FEATURE Implement an Effective Peer Review Program


Stay on track with an ongoing, active process BY ROBERT KURTZ


T


he primary focus for everything that happens at the Orthopedic Sur-


gery Center of Orange County in New- port Beach, California, is patient safety, says Karen Ollila, the ASC’s operations manager. Peer review, she says, is a crit- ically important part of that focus. “If you want to ensure patients con- sistently receive the highest quality care, you need to ensure the care they receive is appropriate,” Ollila says. “Peer review provides that check. It is a vital compo- nent of our quality program.” Sarah Martin, RN, CASC, vice president of clinical services for ASC management company Amsurg, based in Nashville,


Tennessee,


defines peer review as the process by which physicians and allied health professionals (AHPs) are evaluated on the quality of their work by their colleagues to ensure “standards of care” are being met.


“These are the standards physicians


and AHPs are expected to meet—stan- dards expected by the community they serve and representative of what they learned and have agreed to when obtaining their license,” she says.


Keys to Success When developing a peer review pro- gram, documentation is essential, says Nancy Jo Vinson, RN, CASC, pres- ident of ASC resource management firm NJM Consulting in Kernersville, North Carolina. “Everything you do tied to peer review should be recorded somewhere. This includes making sure your medical staff bylaws and rules outline your peer review process.” Another important part of the documentation is the development and use of a form to evaluate patient records Martin says. “The evalua- tion performed should be specific to


18 ASC FOCUS SEPTEMBER 2017 |www.ascfocus.org


your facility. It is not uncommon to see people obtain and use a document from another facility. This is fine, as long as the form is adapted to reflect the appropriate criteria for the special- ties and procedures in your ASC. An ophthalmology center should not have the same elements for peer review as a gastroenterology center.” When working to determine appro- priate criteria, involve your leadership, she advises. “You will want physi- cian engagement. Ask your governing board and quality assurance and per- formance improvement committee to weigh in on the measures for evaluat- ing physicians and AHPs.” Once someone becomes a mem- ber of your ASC’s medical staff, she advises, peer review of their perfor- mance needs to be an ongoing and active process.


Martin recommends that peer


review be performed by individuals sharing a similar license. For example, a physician should review another phy- sician and a nurse practitioner should review a surgical assistant. “If neces- sary, you can have a physician review a nurse practitioner or someone else at a ‘lower level,’ but you do not want to go the other way,” she says. At the Orthopedic Surgery Cen- ter of Orange County, peer review of the medical staff is a monthly process, Ollila says. Every provider who works at the ASC during a month undergoes evaluation the following month. “By performing it monthly, we feel we are more likely to catch dis- crepancies sooner,” she says. “If an evaluation identifies any outliers from our expectations, our administrator and/or medical director is informed. The chart will undergo re-review by our medical director or a surgeon on the governing board or medical advi- sory committee (MAC). Decisions on any necessary next steps will be made following that re-review.” In addition to catching negative trends more quickly, performing peer


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