • Unexpected cardiac or respiratory arrest; • Neurologic deficit not present on admission • Other events designated by the department • A recommendation by the VP of MSA , or other higher officer of the institution, for a focused review requires the department Chair to initiate the review process

  27. The FOCUSED/INTENSIFIED Peer Review - will be initiated if any one of the following Event Indicators is/are present: • Actions or deficiencies demonstrated by an MD that appear detrimental to him/herself, hospital employees, patients or organizational processes of high quality and efficient care. • Sentinel Event • Pre-sentinel event or near miss; • Major Adverse Drug reaction; • Significant variation from established patterns of care, also called “trend”

  28. The FOCUSED/INTENSIFIED Peer Review - A “Trend” is defined as when a member receives: • Two (2) Conclusion “4” evaluations within a 2-year period; • Any combination of three (3) Conclusion “3” or “4” evaluations within a 2-year period; • Any combination of four (4) Conclusion “2”,”3” or “4” evaluations within a 2-year period;

  29. Elevating Issues to the Institution’s Peer Review Committee • The department peer review head will elevate the issue to the hospital Peer Review Committee IF any of the following is noted within an individual member when routine and focused peer review have not remedied the practice concerns : • Persistent problems • Deficiency trends • Worrisome patterns of practice

  30. Elevating Issues to the Institution’s Peer Review Committee • Reasons for an institution Peer Review shall also include matters that involve: • Litigation • Lack departmental expertise • Conflict of interest • Strong disagreements within the department as to how to proceed

  31. Handling Reports and Action Plans • Step1 : Reports/Conclusions of departmental peer review is sent to the Dep’t Chair • Step 2: Chair then creates a WRITTEN ACTION PLAN • Step 3: Peer Review team report and Dept Chair action plans are filed in the Physicians’ Quality Record WITHIN the dept, and …

  32. Handling Reports and Action Plans • Step 4: A Summary Report is filed with the Institution’s Peer Review Committee, within a prescribed period, i.e., within 45 days of the initiation or request for a peer review.

  33. Handling Reports and Action Plans • Step 5: The Dept’s peer review head may be asked by the institution’s Peer Review Committee body to present a detailed presentationof the case to the institution’s full Peer Review Committee - • For their review , and • To assess the adequacy of response.

  34. Handling Reports and Action Plans • Step 6: The Reviewed Member will be asked to respond in writing within a prescribed period, e.g., within 30 daysIF the peer review results in a class “3” or “4” conclusion. • STEP 7: Class “3” or “4” conclusions - need to be reported to the institution’s PRC+Written response of reviewed clinicianand Dept Chair. • Step 8:These reports will be placed in the reviewed member’s quality folder secured in the Medical Staff office.

  35. QUALITY RECORD AND CREDENTIALS COMMITTEE ACTION • THE DEPARTMENT shall maintain a Quality Record for each Medical Staff member. These records will contain any/all of the following: • ALL written products of peer review; • Patient satisfaction survey results; • Patient letters; • Performance reviews; • Other materials that profile the physician’s clinical performance. • MEDICAL STAFF OFFICE shall maintain a SEPARATE QUALITY RECORD for each member.

  36. QUALITY RECORD AND CREDENTIALS COMMITTEE ACTION • The Credentials Committee can have the report available upon request, in its efforts to evaluate an application for reappointment of the Medical Staff. • ACCESS RESTRICTION: ONLY the reviewed member, Dep’t Chair, Institution’s Peer Review Committee, the department and institution’s ExeCom, Credentials Committee and the Medical Director - can access and review a member’s Quality folder secured in the Medical Staff Office. • Other entity including the Office secretariat should not have access to the file.

  37. This protocol was created by the IM department’s Committee on JCI accreditation after its March 8th, 2008 scheduled meeting in an effort to address such requirements. It was principally taken from the Peer Review of Medical University of South Carolina, St Mary’s Hospital, Massachussetts Medical Society’s Model Principles for Incident-related Peer Review , as well as comments from Gail Weiss of Medical Economics2/18/2005 and with subsequent inputs from the committee held during its March 22nd 2008 scheduled meeting, and reviewed by the department’s executive committee in its April 2nd 2008 scheduled meeting.

  38. MANUEL CANLAS, MDAllergology/Immunology SectionMobile: +63-917-279-8239CLAVEL MACALINTAL MDCardiology SectionMobile: +63-917-328-0273GIA WASSMER, MDEndocrinology SectionMobile: +63-919-555-3557BENJIE BENITEZ, MDGastroenterology SectionMobile: +63-917-812-4767PAUL TAN, MDGeneral MedicineMobile: +63-918-911-9066 JESUS RELOS, MDHematology SectionMobile: +63-920-945-3787VILMA CO, MDInfectious Diseases SectionMobile: +63-920-961-1877MILAN TAMBUNTING, MDNephrology SectionMobile: +63-917-882-2788JOEY PARRA, MDOncology SectionMobile: +63-917-823-4321ELIZABETH SANTOS, MDPulmonology SectionMobile: +63-917-792-8542AUGUSTO VILLARUBIN, MDRheumatology SectionMobile+63-917-830-8925 IM COMMITTEE on JCI and its SECTION REPRESENTATIVES, 2007-2008 NAZARIO A. MACALINTAL JR.,MDHead Mobile:+63-917-894-5979 Email: drjunmac3000@yahoo.com

  39. Internal Legal Issue that needs to be put in place. • Data acquisition and Review Activities need to be protected from “discovery, subpoena, or introduction into evidence in any civil /criminal action”.

  40. External Legal Issue A law similar to the Health Care Quality Improvement Actshould give peer reviewers near-complete immunity from claims for damages arising from peer review actions: • provided - there are requisites like: • Peer review was done in the belief that such action furthered quality healthcare • Addressed in the protocol • Those bringing the action made a good-faith effort to obtain the facts; • Addressed in the protocol • The physician reviewed was given adequate notice and afforded due process • Addressed in the protocol • The hospital had a reasonable belief that peer review action was warranted. • Addressed in the protocol

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