By Skip Freedman, M.D.
It’s no secret hospital peer review is a broken process. Its intent – improving the quality of care for patients by protecting them from substandard medical care – is an admirable goal and one that doctors and hospital risk managers agree on. Everyone wants patients to have consistent, high quality treatment. Peer review tries to assure this by having the same specialty and practicing doctors not involved in the procedure in question look over the case. In theory, doctors trained and practicing in a specialty can examine the problematic event and provide objective, unbiased determinations on its cause. They should consider whether the treatment was medically needed; whether it followed the standards of care; whether there was a sentinel event; and if so what was its cause. However the theory conflicts with application.
Problems with Peer Review
Unfortunately, institutions handling peer reviews internally soon find many flaws in the process. Internal peer reviews impact doctors’ time, bring out competitive and personal biases and, more often than not, the doctors conducting the reviews are not working in an equivalent subspecialty.
Time. Taking part in a peer review panel is just one more daunting, time consuming task doctors add to their already overloaded schedules. Their heavy workload makes it easy to put off peer review and delay quality of care solutions. This draws out the peer review process longer so it’s not current with the events in question and prevents quality of care improvements that the process is intended to oversee. Sometimes, the doctor’s patient workload causes doctors not to be as involved or attentive as the role calls for.
Competition. Aware of competition, friendships and the impact on working relationships, doctors don’t like to review peers they work with day-to-day. Nonetheless, peer-review panels often are staffed with doctors either as partner or competitors within the same geography for the same patients. Oftentimes they also compete for recognition in their narrow specialty at the hospital or for positions on medical boards. Criticizing one’s friends and associates is very difficult. Doing so for one’s competition may present legal problems.
Not same subspecialty. Hospitals and medical groups often don’t have multiple doctors with the same subspecialty. This creates a problem during peer review. For example, urologists and obstetricians are both surgeons, but cannot be expected to be knowledgeable in surgical areas outside their specialty.
Outsourcing Peer Review
Slowly hospitals and medical groups are recognizing that outsourcing peer review is a “best practice.” Engaging an independent review organization (IRO) in peer review solves their dilemma. Handing peer review off to an IRO can mean improving practice patters in the hospital. After all, the goal isn’t punishment, but a remedy – whether monitoring or educational. This reduces the conflict among doctors, administrators and risk managers that can too often drag on without resolution.
Onsite or off? Some institutions and even the doctor under review want the IRO to travel to their location, meet the staff and tour the facility. But, it’s almost never necessary. Most of the time, questions about a case deal with a doctor’s performance. That is, the questions deal with the patient’s care, and this is best discerned from a careful review of the patient’s records. These can be reviewed away from the site.
In fact, visits raise new issues, including personal involvement, delays and cost. Getting to know the doctors involved in a case begins to include personality conflicts, individual charisma and other “human” qualities that can hinder objective decision-making and reproduce of the local hospital’s difficulties. Because the “how” of a case deals with the quality of a patient’s care, the doctor’s personality should not be a factor in an investigation. A patient’s records speak for themselves.
Specialists traveling to a hospital site can delay results based on scheduling and personnel to make the visit. Often, specialists are expensive and their day rates too costly to have them visit onsite. And so costs rise, because specialists’ day rates merely increase the cost of the review. Enlisting an IRO for help can speed up the process and reduce the cost. An independent review organization can provide a reasonably priced alternative because they employ specialists actively practice in a like specialty area without asking them to travel. Once all the materials for the peer review are turned over to an IRO, they can usually make a determination within 28 days. After using an IRO for hospital peer review, most hospitals agree that received a better understanding of the problem for far less cost by using an IRO.
Finding a match. It’s difficult for a hospital’s doctors doing peer review to be experts about the latest levels of quality of care in all areas of medicine. Medicine is expanding at light speed and the standard of care constantly changes, research introduces new medical treatments and technologies. To stay current, an IRO is constantly recruiting and credentialing specialists who have the most current knowledge, skill and the capacity to apply it in reviewing cases. Organizations conducting only a few reviews cannot afford the cost of continuously recruiting and credentialing many specialists. Therefore they lag in their ability to identify problems and propose remedies.
To match the doctor under review, an IRO will take care to find a reviewer with the same educational background, similar training and credentials, and working in a similar setting at comparably sized institution. The specialist reviewer will be current on the existing standard of care for the specialty, new experimental and investigational treatments and how they impact current medical decisions. The “like” specialist is in a better position to give the doctor under review an unbiased review based upon the medical evidence presented, and not on organizational or personal conflicts.
Medical groups that come to an IRO for the first time for a medical peer review service often bring cases that have been in litigation for months, or even years, or they bring cases with lawsuit potential. IROs can quickly help litigation teams and doctors in charge of hospital quality sort out the complexities of sentinel events, making it easier to decide their next course of action regarding a doctor’s performance. In cases of litigation, should a hospital know a doctor was at fault, it makes more sense to settle the case quickly, rather than incur bad publicity and increase expense by continuing legal action. When hospitals experience successful case resolution through an outsourced peer review, they begin to believe that outsourcing to an independent review organization can have lasting benefits and should be done more systematically.
Hospitals and medical practices wanting to raise the quality of care, improve patient safety, deal with sentinel events and address negative outcomes quickly and efficiently are outsourcing their peer reviews to IROs routinely. They know they can get an objective non-conflicted decision and fast turn around on quality of care issues. Today hospitals of all sizes use IROs systematically for peer reviews. They’ve developed standards for deciding which cases to send out as opposed to letting them languish in hospital review committees.
Doctors and risk managers inside hospitals or medical centers need to see IROs as partners for peer review – partners that can help resolve matters of questionable patient care on a timely basis while reducing the potential for expensive lawsuits or sanctions, and lessen internal organizational conflict. They can use IROs as a tool to improve decision-making and help prompt the resolution of potential quality of care problems. When outsourced to an independent review organization, peer review provides doctors, risk and quality assurance managers with the capacity to quickly understand the facts surrounding problematic events. It allows them to get an unbiased review of a doctor’s performance based on medical evidence, solve it and the move on to other matters.
Skip Freedman, M.D., is the medical director at AllMed Healthcare Management, an independent review organization based in Portland, Ore. He is a longtime emergency physician and practices at several hospitals in the Portland-Vancouver Metropolitan area.