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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 Medicine Makati Medical Center V4.2.2008.

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Presentation on theme: "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 Medicine Makati Medical Center V4.2.2008."— Presentation transcript:

1 AF ft 3/12/08 9:04 AM Hotel San Ranieri Pisa Italy 3/16/08 1:22 AM PEER REVIEW PROTOCOL Department of Internal Medicine Makati Medical Center V

2 … 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 describes the need for the institution to create this committee.

3 GOAL of the Departments 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

4 GOAL of the Departments 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.

5 GOAL of the Departments 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 Departments Policy Manual Provision Purpose of Departments Peer Review To provide guidelines for effective medical PEER Review and to establish a committee for this purpose as required by the departments policy manual and in compliance to the institutions 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 … SQE.11 Medical staff members participate in the organizations 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)

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 participate in the organizations 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 institutions 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 present their perspective

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14 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.

15 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 departments ExeCom with recommendations for subsequent actions.

16 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;

17 The PEER REVIEW PROCESS

18 The Peer Review Process - This departments 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 institutions Peer Review Committee. It is to be performed within the department under the direction of the current Departments Vice-Chairman.

19 Peer Review is done at different levels: Level 1 - Routine Peer Review Level 2 - Focused /Intensified Peer Review Level 3 - Institutions Peer Review MUSC Policy Manual Jan 2007

20 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.

21 Reporting the Conclusion by 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.

22 Reporting the Conclusion by 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.

23 Reporting the Conclusion by 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.

24 Reporting the Conclusion by 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.

25 Reporting the Conclusion by 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.

26 Reporting the Conclusion by 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.

27 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

28 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:

29 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; 4 Any combination of four (4) Conclusion 2,3 or 4 evaluations within a 2-year period; The FOCUSED/INTENSIFIED Peer Review - A Trend is defined as when a member receives:

30 Elevating Issues to the Institutions 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

31 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 Elevating Issues to the Institutions Peer Review Committee

32 Handling Reports and Action Plans Step1 : Reports/Conclusions of departmental peer review is sent to the Dept 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 …

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

34 Handling Reports and Action Plans Step 5: The Depts peer review head may be asked by the institutions Peer Review Committee body to present a detailed presentation of the case to the institutions full Peer Review Committee - For their review, and To assess the adequacy of response.

35 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 institutions PRC + Written response of reviewed clinician and Dept Chair. Step 8:These reports will be placed in the reviewed members quality folder secured in the Medical Staff office.

36 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 physicians clinical performance. MEDICAL STAFF OFFICE shall maintain a SEPARATE QUALITY RECORD for each member.

37 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, Dept Chair, Institutions Peer Review Committee, the department and institutions ExeCom, Credentials Committee and the Medical Director - can access and review a members Quality folder secured in the Medical Staff Office. Other entity including the Office secretariat should not have access to the file.

38 This protocol was created by the IM departments 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 Marys Hospital, Massachussetts Medical Societys Model Principles for Incident- related Peer Review, as well as comments from Gail Weiss of Medical Economics 2/18/2005 and with subsequent inputs from the committee held during its March 22nd 2008 scheduled meeting, and reviewed by the departments executive committee in its April 2nd 2008 scheduled meeting.

39 IM COMMITTEE on JCI and its SECTION REPRESENTATIVES, MANUEL CANLAS, MD Allergology/Immunology Section Mobile: CLAVEL MACALINTAL MD Cardiology Section Mobile: GIA WASSMER, MD Endocrinology Section Mobile: BENJIE BENITEZ, MD Gastroenterology Section Mobile: PAUL TAN, MD General Medicine Mobile: JESUS RELOS, MD Hematology Section Mobile: VILMA CO, MD Infectious Diseases Section Mobile: MILAN TAMBUNTING, MD Nephrology Section Mobile: JOEY PARRA, MD Oncology Section Mobile: ELIZABETH SANTOS, MD Pulmonology Section Mobile: AUGUSTO VILLARUBIN, MD Rheumatology Section Mobile NAZARIO A. MACALINTAL JR.,MD Head Mobile:

40 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.

41 External Legal Issue A 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


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