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How to Implement an Effective (and Meaningful) Peer Review Program Bruce B. Ettinger, MD, MPH Certified Federal Medicare Surveyor (ret) Consultant for Regulatory and Accreditation Compliance Santa Monica and Los Angeles, CA Steven V. Schnier, JD Counsel, Health Care Practice Group Arent Fox, San Francisco, CA Why Peer Review? “Unconscionably large variation” in physician skills, practices, outcomes, costs of care, etc. (Berwick DM. JAMA 2009;302:2485) Critical component of Medical Staff Affairs • (Peer Review) + (Credentialing) → (Privileges/Appointment) Precedent --• What happens in hospitals is/will filter to ASCs 2 What is (Contemporary) Peer Review “Systematic and credible reviews that yield immediate and long-term improvements in patient care….” (Joint Commission) Competency assessment - first-hand knowledge of skills, judgment; professional behavior GOAL - ensure practitioner’s qualifications and competency to perform the requested privileges. 3 Objectives of Peer Review Primary Objectives • Evaluate/ensure the appropriateness, • adequacy, and effectiveness of care Reduce less-than-desirable outcomes • safety and quality management • risk and liability management QAPI Additional Objectives • (Re)privilege and (re)appoint to medical staff • Continuous, uninterrupted provider care • Medicare &/or Accreditation certification without citations/probation, etc. 4 Policy Development - Critical Points (Bylaws; Rules and Regulations) Process • clearly defined • consistently applied • specific to a given facility Expectations for physician privileges and behavior • what is being evaluated • defined in Bylaws/Rules & Regulations • explained to MDs – not a secret 5 Policy Development - Critical Points Incorporated into QAPI program - CMS • identify, track, resolve less-than-optimal clinical performance (patient safety/quality of care) • follow-up assessments Evidence-based decisions for privileges • quantifiable /reliable - based on data • benchmarking - comparison with other MDs 6 Policy Development - Critical Points What/who is “peer” ? • who performs • what qualifications • same specialty/capabilities • practicing in similar sized/type facility • no conflict of interest Internal facility vs. external review 7 Policy Development What and How is Peer Review Performed? Metrics (what is measured/evaluated) • defined by medical staff • minimum number of cases • general - must be the same to compare across MDs • specific - for each specialty Methods (process - how to measure) • chart review / direct observation / discussion with • • • others monitoring for trends metrics - as defined as-needed, and ongoing evaluations 8 Process – Methods (Policy Implementation) Retrospective - trends • medical record reviews • utilization review • risk management issues (complications, etc.) Prospective - case observation with record review • evaluation for a specific privilege * • continuous evaluation of competence * Frequency • former/current process - static 2 year cycle • new processes - *ongoing, and as-needed evaluations 9 Evaluation for a Specific Privilege Focused Professional Practice Evaluation (FPPE) “Intense assessment” of credentials and competence for a specific privilege (TJC) • match request to training, experience, competency • Question: Is it appropriate to grant the privilege? Objective, evidence-based processes • direct observation (proctoring) • specific procedure or new technology • technical skill - observed strengths / weaknesses • any issues compromising ability to perform 10 Process - FPPE FPPE Indications • new applicant • new/additional privilege • if volume of cases to low to evaluate competency • specific concerns • negative trends/patterns of care/behavior • complications, adverse events, near misses, medical/medication errors, etc. • complaints/issues (Not disciplinary - not reportable to the National Practitioner Data Bank) 11 Specific Events that Trigger Immediate Peer Review (FPPE) Mandated Reporting Requirements • California Adverse Event reporting requirements (CDPH AFL, May 2012) • deaths; transfers >24 hours • accreditation requirements QAPI and Outcomes • unanticipated death • unplanned return to surgery or emergency department • other non-fatal adverse events, near misses • incident reports, other complications • disruptive behavior; serious patient complaint • other risk management 12 Continuous Evaluation of Competence Ongoing Professional Practice Evaluation (OPPE) Ongoing = Periodic • frequency defined by facility (Medical Staff; Gov Body) • 3, 4, 6 months • (every 1 or 2 years is episodic – not ongoing) Limited Retrospective Review • contemporary - since last evaluation • random - percent of MD’s cases • percent (number of cases) defined by facility &/or accrediting agency 13 Ongoing Professional Practice Evaluation Opportunity to correct concerns • supplements FPPE • not punitive Part of Benchmarking and QAPI • all practitioners • all defined in policy Compiled for reappointment 14 Evaluation: “Global Resident Core Competencies” Accreditation Council for Graduate Medical Education adapted to Privileging and Re/Appointment Patient Care • highest standards of practice • procedural skills appropriate to level of training • Metrics – patient outcomes Medical/Clinical Knowledge • use of current clinical knowledge & technology • Metrics - current CME; Board recertification Adapted from Summative Evaluation of Competencies for 12-Month Clinical Phase Residents: Global Resident Competency Rating Form (www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/380_SummativeEvaluation_GPM_AA_04_10_2008.pdf) 15 Evaluation: “Global Resident Core Competencies” Accreditation Council for Graduate Medical Education adapted to Privileging and Re/Appointment Practice-Based Learning & Improvement • integrates patient safety and quality outcome • • concepts into practice implements (self) improvement activities Metrics – use of best practices & evidence-based care Interpersonal & Communication Skills • communicates & works effectively with others • communicates effectively with patients & families • Metrics - patient advocacy (referrals; transfers); patient satisfaction surveys Adapted from Summative Evaluation of Competencies for 12-Month Clinical Phase Residents: Global Resident Competency Rating Form (www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/380_SummativeEvaluation_GPM_AA_04_10_2008.pdf) 16 Evaluation: “Global Resident Core Competencies” Accreditation Council for Graduate Medical Education adapted to Privileging and Re/Appointment Professionalism • integrity - high moral and ethical behavior • practice is within the scope of abilities, training, etc. • Metrics - staff satisfaction surveys/complaints; corporate responsibilities (compliance with policies/bylaws/rules & regs, etc.) Systems-Based Practice • cost-effective care • appropriate & efficient use of resources • promotes patient safety • coordinates care with other providers • Metrics - efficient use of resources; on-time startsturn-over times 17 Example of LIKERT Scale for Physician Assessment Adapted from ASCA: Ambulatory Surgery Center Association 18 Medical Knowledge/Practice-Based Unsatisfactory 1, 2, 3 Learning Patient Care/Systems-Based Satisfactory 4, 5, 6 Practice Superior 7, 8, 9 Medical Knowledge Clinical judgment Ability to perform privileges Competency/technical & clinical skills 1 1 1 1 Appropriate use of consultants 1 Pattern of Resource Use 1 Patient Management 1 Communication Skills/ Professionalism Interpersonal skills 1 Physician-patient relationship 1 Availability 1 Record keeping 1 2 2 2 2 3 3 3 3 4 4 4 4 56 56 56 56 7 7 7 7 8 8 8 8 9 9 9 9 2 3 2 3 2 3 4 56 4 56 4 56 7 8 9 7 8 9 7 8 9 2 2 2 2 4 4 4 4 7 7 7 7 3 3 3 3 56 56 56 56 8 8 8 8 9 9 9 9 19 Peer Review as a “Meaningful Process” Privileging decisions - based on measurable data Quantitative Evaluations & Comparisons • scoreable values (Likert scale) • no longer qualitative (yes/no; good/bad, etc.) benchmarking - gap analysis/closure • Decision Management tool - Evidence-based decisions • privileging and appointment to medical staff (GB) • quality management • cost-effective resource utilization, etc. Risk (Liability) Management tool • decertification (CMS), loss of accreditation • liability - litigation - closure 20 KEY SLIDE “Effective” Peer Review • • • • • achieves goals and objectives (policy) uses Regulations and Accreditation standards as guidelines matched to facility’s scope of services MDs - select metrics and methods Governing Body - approves processes and privileges “Meaningful” Peer Review • data & evidence-based decisions • OPPE/FPPE Effective + Meaningful = Value (“value-added”) • for ASC & patient - quality and safety • for physicians – motivation/incentives to improve 21 Peer Review-Related Medicare Regulations • Governing Body • Medical Staff • Surgical Services • Quality Assessment/Performance Improvement (QAPI) 22 GOVERNING BODY RESPONSIBILITIES CMS: ASC CONDITIONS FOR COVERAGE §416.40 - Compliance With State Licensure Law The ASC must comply with State licensure requirements • IG: Including facility licensure and healthcare professional licensure laws §416.41 - Governing Body and Management The ASC’S Governing Body assumes full legal responsibility for the ASC’s total operations. • IG: Including quality of the ASC’s healthcare services, [and] the safety of the ASC’s environment. 23 Challenges for the Governing Body Not standardized • inconsistent – within/across ASCs • assigned to persons with least understanding • time consuming/labor-intensive – cursory • subjective, “good old boy” standards Not consistent with facility’s documented process … • policies, procedures, bylaws, committee minutes • integration into QAPI programs • Governing Body involvement 24 Challenges for the Governing Body Not timely – failure to allow for delays… • physician non-compliance with reminders and • cautionary notices – not a priority incomplete credentialing/peer review → suspension Not optional • Medicare mandate - follow State laws • licensing • scope of practice • other • Medical Board oversight – for Accredited ASCs 25 Governing Body --Common Errors in Peer Review (and Privileging) Not documenting that request for privileges has been peer-reviewed , and ... Failure to document privileging and appointment. • GB minutes; letter to MD Wholesale adoption of privileging lists from a hospital. • privilege list not specific to the facility • must match scope of provided services Overlooking additional physician “service” privileges. • eg, operating x-ray equipment; reading/ interpreting pain management x-ray films 26 Additional Considerations • Options for in-house Peer Review, ie, external Peer Review • physician • Independent Review Organization for External Peer Review • Options for the physician who is denied, terminated or has limited privileges in an ASC • Sham Review - to exclude MD from Medical Staff for personal/political reasons • Non-physician review • Allied Health Providers • Nursing Staff – competency assessments • Dedicated in-house Credentialing Specialist 27 Suggestions for Peer Review Process • Use CMS regulations and/or accrediting agency’s standards as guidelines and check lists • dual/deemed – follow both • CMS – broad (follow IGs); Accreditation – specific • Use regs as overarching “rule;” Accreditation standards for specific issues • Parameters and Metrics/Criteria • facility’s scope of services • MDs’ specialties • size of MD staff, etc. • Complete update at the time of reappointment • MD’s active review of information • not “Has anything changed?” • Advise MDs of process and what is expected • metrics • recognize & manage conflicts of interest 28 Other Suggested Metrics Performance - case volume – for each type of case • low numbers - potential for error • high numbers - risk of complacency • for broad privileges/types of cases- which/how many • to chose or as required by Accrediting Agencies Professional Judgment • appropriateness of procedures • pre vs. post OP diagnosis, vs. path reports • departures from established patterns of practice • resource use/utilization – medications, supplies, etc. Outcomes - same as Specific Triggers for immediate peer review (FPPE) 29 Other Suggested Metrics (continued) Professionalism • “Corporate“ responsibilities and accountability • compliance with Bylaws, Medical Staff Rules and • • • • Regulations, Policies and Procedures meeting attendance; response to administration requests adequacy of documentation medical record completion (eg: all entries are dated, timed and signed, including verbal orders) risk management concerns • Professional Behavior/Communication Skills • patient/staff complaints • disruptive behavior • Malpractice claims • DOJ, NPDB, California 805 reports 30 The Future for ASC Peer Review Follow hospital processes • Performance and outcome oriented: OPPE/FPPE • evidence-based • use of dedicated, trained staff • Focused on organizational quality improvement • objective - motivate MDs to improve Quality of Care • Precedent: Affordable Care Act – CMS requirements for payment rewards based on performance (“P4P”) (Myers SS, et al. Focusing measures for performance-based privileging of physicians on improvement. Jt Comm J Qual Patient Saf. 2008 Dec;34(12):724-33) 31 Do You Do What You Say You Do? What you SAY you Do • Policies and Procedures • Bylaws/Internal Rules and Regulations • Other Facility Documents What you ACTUALLY Do • Credential and personnel file review • Staff Interviews • Medical Record Review • Governing Body and other committee meeting minutes 32 Caveats – “WORDS” to the Wise! • KNOW AND FOLLOW YOUR CHOSEN CMS OR ACCREDITATION REQUIREMENTS !!! • EVERYTHING MUST BE DEFINED in facility documents !!! • DOCUMENT, DOCUMENT, DOCUMENT !!! • credential and personnel files • meeting minutes (QAPI, medical staff, governing body) 33 The (as yet) Unanswered Questions • Is there a relationship between Peer Review and healthcare outcomes? • What is the relationship between Peer Review and healthcare outcomes (safety and quality)? 34 Bruce B. Ettinger, MD, MPH [email protected] 35