Professional review committee improves the peer review process.

Does this sound familiar? There is an adverse patient outcome secondary to a complication, you are the department chair and the complication happened to your best friend and partner.

To make matters worse, no one wants to be on your ad hoc committee secondary to peer/colleague matters. Weeks or months may pass before any action is taken and the hospital staff and physicians involved forget some of the details.

Although the particulars may be different, this is typical of a scenario that plays out on a fairly routine basis at hospitals around the country. At Banner Estrella Medical Center, the newest hospital within Phoenix-based Banner Health, physicians had the opportunity to create a better process for peer review by developing an innovative approach called the called the professional review committee (PRC).

The PRC comprises of physicians who meet bi-weekly to discuss concerns including clinical issues, conduct/behavioral complaints, documentation issues, individual data and any related physician concerns involving patient care. The PRC enables Banner Estrella Medical Center (BEMC) to quickly and efficiently resolve any issues involving physicians practicing at the 172-bed, acute care facility.

The PRC includes a minimum of five members, including the chief medical officer (CMO) who serves as chairman, as well as active physicians of BEMC who are elected by majority vote by a selection committee.

The selection committee is made up of the chief of staff (COS), chief executive officer (CEO) and four active medical staff physicians who are selected by the COS and the CEO; both the COS and the CEO serve as ex-officio members on the committee.

The four physicians elected to serve on the PRC contract with Banner Estrella for staggered, three-year terms. This ensures that there are always experienced members on the committee who not only provide expertise but are able to mentor newer members regarding the process.

The selection process is open to all staff physicians. Applications are received, reviewed, and the qualified candidates interviewed by the selection committee. Each of the four contracted physicians is paid an hourly rate.

Open-minded, timely complaint resolution

The PRC provides physicians and staff with open-minded, timely resolution of behavioral and clinical issues pertaining to physicians. The committee members evaluate issues on a daily basis and provide reports to the PRC at its bi-weekly meetings.

Frequent review allows issues to be evaluated while details are still fresh in the participants' minds. Thus, when additional interviews are needed with physicians or hospital staff, answers are easily obtained. The PRC is able to act quickly to resolve issues--a key benefit for both physicians and the hospital.

The ability to expeditiously resolve issues, particularly when it comes to behavioral issues affecting staff, is a key advantage of the new process. That advantage quickly became evident in a series of complaints the PRC received regarding incidents of inappropriate behavior that occurred over a one-week period by a physician.

The behavior led to clinical compromise and staff displeasure. Within two weeks of the occurrence, the complaints had been investigated and reviewed by both the peer reviewer and the PRC. The physician was then given an opportunity to present his account of what occurred at a follow-up PRC meeting.

With that input in hand, the committee presented its recommended course of action to the hospital's medical executive committee (MEC), which agreed with the recommendations.

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A behavioral modification plan was put in place for the physician within one month of the incident, resulting in improved physician/staff relations and, more importantly, better patient safety and quality.

Additional benefits

Another major benefit of the PRC is that it potentially alleviates putting the department heads in the awkward situation of dealing with individual physicians regarding sensitive scenarios.

No longer will they have to conduct reviews on friends and/or colleagues, allowing them to maintain their focus on improving quality of care, evidence-based medicine and the analysis of aggregate data within their practice and the hospital.

With physicians from all modalities serving on the PRC, committee members are able to comfortably talk through issues that affect the entire facility. However, if additional expertise is required, the committee will first seek advice and consultation from other physicians within the hospital.

If that expertise is not available or not appropriate, the committee will consult with physicians from other hospitals within the company's network, following a consultation with the COS, CEO and department chairs.

For example, in one recent case, a patient presented with hyponatremia showing clinical symptoms. Three percent NaCl was started, but an overcorrection of the Na level occurred, resulting in medical complications for the patient. Upon its review of the case, the PRC reviewed literature on the topic and then consulted with a nephrologist from another Banner hospital to avoid physician/group bias.

Within two weeks of the incident, interviews with physicians involved in the case were concluded and a recommended plan of action from the PRC was approved by the MEC. One of the proposed actions endorsed was to educate the entire medicine department, using the latest literature.

Additionally, electronic medical record/computerized physician order entry order sets were changed with specific parameters and protocol instituted after review and input from the pharmacy and therapeutics committee, and MEC.

All recommendations, education and actions were completed within two months. At most hospitals, this process would often take several months.

Reviews by the PRC are obtained in traditional ways. Quality issues are brought by the quality management department and behavioral issues come to the committee via online incident reports and reviews.

In addition, issues are brought forth by the medical and hospital staff. To further enhance communication, representatives from the quality management and medical staff services departments attend the PRC meetings.

There are five process flow charts to help aid new committee members in specific issues: clinical care, aggregate data, sentinel event, behavior and suspected practitioner substance abuse (see Diagram 1).

Upon completion of a review, the actions and/or non-actions are recorded in the physician's medical staff record (see Diagram 2).

Peer review scores

The PRC and/or a PRC member may review a case with the involved physician for a score of I or II if it's felt the physician would benefit from having additional information, such as evidence-based medicine or new protocols, shared by the committee or a committee member.

When the physician receives a peer review score of III, the PRC and/or a PRC member visit with the physician to review the case and the reasons for the peer review score given. A letter summarizing the discussion is then given to the physician, with a copy inserted in the physician's medical staff file.

All peer review scores of B2 or IV are reviewed with the involved physician and then discussed with the departmental chair and submitted to the MEC for review. The MEC examines each of these cases to determine actions as well as the final committee peer review score.

The PRC has the option to take immediate actions such as temporary suspension before the MEC examines the case, but the hospital administration and departmental chair would have to be informed beforehand. The case would then proceed to the MEC for final actions. Any physician may ask to present their findings and comments to the PRC involving peer review score.

Last year, in the hospital's first year of operation, the PRC reviewed 110 cases. Diagram 3 shows the breakdown of peer review scores for 2005 from the PRC. Diagram 4 represents the departmental breakdown of cases and includes cases when outside reviewers were required.

The PRC supports Banner physicians by providing them an efficient, open-minded process that is quick to respond to concerns regarding patient care. Additionally, the medical staff of Banner Estrella Medical Center has welcomed and supported the PRC, as it has facilitated the difficult process of peer review. The quick resolution of cases reviewed by the PRC is both innovative and successful.

Charlie Agee, MD, is chief medical officer of Banner Estrella Medical Center in Phoenix, Ariz. He can be reached at Charlie. [e-mail]

By Charlie Agee, MD

Diagram 2 Banner Estrella Medical Center Professional Review Committee
Actions in 2005

                                             Percentage

No varience or Unpredictable/Predictable     0.7
  event within expected level of care
Required PRC action (e.g. letter, phone      0.17
  call, interview)
Systems, behavioral or documentation issues  0.13

Note: Table made from bar graph.

Diagram 3 Banner Estrella Medical Professional Review Committee Actions
in 2005

PRC Reviews by Department  Percentage

Surgery                    21.8%
Medicine                   20.9%
Emergency                  18.2%
Cardiology                 14.5%
OB-GYN                      9.1%
Radiology                   9.1%
Anesthesia                  3.6%

Note: Table made from bar graph.

Diagram 4 Banner Estrella Medical Center PRC, Non-PRC and Banner Non-PRC
Reviews

                Percentage

PRC             87.3%
BEMC Non-PRC     7.3%
Banner Non-PRC   5.5%

Note: Table made from bar graph.