​Many medical staff professionals (MSPs) and medical staff leaders throughout the country have identified the following techniques and initiatives as useful for reducing the cost of obtaining EPR.
These six techniques have proven to be successful in ensuring the cost-effectiveness of EPR:

1. MSPs should have a predetermined agreement with individual peer reviewers, hospitals located in other geographic areas within the state and/or with consulting/EPR firms. Pre-negotiated professional fees can be achieved through the use of a request for proposal when time is not a factor in obtaining an expedited review. MSPs are often under pressure to confirm the competency of a physician requesting privileges for a new procedure or to use new equipment. A predetermined agreement can expedite the review at your particular hospital when no other medical staff member has the privilege to use that procedure or new equipment.
2. Minimize the number of cases that an external peer reviewer has to review. MSPs and quality improvement (QI) directors know that this is best accomplished by clearly defining what concern needs to be addressed. In doing so, the number of cases needed to answer that concern will be specific to the purpose of the review. Of course, it may depend upon the number of problem cases available. Sometimes, it may be just one case that needs evaluation. The review can always be expanded easily, depending on the results of the initial review.
3. Use more contemporary ways to communicate.Use conference calls to review and confirm the external physician’s or organization’s qualifications, methodology, case selection and sample size, as well as the results of the review. Often hospitals or group practices pay for on-site visits to review the results and conclusions of the clinical review report, but MSPs report that telephone or web conferences are usually a far more timely way to communicate as well as more cost-effective.
4. Review case selection and methodology with the physician(s) being reviewed in advance, if possible. This will increase the potential acceptance of the reviewer’s conclusions.
5. Ensure that the hospital, external review consulting firm, and/or the individual physician reviewer does not put another person between the reviewer and the medical record. By that, we mean that the peer reviewer should receive the entire medical record, supporting documents and films without these items being pre-screened/filtered by a non-physician. Pre-screening may leave out key parameters that impact the clinical reviewer’s conclusions and lead to an erroneous result.Prescreening and sending only portions of a medical record may be appropriate when doing a focused review to answer a specific question or concern.
6. It is usually not cost-effective to ask the clinical reviewer to recommend corrective actions. In other words, respect the boundaries between peer review and corrective action. Make sure that the reviewer clearly states his or her conclusions. MSPs should obtain a pre-review agreement on the methodology and reporting. Many medical staffs receive vague conclusions from a first review and have gone on to get one or two more reviews to try to clarify the initial EPR evaluation. Multiple EPRs are costly! MSPs should have the external peer reviewer provide comments regarding the care rendered in each case and leave recommendations regarding corrective actions to the medical staff leadership as required by the medical staff bylaws, rules and regulations, and EPR policy.

MSPs, in collaboration with the vice president of medical affairs (VPMA) and the QI director, are often the point persons for identifying and arranging the resources for performing EPR after the quality improvement/peer review process has identified the need for EPR. It is hoped that MSPs will use and/or instruct their leaders with these suggestions for enhancing cost effectiveness and improving the timeliness of EPR.
These are practical lessons learned from the field that will save the medical staff leaders, the individual being reviewed and their organizations much time, money and effort when performing EPR.

Midwest Rehabilitation Hospital started a new Wound Care Service (WCS) to complement their expanding ambulatory orthopedic surgery initiatives in April of 2015. At the February, 2016 MEC meeting the Chair of Orthopedic Surgery indicated that a 5 member private orthopedic group complained to him about the quality of care their patients had been receiving from the general surgeons staffing the WCS. The orthopedic group requested that all of the 78 patients they had referred to the WCS be reviewed for appropriateness by an objective outside physician reviewer as the WCS surgeons were either employed by the hospital or in a competing group practice. The MEC directed the Orthopedic Chair to work with the CMO in determining an appropriate review.

The CMO met with the orthopedic group and identified that four primary modalities of wound care were involved with their 78 patients. Next she met with the WCS Clinical Director who had been doing Ongoing Review (OPPE) for the new WCS. They designed an external review that analyzed the top four prevalent clinical protocols provided in the WCS to confirm that the protocols employ contemporary standards of wound care approaches, modalities, and techniques. A randomized and stratified sample of thirty-two (32) medical records (12 from the Orthopedic group) was selected for external review by the CMO. Three records were selected for each of the four protocols for the higher volume WCS surgeons and two cases were selected for each of the four protocols for the lower volume WCS surgeon.

Conclusion: The external reviewer’s finding indicated that a generally recognized standard of care was met as documented in each of the records reviewed. The overall patient care was sound and the results were good. There were minor legibility issues with some provider notes; although it does not appear to have affected care delivery.
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It was the reviewer’s opinion that the WCS’s top four protocols and/practice guidelines were based on generally accepted principles of evidence-based wound care management. The overall WCS physician competency and WCS protocols and quality were confirmed for the entire program with the review of 32 patient records which cost far less than just reviewing 78 of one groups cases. Start small and increase the review if concerns are identified by type of case and by physician.

HeartLove Hospital Peer Review Committee (PRC) had a Board Certified cardiologist from a private multispecialty group perform an external review of eight (8) CTA Heart images for completing Focused Professional Practice Evaluation (FPPE). The PRC was verifying the competency of a hospital employed cardiologist who was recently granted a new privilege to do CTA Heart with 3D imaging (Heart CT) at the HeartLove Hospital. The hospital employed cardiologist is Board Certified by the American Board of Internal Medicine in Cardiovascular Disease and has completed the Certification Board of Cardiovascular Computed Tomography (CBCCT) examination in June 2016.

The private multispecialty cardiologist, who was not certified in Heart CT and was critical of the Heart CT interpretations, would not put his opinions in writing other than to indicate on the internal peer review form that 5 of 8 interpretations were questionable. He would not give specific reasons.

The PRC obtained a second external review performed with an ABIM board certified, CBCCT cardiologist experienced in heart CT who re-read the exact same 8 Heart CT interpretations and completed a comprehensive evaluation report (commenting on physician knowledge, judgment, technique, documentation) for each heart CT. The physician consultant’s findings and conclusions indicated: "Given the fact that only 8 images were reviewed, the conclusions of this review in no way reflect on the total quality of care provided by the physician being reviewed. However, a generally recognized acceptable standard of care was met in the images reviewed.” The PRC received confirmation of acceptable care being provided, and recommended continuing privileges to the MEC. They also adjusted their approach to avoid conflict of interests and to seek an exact match relative to the credentials of the external reviewer with the physician being reviewed.

Carefine Hospital’s internal Peer Review Committee (PRC) reviewed a patient case referred from the risk management department based on a patient complaint. They found the care by the physicians and nursing/therapy staff to be appropriate. The Director of Quality/Risk Management Department was concerned that the CMO and VP of Patient Services communication with the patient was not satisfying the patient’s concerns. The CMO asked the Medical Staff Professional (MSP) to objectively review the case and make suggestions. The MSP reviewed the entire case review up to that point. She identified the real issues were:

1. The need to objectively confirm the internal PRC opinion that the care provided and documentation was, in fact, appropriate. The external peer review (EPR) policy states that there are many instances in which EPR is requested to obtain confirmation that work was performed well -not just for “problem cases”. Carefine leaders fostered a culture of not making PRC members say that care was bad – only that it needs further objective review.
2. Carefine Hospital needed to be able to show the patient that the quality of care provided was appropriate based on the opinion of objective, national experts who have handled many similar cases; and,
3. Questions were being raised by the patient that went beyond physician care requiring nursing rehabilitation care to be objectively reviewed and answered.

The MSP recommended and obtained the approval of the CEO for an external peer review (EPR). The MSP made it clear to the external reviewer to address the risk management and patient concerns which were provided with the medical records. This positioned the CMO to have the information needed to openly communicate the objective findings/opinions with the patient (after discussing with risk management and legal counsel).

Conclusion: The external review report, in fact, confirmed that the care and documentation provided was appropriate and met a generally recognized standard of care. The physician, nurses and therapists involved with the patient’s care were thanked. The specific patient’s questions asked by Carefine were answered by the EPR. Segments of the actual EPR report were shared with the patient. The EPR report positioned the CMO to have a number of productive discussions with the patient and his family to respond to their questions. Additional risk management approaches were also used to enhance the patient’s relationship with Carefine. The patient is continuing to be treated at Carefine’s outpatient rehabilitation facility. The MSP’s careful coordination skills, knowledge and approach made a quality review happen in a timely and cost effective manner.
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The MSP plays a significant role in the Medical Staff Peer Review process. Many facilities are now incorporating the medical staff peer review process into the job description of the medical staff professional. Medical staff leaders trust the medical staff professional when it comes to a fair peer review process. Where once this was solely the responsibility of the quality department, more and more facilities are now incorporating the peer review process into the medical staff resources department.

The performance of a hospital employed gastroenterologist was questioned by some complaints over the past several years with little or no investigation or follow up. In February 2016 the GI Nurse Manager went to the VP of Nursing about the physician to complain that he did colonoscopies on patients with poor preps, too fast, and documented scopes to the cecum when this didn’t happen. The VP of Nursing brought this issue to the attention of the Chief Quality Officer (CQO) and the Chair of the Medical Staff Quality Committee (MSQC).

Upon the recommendation of the MSQC, the MEC required Focused Professional Practice Evaluation (FPPE) with supervision of the gastroenterologist’s next thirty colonoscopies and ten upper endoscopies. Proctoring was performed as a requirement of his employer (hospital) and involved the Department Chair and the Chief of GI. The results of the proctoring indicated no technical problems. In short, under observation his performance was acceptable.

The GI Chief was also requested by the MSQC to conduct a random review of 100 of the GI physician’s charts. The GI Chief reviewed every third chart and found the following:
- withdrawal time averaged 4-5 minutes (literature recommends 6 minutes);
- a large number of cases with inadequate bowel prep;
- overall procedure time was short and the polyp detection rate was 14% compared to the GI department average of 25%.

Random review of an additional 100 charts showed that the other GI physicians at the hospital all got better results.

The MEC concluded that there was a problem prior to the FPPE and the GI Chief’s review results led the MEC to want to pull his privileges. This may have led to a fair hearing and a NPDB report.
The Chief Quality Officer working in collaboration with the Quality Improvement Director and Legal Counsel recommended outside peer review to answer the following issues and questions:

1. Confirm the internal review findings. Prior to the FPPE was the doctor performing upper and lower endoscopies at the standard of care?
2. Does the GI physician’s performance meet a generally acceptable standard of care post FPPE?
3. What options should the hospital consider with regard to informing patients - disclosure of possible inadequate scopes, call backs for repeats, and shortened rescreening periods?
4. What are the quality/screening indicators that should have been used or should be used in the future to assure quality performance of UGIs and colonoscopies?
5. Legal Counsel asked the question: “what will we do with the results once we get the
report?”
The hospital contracted with an External Peer Review (EPR) firm who they had experience with. The external review firm agreed to be available to answer the above questions and engage in discussion on the follow up recommendations.
6. The CQO and Legal were not concerned that proctoring needed to be repeated. They were confident in the proctor’s and the GI Chief’s review. However, Legal Counsel
suggested that interviews be done with the GI nurses to establish the nature of concerns
regarding professional behavior, falsifying charting and patient communication.

Conclusion: EPR confirmed that the GI physician was not performing upper and lower endoscopies at a generally recognized acceptable standard of care prior to FPPE. The internal review results were also confirmed. Patients were protected and physician performance has improved. A fair hearing/appeal and a report to the National Practitioner Data Bank were avoided.
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The MSQC recommended to the MEC (who informed the Board) of the following actions:
- Clear performance expectations and outcome targets for withdrawal time and polyp detection rates. These targets were set consistent with the department and national averages.
- Clear performance expectations regarding professional behavior, false charting and patient communication were also set. In short, one additional occurrence of inappropriate behavior, false charting or poor patient communication would result in privileges being impacted.
- Performance will be confirmed by proctoring (at the GI physician’s expense, performed by a physician approved by the MSQC).
- Concurrent QI monitoring for the next quarter with results communicated to the MSQC.