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

…

“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.

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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


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.


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.


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


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.

…

“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)

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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.


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.


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.


Conclusion “1” - No concerns / Fallout Acceptable.If the case falls into monitoring

process, but clinical practice is expected and accepted.



Conclusion “2” - Minor concerns - Questioned Practice.IF the practice is not consistent with

accepted standard of care, but no potential for significant harm exists.



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.



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 …


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.


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.


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]

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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


The hospital had a reasonable belief that peer review action was warranted.


AF185 32000ft 3/12/08 9:04 AM Hotel San Ranieri Pisa Italy 3/16/08 1:22 AM PEER REVIEW PROTOCOL...

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