PEER REVIEW FOR QUALITY MANAGEMENT EDUCATION FOR PROVIDERS

VHA Directive 2010-0251

PEER REVIEW FOR QUALITY MANAGEMENT

Traditional organizational function designed to improve - Quality of careAppropriate utilization of health

care resources Carried out by health care

professionals or select committee of professionals 2

TYPES OF REVIEWSPeer Review for Quality Management

Title 38 U.S.C., Sect. 5705 (Protected Reviews)

Management ReviewsNot confidential and not protected under Title 38 U.S.C. Sect. 5705 (Non-protected Reviews)

WHAT IS 5705 PROTECTION? Title 38, United States Code, Section 5705 –

Confidentiality of Medical Quality-Assurance Records

Document must –Identify (implicitly or explicitly) individual providers or other employees, patients, or reviewers

Contain discussions relating to quality of VA patient care

Be designated in writing as a quality assurance document

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PEER REVIEW FOR QUALITY MANAGEMENT

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Protected Reviews (Title 38 U.S.C., Section 5705)

Designated in writing ahead of timeCannot be used for administrative

purposesNon-punitive, non-disciplinary

process

MANAGEMENT REVIEWS Not considered a Peer Review for

quality managementNot protected as confidential and

privileged under 38 U.S.C., Section 5705

Can be disclosed for legal and administrative purposes

Must be kept separate from protected reviews

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DEFINITIONS OF KEY TERMS

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DEFINITIONS OF KEY TERMSPeer Review

Critical review of care performed by a peer or group of peers

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PEER REVIEW FOR QUALITY MANAGEMENT Essential elements –

Concerned with only a selected episode of care

Looks at the necessity of specific actions in the episode of care

Provides confidential feedback to the providers being reviewed

Identifies systems and process issues that may require investigation/administrative action 9

DEFINITION: PROVIDERProfessional authorized to deliver

health care Exercises autonomous clinical judgmentActions are subject to review

Providers include, but are not limited toPhysiciansNursesAllied health care professionals

Does not include trainees 10

DEFINITION: PEER REVIEWER Health care professional who can make

a fair and credible assessment of the actions taken by the provider in the episode of care under review

Factors to considerSimilar or more advanced educationTrainingExperienceLicensureClinical privilegesScope of practice 11

PEER REVIEWER QUALIFICATIONS Peer Reviewer must –

Have clinical expertise necessary to make accurate judgments about the episode of care

Complete adequate training regarding thePeer review processResponsibilitiesAssociated legal and ethical requirements

Make a fair and credible assessment of the actions taken by a provider relative to the episode of care

Possess knowledge of current evidence-based standards of care relevant to the case 12

PEER REVIEWER QUALIFICATIONS • Peer Reviewer must -• Withdraw from the Peer Review if

– They had direct involvement with the care in question– Specialized knowledge required exceeds his/her

expertise– They feel uncomfortable judging the care

•  Abstain from review of cases if– There is a conflict of interest– Unable to conduct an objective, impartial, accurate,

and informed review 

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THE PEER REVIEWER MUST • Use the Levels of Care to assign the

standard of care given by an individual provider

• Conduct each review through application of current standards of care

• Use peer-reviewed professional literature to support clinical determinations

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THE PEER REVIEWER MUST Address any system issues identified and

any other information that supports the rationale for their decision on the Level of Care

Complete the initial Peer Review on time Maintain confidentiality

Do NOT interview anyone involved in the caseDo NOT discuss the case with anyone

Conduct a review of documentation only 15

ELEVEN ASPECTS FOR REVIEW OF CARE1. Choice of diagnostic tests and timely

ordering of diagnostic tests2. Performance of a procedure or

treatment3. Addressing abnormal results of

diagnostic tests4. Timeliness of diagnosis and

appropriateness of diagnosis5. Timing of treatment initiation and

appropriateness of treatment16

ELEVEN ASPECTS FOR REVIEW OF CARE6. Adequacy of technique during

procedures7. Recognition & communication of

critical clues to patient’s condition during a period of clinical deterioration

8. Timely initiation of appropriate actions during periods of clinical deterioration

9. Health record documentation10. Supervision of health profession

trainees11. Other relevant aspects of care 17

THE PEER REVIEWER MUST Immediately notify the Chief of Staff,

Associate Director for Patient/Nursing Service, or other Executives if there is a possibility of Substandard careNegligenceAny other competency issue

Use the 11 Aspects for Review of Care to evaluate quality and resource issues related to the care of an individual provider

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WHAT IS THE PROCESS?

Need for Peer

Review is

identified

Peer Reviewe

r evaluate

s the record

Peer Reviewe

r assigns an Initial Level of

Care

Peer Review

Committee

discusses the

review and

assigns Final

Level of Care*

The Provider

being reviewe

d receives feedback about the care

19*Input from provider will be solicited for presentation to the PRC

DEFINITION: PEER REVIEW LEVELS Level 1:

Most experienced, competent practitioners would have managed the case in a similar manner.

Level 2: Most experienced, competent practitioners

might have managed the case differently.

Level 3: Most experienced, competent practitioners

would have managed the case differently. 20

PEER REVIEW TIMELINES Initial screening for referral to Peer

Review3 business days of discovery or

identification of event Initial Review Completed

45 calendar days from determination of need for review (Local timelines may vary)

Final Review Completed120 calendar days from determination

of need for review (Director must approve any extensions in writing before 120 days) 21

PEER REVIEW COMMITTEEMembership requirements

Chief of Staff is chairNurse ExecutiveMultidisciplinary representationSenior members of key clinical

disciplinesRole of substitute membersRole of Ad hoc members

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PEER REVIEW COMMITTEE MEMBERS Must withdraw from a case if

They lack the specialized knowledge required

They feel uncomfortable about judging the care

Abstain from a review of any case ifThey have a conflict of interestThey are unable to conduct an objective,

impartial, accurate, and informed review23

PEER REVIEW COMMITTEE Responsibilities

Reconsiders all Peer Reviews when the initial level of review is a Level 2 or Level 3

Conducts secondary review of representative sample of Level 1 cases (10 cases or 15%/quarter; whichever is greater)

Meets at least quarterlyReports quarterly to Medical Executive

CommitteeCoordinates referral of systems issues and

follow-up 24

PEER REVIEW COMMITTEE Responsibilities

Provides a final level assignment for all cases presented

Recommends non-punitive, non-disciplinary actions to improve the quality of health care or use of resources

Receives feedback of actions taken by supervisor/service chief/program director

Evaluates care provided by trainees25

PEER REVIEW COMMITTEE Responsibilities

Gives providers an opportunity to provide written input or appear in person before a Level 2 or Level 3 is finalizedProvider being reviewed must have an opportunity to provide input to the Peer Review Committee

Provides feedback and mentoring to peer reviewers

Documents issues related to patient safety, law enforcement, or administrative investigations

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WHEN TO CONSIDER PEER REVIEWS Mortality Reviews

Major morbidities associated with clinical care Unexpected or Negative Occurrences Executive Concerns Concerns of Other Facility Groups

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WHEN TO CONSIDER PEER REVIEWS

•  Occurrence Screens• Readmission within 10 days of discharge• Admission within 3 days following unscheduled

Ambulatory Care visit (includes Emergency Dept.)

• Unplanned or unscheduled return to the operating room in same admission

• Mortality during inpatient hospitalization28

WHEN TO CONSIDER PEER REVIEWS• Pre-payment Tort Claims • Initial notification of filing of a tort claim

may generate a Peer Review for quality management

• Regional Counsel can request a copy of the completed Peer Review as part of their document review; however, the completed Peer Review maintains its 38 U.S.C. Sect. 5705 protection

 

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CLINICAL EVENTS THAT REQUIRE PEER REVIEW1. Lack of adequate documentation of patient’s deterioration during

48 hours preceding death

2. Change in patient’s condition with no, or inadequate, action taken during 48 hours preceding death 

3. Cardiac or pulmonary arrest that could have been avoided4. Lack of agreement between patient’s pre-mortem and post-

mortem diagnosis

5. Signs of patient’s deteriorating condition that should have been noted and/or communicated to the provider, but were not

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CLINICAL EVENTS THAT REQUIRE PEER REVIEW6. Death appears to be related to a failure to carry out orders

7. Lack of documentation indicating explanation for the death

 8. Lack of documentation indicating that the patient’s

death was expected

9. Death appears to be related to a hospital-incurred incident or a complication of treatment

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CLINICAL EVENTS THAT REQUIRE PEER REVIEW

10. Death within 24 hours of admission (except in cases in which death is anticipated and clearly documented, such as transfer from hospice care)

11. Death within 72 hours of transfer out of a special care unit (unless transfer was made because death was anticipated) 

12. Death during or within 30 days of a surgical procedure or (if after 30 days) death is suspected to be related to the original procedure

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CLINICAL EVENTS THAT REQUIRE PEER REVIEW13.  Death appears to be related to a medication

error or a choice of medication14. Death appears to be associated with a lack

of appropriate palliative care15. Any reason to think death may have been

preventable16. Suicide within 30 days of a clinical encounter

with a VA health care professional

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COMMUNICATION BACK TO THE PROVIDER BEING REVIEWED Must include

Outcome of the Peer Review Recommendations to improve performance Summary of the Peer Review level Rationale for the level selected

• Cannot include any administrative actions such as modification of privileges

The provider being reviewed cannot look at or be given a copy of the actual Peer Review

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IN SUMMARY:PEER REVIEW FOR QUALITY MANAGEMENT

Provides an opportunity to evaluate the care delivered to a Veteran

Is confidential and protected Is non-punitive, non-disciplinary Is an avenue to discover system or

process issues Is a tool to improve the quality of care

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