1. The Basics of Peer Review Sandy Fogel MD FACS Assoc Prof Surgery Medical Director of OR Services Surgical Quality Officer NSQIP Surgeon Champion

2. Purpose

3. To improve care

4. Law Federal – OPPE State Medical Staff

5. Structure Board MEC MSPROC Departmental peer review committee Section peer review committee

6. MSPROC Voting member from each department and 3 at large members Numerous non-voting members from quality management Chaired by Chief of Staff elect (non-voting) Any non-physician related issues, process issues, sent to the QM staff.

7. MSPROC Indicators Sentinel events Unexpected death Harm to a patient Behavior incidents

8. How does a case become known? Verbally 7 – SAFE Soft med online event reports Regular chart reviews RCA, IA Other

9. Why does a case get reviewed? Must meet the indicators – MSPROC vs department/section review If you think a case should be reviewed that does not meet indicators, change the indicators. Must follow your process

10. Once a case identified for review Goes to 2 reviewers Must be rated – Ours Exemplary Appropriate Questionable or controversial Inappropriate

11. Ratings If both reviewers agree that medical care was exemplary or appropriate, no further discussion If reviewers disagree, or if any lower rating, must be discussed at full committee Some judgment needs to be made

12. Case Being Reviewed Physician notified of review If anything less than appropriate, physician gets letter with opportunity to answer questions from the committee and/or give any additional information not readily obtained from the chart Physician get letter of outcome

13. Reports All levels of committee report up MSPROC keeps track and files reports to the MEC, who then reports to the board

14. Actions If there is an egregious breech, MSPROC can ask section chief or department chief to come up with plan of remediation If not satisfactory, MSPROC can ask the MEC to intervene If still not satisfactory MSPROC can go to the board

15. Actions For a series of events that are not egregious, MSPROC may ask MEC for FPPE

16. Peer Review Hard work Process really does work Most physicians take it as intended

17. Questions?