Peer review also supports the other processes that healthcare organizations have in place to assure that physicians are competent and practice within the boundaries of professionally accepted norms.
[5] In addition, peer review methods are frequently used by state medical boards with respect to licensing decisions and complaint investigation.
"[9] Medical staffs generally rely on generic screens for adverse events to identify cases for peer review, even though that might not be the most efficient or effective method.
[6] These are generally applied through administrative data analysis, but referrals for peer review are frequently made by risk managers, nurses and medical staff.
Peer review plays a role in affecting the quality of outcomes, fostering practice development, and maintaining professional autonomy.
American Nurses Association guidelines define peer review as the process by which practitioners of the same rank, profession, or setting critically appraise each other's work performance against established standards.
Written and standardized operating procedures for peer review also need development and adoption by the direct care staff and incorporation into the professional practice model (shared governance) bylaws.
The APR is a managerial human resource function performed with direct reports, and is aimed at defining, aligning and recognizing each employee's contribution to the organization's success.
[21] The first documented description of a peer review process is found in the Ethics of the Physician written by Ishap bin Ali al-Rahawi (854–931) of al-Raha, Syria.
[23] In the 1900s, peer review methods evolved in relation to the pioneering work of Codman's End Result System [24] and Ponton's concept of Medical Audit.
[25] Lembcke, himself a major contributor to audit methodology, in reviewing this history, notes the pre-emptive influence of hospital standardization promoted by the American College of Surgeons (ACS) following WWI.
These screens were originally developed to evaluate the feasibility of a no-fault medical malpractice insurance plan and were never validated as a tool to improve quality of care.
[33] In the process, a QA model for peer review evolved with a narrow focus on the question of whether or not the standard of care had been met.
[38] It also showed that important differences among programs predict a meaningful portion of the variation on 32 objective measures of patient care quality and safety.
It is argued that the outmoded QA model perpetuates a culture of blame that is toxic to efforts to advance quality and high reliability among both physicians and nurses.
When peer review leads to an action to limit or revoke clinical privileges, the physician is entitled to both a fair hearing and the right of appeal.
(5) There is an overriding national need to provide incentive and protection for physicians engaging in effective professional peer review.
[46] From the time of the HCQIA, there has been good alignment between regulatory and accrediting bodies with respect to due process requirements for physician disciplinary actions.
These formalities apply primarily to questions of competence (credentialing and privileging) rather than performance (routine clinical peer review).
HCQIA enabled the creation of a National Practitioner Data Bank and required hospitals, state medical boards and other health care entities who engage in formal peer review activities to report all disciplinary actions that affect clinical privileges for more than 30 days.
The final rule promulgated by the Agency for Healthcare Research and Quality in 2008 at 42 CFR Part 3 [51] also includes protections against reprisals for good-faith reporters of adverse events, near misses and hazardous conditions.
Several Florida health systems subsequently formed PSOs in expectation of using federal statutory protections to maintain the confidentiality of peer review activity that would have been exposed under Amendment 7.
[53] The PSRO model was not considered to be effective and was replaced in 1982 by a further act of Congress which established Utilization and Quality Control Peer Review Organizations (PROs).
As a result, in the mid-90s, the PROs changed their focus and methods; and began to de-emphasize their role as agents of external peer review.
[62] Controversy exists over whether medical peer review has been used as a competitive weapon in turf wars among physicians, hospitals, HMOs, and other entities and whether it is used in retaliation for whistleblowing.
Abuse is also referred to as "malicious peer review" by those who consider it endemic, and they allege that the creation of the National Practitioner Data Bank under the 1986 Healthcare Quality Improvement Act (HCQIA) facilitates such abuse, creating a 'third-rail' or a 'first-strike' mentality by granting significant immunity from liability to doctors and others who participate in peer reviews.
[63] Parenthetically, it is difficult to prove wrongdoing on behalf of a review committee that can use their clinical and administrative privileges to conceal exculpatory evidence.
[66] Dishonesty by healthcare institutions is well-described in the literature[67][68][69] and there is no incentive for those that lie to the public about patient care to be honest with a peer review committee.
[65][70][71] Incidents of alleged sham peer review are numerous and include cases such as Khajavi v. Feather River Anesthesiology Medical Group,[63][72][73] Mileikowsky v. Tenet,[74][75][76] and Roland Chalifoux.
Physicians who allege they have been affected by sham peer review are also less able to find work when they move to another state, as Roland Chalifoux did.