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The What, Why and How of Peer Review

Kathy Williams Beydler

Peer review is a way of implementing organization-wide self-assessment by the people most qualified to assess it: similarly licensed health care professionals. Your organization and your patients will benefit from an effective, ongoing process of performance improvement based on peer review.

What is the purpose of peer review?

Peer review provides a method to review, assess, and validate the current competence of providers within a health care organization. Collecting and analyzing data, including trends and occurrences affecting patient care, provides an overall picture of the level of care provided by individuals and by the organization as a whole.

How does peer review differ from peer references?

Peer references are used for initial appointment only.  Since a new provider will not have completed cases at the facility, references are needed to verify current competence.

Once the provider has been credentialed and granted privileges, peer review becomes an ongoing process.

What is the value of peer review? 

For individual providers, this overall picture of their performance is part of what is presented to the governing body when making decisions about re-appointment and the granting of privileges. The governing body is responsible for organizational oversight and for ensuring that the criteria for reappointment are applied in a consistent manner.

At the organizational level, peer review is used to establish internal benchmarks. For instance, counting surgical site infections, or measuring transfers to the hospital for each provider over time, will provide an internal benchmark based on current performance. It is important to know if an individual provider’s performance fails to meet the benchmark. Often, the self-awareness created through the use of scorecards that allow providers to compare their performance is enough to correct smaller discrepancies in performance. Positive outliers can be studied for best practices and individual interventions can be implemented for low performers or negative outliers. If the aggregate trend of performance over time shows a decline (or if it isn’t adequate to begin with), a quality improvement study may be warranted.

Analysis of the peer review data is key. Trending and physician scorecards should be included in the reappointment process and review of these should be noted in the governing body minutes.

What elements should be included?

The elements should be determined with input from the providers being peer reviewed.  Review elements will be different for each type of provider based on their practice. In a surgical setting, the surgeons should have input into the development of their key performance metrics. Chart audits may be part of the process but may not be the entire process.  Elements for review should be consistent with the organization’s policies and procedures and might include components such as the presence of a complete history and physical on each chart, an immediate post-operative note that includes the required elements, infection rates, patient satisfaction, acceptable and unacceptable outcomes, etc.

The governing body will approve the elements for review.

Who participates in peer review?

Providers who are credentialed and privileged should participate in peer review.  Allied health professionals, if employees of the organization, may be privileged within a job description.

We only have one solo practitioner.  How can peer review be done for this practitioner?

Peer review should be provided by an outside practitioner who is similarly licensed.  At least two physicians or dentists are involved in the peer review process.  This can be accomplished by providing the peer review criteria and data to the outside practitioner for assessment. Some solo practitioners are hesitant to have their care reviewed by another provider in the same area due to concerns about competition. It is not necessary for the provider to be from the same area, merely that he or she is similarly licensed. Or perhaps the reviewer feels compelled to “go easy” on a colleague. In this case, the requesting provider should make clear that the assessment is to be based strictly on the objective data. As with any peer review, the data should include any trends and unexpected outcomes to provide an overall picture of the care provided.

Can a staff nurse or PA peer review a physician or CRNA?

A provider must be peer reviewed by a similarly-licensed peer. Peer review cannot be done by a lower level of licensure to a higher level of licensure. For instance, a CRNA cannot peer review a physician because the physician has the higher level of licensure. A physician can review a CRNA.

A staff nurse cannot peer review a CRNA. But a CRNA can review a staff nurse.

A physician’s assistant (PA) cannot peer review a physician; however, the physician can review the PA.

A successful peer review program requires a willingness on the part of everyone in the organization – from the governing body to members of the medical staff – to work together collaboratively. Done well, peer review is an integral part of a system for improving efficiency and raising the quality of care across an organization.


About the author

Kathy Williams Beydler is a surveyor for AAAHC and, previously, was the Director of Surgical Services at Regional One Health, a Level I Trauma Center in Memphis, Tennessee. In Outpatient Surgeries, she was the administrator of a start-up surgery center and later transferred to the flagship center in Memphis. As a surveyor, she especially enjoys the opportunities to teach during her surveys and encourage centers to become the best they can be.



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