AF185 32000ft 3/12/08 9:04 AM Hotel San Ranieri Pisa Italy 3/16/08 1:22 AM PEER REVIEW PROTOCOL...
Transcript of AF185 32000ft 3/12/08 9:04 AM Hotel San Ranieri Pisa Italy 3/16/08 1:22 AM PEER REVIEW PROTOCOL...
AF185 32000ft 3/12/08 9:04 AM Hotel San Ranieri Pisa Italy 3/16/08 1:22 AM
PEER REVIEW PROTOCOL
Department of Internal MedicineMakati Medical Center
V4.2.2008
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“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 ….”
“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.
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
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 happen and to improve care in the future
GOAL of the Department’s PEER REVIEW
To provide assistance to member physicians and protection to patients should a member demonstrate actions/deficiencies perceived as detrimental to himself/herself, or to patients or organizational processes of high quality and efficient care.
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.
Department’s Policy Manual Provision
Purpose of Department’s Peer ReviewTo 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.
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.
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
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.
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“SQE.11 Medical staff members participate in 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.”
from Staff Qualification and Education.doc of our JCI …re: Medical Staff (applied to Doctors’-in-training also)
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
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 participate in 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.
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 present their
perspective
INSTITUTION PEER REVIEW ORGANIZATIONAL CHART
Member ! Member 2 Member 3 Member 4
IM Dept PEER REVIEW CommAn AD Hoc Committee
Headed by theDept Vice-Chairman
Other DepartmentRepresentative
PEER REVIEW COMMITTEEA Subcommittee of Execom
MSA VP - Chairman
Other Subcommitteess
EXECUTIVE COMMITTEE
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.
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 review to the department’s ExeCom with recommendations for subsequent actions.
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;
The PEER REVIEW PROCESS
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.
Peer Review is done at different levels:
Level 1 - Routine Peer Review Level 2 - Focused /Intensified Peer ReviewLevel 3 - Institution’s Peer Review
MUSC Policy Manual Jan 2007
The ROUTINE Peer Review The timing and nature of routine patient care reviews intended
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 names of Medical Staff are not identified from the minutes.
Instead, hospital ID Number shall be utilized in all the reports.
Reporting the Conclusionby the Department Peer Review
CONCLUSION “0” - Unable to reach a conclusion due to inadequate information
CONCLUSION “1” - No concernsCONCLUSION “2” - Minor concernsCONCLUSION “3” - Major concernsCONCLUSION “4” - Serious concernsThe reviewed member will be notified of a planned peer review to allow
the clinician to participate as outlined in the departmental protocol.
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.
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.
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.
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.
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.
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
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”
The FOCUSED/INTENSIFIED Peer Review - will be initiated if any one of the following
Event Indicators is/are present:
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”“4” evaluations within a 2-year period;
The FOCUSED/INTENSIFIED Peer Review -
A “Trend” is defined as when a member receives:
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 problemsDeficiency trendsWorrisome patterns of practice
Reasons for an institution Peer Review shall also include matters that involve:LitigationLack departmental expertiseConflict of interestStrong disagreements within the
department as to how to proceed
Elevating Issues to the Institution’s Peer Review Committee
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 …
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.
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 presentation of the case to the institution’s full Peer Review Committee - For their review , and To assess the adequacy of response.
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 days IF 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 clinician and Dept Chair.
Step 8:These reports will be placed in the reviewed member’s quality folder secured in the Medical Staff office.
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.
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.
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.
IM COMMITTEE on JCI and its SECTION REPRESENTATIVES, 2007-2008
MANUEL CANLAS, MDAllergology/Immunology Section
Mobile: +63-917-279-8239
CLAVEL MACALINTAL MDCardiology Section
Mobile: +63-917-328-0273
GIA WASSMER, MDEndocrinology Section
Mobile: +63-919-555-3557
BENJIE BENITEZ, MDGastroenterology SectionMobile: +63-917-812-4767
PAUL TAN, MDGeneral Medicine
Mobile: +63-918-911-9066
JESUS RELOS, MDHematology SectionMobile: +63-920-945-3787
VILMA CO, MDInfectious Diseases SectionMobile: +63-920-961-1877
MILAN TAMBUNTING, MDNephrology SectionMobile: +63-917-882-2788
JOEY PARRA, MDOncology SectionMobile: +63-917-823-4321
ELIZABETH SANTOS, MDPulmonology SectionMobile: +63-917-792-8542
AUGUSTO VILLARUBIN, MDRheumatology SectionMobile+63-917-830-8925
NAZARIO A. MACALINTAL JR.,MDHead Mobile:+63-917-894-5979 Email: [email protected]
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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”.
External Legal IssueA law similar to the Health Care Quality Improvement Act
should 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