Sometimes you may find that the problem goes beyond a single physician’s actions on a case. “If there is a problem with a case, find out whether it’s an aberration or if the problem needs to be addressed,” says Dr. Rohr. “Some things are not a physician’s fault, so much as [they are] signs that a medical system doesn’t work as effectively as it should or [that there is] a general lack of training. For example, an ER [emergency room] doctor misses a fracture. Was finding that fracture outside his competency? Does he need training reading X-rays, or can you manage to get radiologists in to check X-rays fast enough to become part of the process?”
Use a Set Structure
It’s up to the hospital medicine program director to set up a peer review process, which should be done within the structure established by the hospital. Peer review meetings “should be done on a regular basis,” advises Dr. Rohr. “How often depends on the volume of the program, but a typical group should meet monthly. You’ll probably look at three or four cases, which is a reasonable number to cover in one meeting. Look at unexpected mortalities or complications—you have a responsibility to the public to examine these.”
You might do best by bringing in an outside facilitator for the meetings. This creates an impartial atmosphere for discussions. “We bring in an external facilitator from a local teaching hospital,” says Dr. Rohr. “It’s good to have an educator lead the meeting; someone from academia will have a greater fund of knowledge and [a stronger] grasp of the medical literature, which helps bring the discussion to a more educational level. Everyone respects medical science.”
Note that the facilitator may need to be credentialed as a member of the medical staff in order for the proceedings to be protected from legal discovery.
“Peer review is difficult in smaller practices, because everyone knows everyone and they may be uncomfortable addressing problems,” explains Dr. Rohr. “Here, it’s especially helpful to have a leader from the outside who can render opinions and get everyone to chime in and render their own opinions.”
Remember that your peer review system is reportable. “As part of the hospital’s peer review structure, you’ll have to report findings from the meetings,” adds Dr. Rohr. “If someone is showing a pattern, these things have to be trended. Do they need training, or should they be dismissed?”
Giving Feedback through Peer Review
When you participate in a peer review discussion, don’t let your comments get too personal or subjective. “The most important thing is to keep it professional and make it educational to the greatest extent possible,” says Dr. Rohr. “Reference facts in the medical literature as often as possible. Point to something that’s been published to support your opinion. Base your comments on what’s known, and apply that to your analysis of the case.”