Policy AD-350 Peer Review 2021-06-22

Purpose

It is the goal of Westside Family Healthcare (Westside) to provide continuous quality improvement in all aspects of patient care.  Peer chart reviews contribute to this goal by monitoring clinical treatments and the medical record, by providing feedback to the providers, and by helping inform the performance evaluation and privileging processes. Additionally, the peer review process serves as an opportunity for providers to receive additional input on specific cases to further improve their care for the patient.

Finally, conducting peer review meets requirements of both HRSA and The Joint Commission and is also an important component of risk management for the organization.

Policy

Peer chart reviews are performed by an assigned provider each quarter during the calendar year, as outline in the procedures below.

Scope

Medical, dental, behavioral health, and nutrition providers who have been at Westside for more than six (6) months are required to participate.

Definitions

Peer Review – Peer review at Westside is an ongoing provider performance evaluation and feedback activity in which retrospective review of patient charts is conducted in order to review the clinical care provided, evaluate appropriateness based on best practices for the discipline, and provide input to the relevant providers, with the primary purpose of improving safety and quality of care.

Procedures

Each provider is required to review three charts per quarter with a focus upon clinical care and documentation.

• 1. Each provider peer group (Medical, Dental, Behavioral Health, and Dental) has peer chart review forms specific to their discipline.
  2. Peer review forms are available to providers on the intranet under the Provider Relations tab. http://companyweb/SitePages/ProviderRelations.aspx

The reviewing provider is assigned a different clinician in their peer group to review each quarter on a rotating basis.

• 1. This schedule is emailed to all providers along with a due date for completion.

Providers are expected to schedule time outside of scheduled patient care activities to complete this process by the deadline.

Upon completion of the chart review, documents are returned as follows:

• 1. If using fillable PDF forms, the documents are emailed to the Provider Relations Manager.
  2. Otherwise, the forms are scanned into the Provider Relations Scan folder (available on all Westside copiers) by the provider.

If the documents are not completed and scanned back by their due date, a notice will go to the CMO via email.

• 1. At the discretion of the CMO the timeframe can be waived/extended when the circumstances did not allow the provider to complete his/her reviews with proper notification.

References

1. Relevant Health Services Resource Administration (HRSA) requirement:
   1. Chapter 5: Clinical Staffing, HRSA Health Center Program Compliance Manual, August 2018.  https://bphc.hrsa.gov/programrequirements/compliancemanual/chapter-5.html
      1. The health center has operating procedures for the initial granting and renewal... of privileges for clinical staff members… These privileging procedures would address the following: For renewal of privileges, verification of current clinical competence via peer review or other comparable methods.
   2. Clinical Staffing chapter, HRSA Site Visit Protocol (SVP), May 27, 2021.  https://bphc.hrsa.gov/programrequirements/site-visit-protocol/clinical-staffing
2. Relevant standard from The Joint Commission (TJC), Human Resources chapter, Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021:
   1. HR.02.01.03 – The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
      1. Element of Performance (EP) 6 – Before granting initial, renewed, or revised privileges to a licensed independent practitioner, the organization’s leadership documents current evidence, which includes peer and/or faculty recommendations, of the individual’s ability to perform the privileges requested.
      2. EP 7 – Before granting renewed or revised privileges to a licensed independent practitioner, the organization does the following: - Evaluates the results of any peer review of the individual’s clinical performance.