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Use objective criteria for external review
Ensuring objective reviews
At Memorial Hermann Texas Medical Center in Houston, quality professionals are well aware of the importance of getting an outside perspective. "When you are in the midst of the forest, you can't see some of the processes that have become a habit to you," says Angela Lenox, the hospital's peer review manager.
"If you've been at an institution for years, everyone you encounter in that facility is either your partner, competitor or referral source. So you can't really get an objective review," says Lenox.
She points to Vermont's state peer review process, which hospitals in that state can refer cases to. The cases go out for a blind review with no name attached and only the facts of the case. The external source then can offer the hospital guidance for sources with continuing education units that could improve the educational process for standards of care, which may not be known to that physician.
This process has been very positive, especially for an organization that has small numbers of specialists. "They can't get peers to review the cases because there are not a lot of them," says Lenox. "To get someone who can be really objective in evaluating the standard of care, you may have to look outside what has 'always' been done at your facility," she says.
Developing criteria for external review
Currently, the organization is developing its own criteria for external peer review. "Criteria are important, because one of the pitfalls in the peer review process is it may give a cause and means to people who might be competitors to give an adverse opinion for personal gain, or colleagues to not provide an adverse opinion."
If all incidents are treated equally with the use of objective criteria, the hospital can't be accused of unfairly targeting an individual, says Lenox.
The key is to develop a set of guidelines to use universally, and refer any case that meets those criteria no matter which doctor is involved. "That way, it doesn't come back to you as discrimination litigation. Any other way you select cases might be seen as prejudicial," says Lenox. She points to a Dallas lawsuit that involved a provider claiming that his competitors had targeted him because of his ethnic background. "You may say, 'No way could that ever happen here,' but it can happen," says Lenox.
With clear criteria, a physician's practice is the determining factor that a case be reviewed. "So it empowers the organization to feel less threatened by implementing their peer review process," says Lenox.
The whole point of peer review is to improve the quality of care, says Lenox. "If it doesn't lead to improving the quality of care, don't even bother doing it," she says. "Because what you are doing is pointing out to a physician who may be unaware that he is weak in this area. Then you can point to education to help with that. Nobody wants to have a knowledge deficit."
One criteria for external review are cases that have not been reviewed in a timely manner. "For cases that I've had on the table for 30 days, we go to outside review to get a speedy decision," says Lenox. Another criteria is when the hospital has only a few providers in a given specialty. "If there is a major patient injury or death, that should be externally reviewed," says Lenox. "I think it's too sensitive for the docs in-house to judge that."
Each hospital needs to devise its own threshold for when it needs help, but the time to develop criteria is before a controversial case crops up. "You need to decide this in advance of when things starts to heat up, because at that point there are already those for and those against, and you lose that objectivity," says Skip Freedman, MD, executive medical director of AllMed Healthcare Management in Portland, OR.
[For more information on developing criteria for external peer review, contact:
Angela Lenox, Peer Review Manager, Memorial Hermann Texas Medical Center, Houston, TX. Phone: (713) 704-5076. E-mail: angela.lenox@memorialhermann.]