Frank J. Chapman, MBA
Units who participate in the Medicare/Medicaid program or those who seek accreditation are required to have a Peer Review program. The purpose of Peer Review is to quantify the patient safety and quality of care of a provider.
It is not uncommon for a unit’s Peer Review program to consist solely of chart reviews conducted by peer providers. A common concern is the time consumption of reviewing physicians combined with hesitation to critique the care provided by a colleague. The result is often no findings or suggestions on how to improve the care provided. While chart review may provide insight into the accuracy of documentation, the chart is typically limited to reporting specifics of a procedure but does not include clinical outcomes or other aspects of care important to the peer review process.
Approaching Peer Review using a balanced scorecard can provide a more holistic view of patient care while reducing the time consumption by reviewers by focusing on data that is routinely collected by the medical practice or the department.
In the example below, the Peer Review process is divided into four quadrants, each with a numeric value of 25 points resulting in a potential overall score of 100 points. Using numerics eliminates the value judgment of a provider’s care as “good” or “bad.”
Clinical Quality
Data Source – GIQuIC – GI Quality Registry Reporting or unit-specific quality measures.
Suggested elements:
Comments: The unit should choose elements that are identified nationally as indicators of a quality exam.
Clinical Outcomes
Data Source – The unit’s ongoing reporting of significant clinical events.
Suggested elements:
Comments: In the place of “Hospital Transfers” a hospital unit may wish to include transfers to a higher level of care within the hospital. An adverse incident is defined as an unexpected occurrence that led to or could have led to, serious unintended or unexpected harm, loss, or damage. Adverse incidents result in unintended harm to the patient by an act of commission or omission, rather than by the underlying disease or condition. An incident is defined as any deviation from expected policy and procedure.
Documentation
Data Source – A review of medical records.
Suggested elements:
-
The endoscopy report agrees with nurse’s notes/anesthesia notes. 5 points
-
The diagnosis agrees with the findings. 5 points
-
The surveillance interval agrees with the findings. 5 points
Comments: The number of records reviewed should account for the variation in the number of cases performed in the unit by specific providers. The use of macros to complete an endoscopy report can lead to conflicting documentation when comparing the endoscopy report to the nurse’s notes or anesthesia record.
Patient Interaction
Data Source – A review of periodic reporting from a variety of sources.
Suggested elements:
-
Patient Complaints 5 points
-
Results of Patient Satisfaction Survey 5 points
-
Is the patient notified of findings in a timely manner? 5 points
Comments: The Patient Interaction quadrant is designed to focus on provider activity that impacts patient care and patient satisfaction. If the unit’s patient satisfaction surveys do not provide provider level granularity another metric should be substituted. On-Time Starts not only impact patient flow but can lead to patient dissatisfaction throughout the surgical day. Physician Canceled cases and the reason for the cancellation is an important metric, not all units track but impact patient satisfaction as well as overall unit efficiency.
Process
Components of the overall process include sources of data, data gatherers, frequency of review, method of review, and review responsibility.
Sources of Data
When selecting elements to be reviewed, every effort is made to rely on preexisting reporting within the unit so that the expanded process does not significantly increase the overall workload of either clinical staff or providers involved in the process. These reporting mechanisms include such things as the periodic reporting of quality registries such as GIQuIC along with state-specific reporting requirements. The intent is to include additional elements of review without creating a requirement to include additional data gathering workload.
Data Gatherers
As the design of the process is to focus on preexisting reporting, the intent of data gathering process is to make no effort to evaluate the elements of the Peer Review process. Therefore, there is no licensure requirement (such as a Registered Nurse) for those gathering and collating the majority of data elements. The unit may wish to create a template to be used for chart abstraction and have a Registered Nurse collate the results for review. The process of chart abstraction is to identify elements for review, not to evaluate the value of those elements which in most cases is beyond the reviewer’s scope of practice.
Frequency of Review
Peer Review is to be an ongoing activity and the frequency of review should be determined by the volume of procedures performed by the unit and the frequency of routine reporting of the elements involved. For most units, a quarterly review serves to break down the review workload into manageable episodes. The purpose of determining the frequency of review is to provide ongoing feedback to the provider to facilitate correcting a pattern of deficits prior to the next credentialing cycle.
Method of Review
According to the design of the example, each provider begins with a total of 100 points consisting of 25 points within each of the four quadrants. The Peer Review process which is reviewed and approved by the unit’s governing body determines the elements included along with a methodology for scoring performance deficits on a uniform basis. This is the most challenging component of the overall process. As an example, if two physicians each have one bowel perforation over the review period and one physician performed 100 cases during the period and the other physician performed 250 cases during the review period the scoring methodology should account for the variation in caseload.
A member of the clinical staff should have the responsibility of taking the results of data gathering and collating these data into a format that facilitates a quick and straightforward presentation to the providers selected by the unit for the actual review and scoring.
Review Responsibility
The actual review and scoring of the results from data gathering should be a licensed peer or a peer with a similar scope of practice. For gastroenterologists, for whom the example is designed, this is straightforward. However, for anesthesia professionals, using a different set of criteria, determining who is a peer for the purpose of review can be more complicated. If a similar model is used to evaluate cognitive care provided in the office or hospital, a determination would need to be created on who can evaluate whom.
In most cases, Peer Review responsibility within a unit falls to the unit’s Medical Director, or in the case of evaluating the care provided by the Medical Director, a designee. Dependent upon the workload, a unit may wish to divide the workload among physicians within the unit. A downside of spreading the workload among various physicians is the variation of evaluation bias that can be expected. Every effort should be made to deploy a review method that results in uniform results.
Reporting of Outcomes
A benefit of this approach to Peer Review is to provide each participant with an overall numeric result as well as the participant’s value within each quadrant. The results of each participant can easily be compared to the unit’s average overall score and the average score with each quadrant. This allows the participant insight into which area they may need to focus on to increase their overall score in relation to that of the unit as a whole.
It is up to the unit’s governing body to determine the level of transparency applied to the unit’s results and to what extent the outcomes are shared within the unit.
Periodic results of Peer Review should be tracked to determine performance trends and included in the reappointment packet. A benefit of the process is to unemotionally determine if senior physicians are maintaining a high level of patient care and safety or if their performance and efficiency degrade over time, or areas of improvement of new physicians added to the unit.
Conclusion
While Peer Review is a requirement of many endoscopy units, it is also the right thing to do. Many units focus on the requirement and minimize the workload and the scope of review which may not provide an overall picture of the variation of care provided within the unit.
Designing and deploying a Peer Review process based on the use of a Balanced Scorecard may provide a broader view of a physician’s performance within the unit.
Frank Chapman is currently Director of Strategic Development at Ohio Gastroenterology in Columbus, Ohio. Frank is a trained and active Medicare surveyor for AAAHC where he serves as chair of the Standards Committee and serves as vice-chair of the ASGE Practice Operations Committee.