Peer Review: Protecting Your Investment Peer Review: Protecting - PDF document

Peer Review: Protecting Your Investment Peer Review: Protecting Your Investment So… Hospitals will be paid less unless: Good scores on …  Incentive payments  Meeting 17 clinical processes  Funded by 1% cut in base (aspirin, antibiotic timing, Dx DRG payment instructions)  Patient-centeredness (HCAHPS)  Soon, mortality data Costs:  Potential for patient harm  Recruitment/relocation investment  Hospital reimbursement tied to What is at stake when peer performance  Morale/turnover review fails?  Vicarious liability  Hearing  Litigation  Recruit replacement  Criminal, licensure issues K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 1

Peer Review: Protecting Your Investment Licensure Action  Unprofessional conduct in the practice of medicine In the Matter of  Willfully making a false report or record in the practice of medicine Mark G. Midei, M.D.  Gross overutilization of health care services  Violations of the standard of quality care  Failure to keep adequate medical records  Implanted cardiac stents unnecessarily Dr. Midei was present for  Falsified the extent of blockage of the proceedings and was the patients’ coronary arteries by represented by nine attorneys. reporting that it was 80% when it was in reality lower – much lower  Falsely reported that they suffered from unstable angina “Dr. Midei was not paid per stent inserted…was employed under License revoked July 13, 2011. circumstances in which any May not apply for reinstatement employee would feel at least some for two years. pressure to produce a high volume of stents.” K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 2

Peer Review: Protecting Your Investment How Did the Board Know? Anonymous letter from Hospital The outside reviewer was employee. impressive to the state board hearing officer. Dr. Chacko was subjected to Midei claimed Dr. Chacko’s unacceptable harassment and report was “paid for.” intimidation by [Dr. Midei’s attorney]. Disciplinary proceedings Dr. Chacko was paid $1,400 for his against a physician are not report and expert testimony. intended to punish the offender (Dr. O’Neill (Dr. Midei’s expert) was paid but rather to protect the public. more than twenty times that much.) K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 3

Peer Review: Protecting Your Investment The violations proven were repeated and [Dr. Midei] unnecessarily exposed serious. Although none of the patients patients to risk of harm. This factor suffered any adverse consequence, such warrants a severe sanction. as bleeding or blood clots, as a result of [Dr. Midei’s] practice of inserting [Dr. Midei’s] care, one of the patients stents increased the cost of the patients’ suffered a tear in an artery, requiring the medical care to the health care system. placement of another stent, and the PCI is much more expensive to a patient, patients were required to take Plavix for the Medicare program, and insurers than a year and aspirin for life after their medical therapy. stents were inserted. Traditional “peer review”: [Dr. Midei] was a salaried employee  Retrospective at SJMC; he had no apparent  Subjective financial motive for his conduct. He  No sufficient interaction was devoted to his profession,  Novice reviewers respected by his peers and co-  Personal workers, and had a loyal following of  No end point/trend referring physicians.  Fear of litigation The Joint Commission calls it: We call it: OPPE Professionalism/ FPPE Lifelong learning K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 4

Peer Review: Protecting Your Investment Continuous Professional Performance Process Orientation Set clear, high standards* It must start earlier Preceptor/mentor Replace “lost” hours of training *Requires bylaws change/contract language How? Mutual Benefits  Multiple input process  Physicians  Employees  Gives each physician the  Patients (www.cahps.ahrq.gov) best chance to be successful  Protocol/guideline compliance  Maintain currency  Reviewers’ CME  Medical necessity (compare with Dartmouth/Dx statistics)  Sentinel events/never events  Specialty-specific indicators What? What?  Triage: Identify system issues  System issues  Share data/information with physicians  Conduct (de-identified)  Health  Educational letters/follow-up  Quality  PIPS  Progressive discipline (bylaws change) K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 5

Peer Review: Protecting Your Investment Role of Medical Staff Role of Board  Ultimate responsibility Participants must be:  Assure  a good process  Accountable  participants are trained and diligent  Well trained  system issues identified and correction plan implemented  Compensated?  Require conformance to quality and safety initiatives  Require reports on unusual or long-standing problems Who serves on committee? Role of Management  Assure resources for ongoing process  Physician leaders with training  Determine if it is contract/employment  Quality Director issue  MSP  PMG CMO Peer Review Privilege  Attaches to Medical Staff, but to PMG? What if problem is with  Documentation matters – keep out of PMG physician? employment files K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 6

Peer Review: Protecting Your Investment Required Documents to Clarify Who finally acts? and Guide Process  Information Sharing Agreement  Release Employer?  Contract Language PPEC?  Bylaws Language  Policy on Performance Review Based on Established Benchmark Data Beneficiaries → Tweaking current system won’t  Patients work  Physicians → Bylaws/contracts must require compliance  Hospital → Standards must be clear → PPEC must be trained, vigilant K:/Pres/Handout/EPI/1112/03Naples/Linda/PeerReview_Investment.ppt 7