Download Peer Review in ASCs (DC Slides)

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
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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.
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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.
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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)
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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
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Example of LIKERT Scale for Physician Assessment
Adapted from ASCA: Ambulatory Surgery Center Association
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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
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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
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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
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Peer Review-Related Medicare Regulations
• Governing Body
• Medical Staff
• Surgical Services
• Quality Assessment/Performance
Improvement (QAPI)
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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.
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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
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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
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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
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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
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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
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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)
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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
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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)
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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
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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)
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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)?
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Bruce B. Ettinger, MD, MPH
[email protected]
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