Medical peer review

Medical peer review is the process by which a committee of physicians examines the work of a peer and determines whether the physician under review has met accepted standards of care in rendering medical services. Depending on the specific institution, a medical peer review may be initiated at the request of a patient, a physician, or an insurance carrier. The term "peer review" is sometimes used synonymously with performance appraisal.

The first documented description of a peer review process is found in the Ethics of the Physician written by Ishap bin Ali al-Rahawi (854–931) of al-Raha, Syria, who describes the first medical peer review process. His work, as well as later Arabic medical manuals, states that a visiting physician must always make duplicate notes of a patient's condition on every visit. When the patient was cured or had died, the notes of the physician were examined by a local medical council of other physicians, who would review the practising physician's notes to decide whether his or her performance met the required standards of medical care. If their reviews were negative, the practicing physician could face a lawsuit from a maltreated patient.

The definition of a peer review body can be broad, including not only individuals but also (for example, in Oregon), "tissue committees, governing bodies or committees including medical staff committees of a [licensed] health care facility...or any other medical group in connection with bona fide medical research, quality assurance, utilization review, credentialing, education, training, supervision or discipline of physicians or other health care providers."

Overview
The objective of a medical peer review committee is to investigate the medical care rendered in order to determine whether accepted standards of care have been met. The professional or personal conduct of a physician or other healthcare professional may also be investigated. If a medical peer review committee finds that a physician has departed from accepted standards, it may recommend limiting or terminating the physician's privileges at an institution. Remedial measures including education may also be recommended.

In Nursing, as in other professions, peer review applies professional control to practice, and is used by professionals to hold themselves accountable for their services to the public and the organization. Peer review plays a role in affecting the quality of outcomes, fostering practice development, and maintaining professional autonomy. The American Nurses Association guidelines on peer review define peer review as the process by which practitioners of the same rank, profession, or setting critically appraise each other’s work performance against established standards. Professionals, who are best acquainted with the requirements and demands of the role, are the givers and receivers of the feedback review.

The medical peer review system is a quasi-judicial one, similar in some ways to the grand jury / petit jury system. First, a plaintiff asks for an investigation. Discretionary appointments of staff members are made by the medical Chief of Staff to create an ad hoc committee, which then conducts an investigation in the manner it feels is appropriate. There is no standard for due process, impartiality, or information sources; the review may consult the literature or an outside expert.

An indicted (and sanctioned) physician may have the right to request a hearing, with counsel allowed. A second panel of physicians is chosen as the 'petit jury', and a hearing officer is chosen. The accused physician has the option to demonstrate conflicts of interest and attempt to disqualify jurors based on reasonable suspicions of bias or conflicts of interest in a process akin to voir dire.

The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41) created Patient Safety Organizations, whose participants are immune from prosecution in civil, criminal, and administrative hearings, in order to act in parallel with peer review boards, using root cause analysis and evaluation of "near misses" in systems failure analysis.

History
Medical audit, which remains the predominant mode of peer review in Europe, is a focused study of the process and/or outcomes of care for a specified patient cohort using pre-defined criteria, focused on a diagnosis, procedure or clinical situation. This audit process was revised by changes to The Joint Commission standards were revised in 1979, dispensing with the audit requirement and calling for an organized system of Quality Assurance (QA). Thus the objective of a medical peer review committee became, to investigate the medical care rendered in order to determine whether accepted standards of care have been met. Contemporaneous with this change, hospitals and physicians adopted generic screening to improve quality of care, despite warnings from the developers of these screens that they were not validated for this purpose, having originally been developed to evaluate no-fault malpractice insurance plans.

The focus on the question of whether the standard of care had been met persisted despite many criticisms,  but is increasingly recognized to be outdated, replaced over the past decade by Quality Improvement (QI) principles.

Composition of peer review boards
There is no one standard composition of Medical peer review bodies, nor are there different names for peer review bodies of varying constituent parts. They may be carried out by State medical boards (with different standards for membership), hospital administration, senior staff, department heads, etc., or a combination of these.

State medical boards conduct peer review of licentiates, composed of physicians only or including attorneys and other non-physicians, varying by state. Physicians may be board members in primarily advisory capacities. Medical peer review may be carried out by committees that may include physicians not on the board. The same is true of state boards run by physicians from that state; board physicians or physicians unaffiliated with the board may be in medical peer review committees.

In hospitals, only a peer review committee authorized by the physician medical staff is authorized to take action regarding a physician's medical privileges at that institution. A committee convened by the hospital administration or other group within the hospital may make disciplinary recommendations to the physician medical staff.

Departmental peer review committees are composed of physicians, while hospital-based performance-appraisal and systems-analysis committees may include nurses or administrators with or without the participation of physicians.

Although medical staff bodies utilize hospital attorneys and hospital funds to try peer review cases, the California Medical Association discourages this practice; California legislation requires separation of the hospital and medical staff.

Nursing professionals have historically been less likely to participate or be subject to Peer Review. This is changing, as is the previously limited extensiveness (for example, no aggregate studies of clinical nursing peer review practices had been published as of 2010) of the literature on nursing peer review

In response to the Health Care Quality Improvement Act of 1987, (HCQIA) (P.L. 99-660 ) national medical associations' executives and health care organizations formed the non-profit American Medical Foundation for Peer Review and Education to provide independent assessment of medical care.

Abuse
Sham peer review is a name given to the abuse of a medical peer review process to attack a doctor for personal or other non-medical reasons.

Controversy exists over whether medical peer review has been used as a competitive weapon in turf wars among physicians, hospitals, HMOs, and other entities. The American Medical Association conducted an investigation of medical peer review in 2007 and concluded that while it is easy to allege misconduct, proven cases of malicious peer review are rare.

Abuse is also referred to as "malicious peer review" by those who consider it endemic, and they allege that the creation of the National Practitioner Data Bank under the 1986 Healthcare Quality Improvement Act (HCQIA) facilitates such abuse, creating a 'third-rail' or a 'first-strike' mentality by granting significant immunity from liability to doctors and others who participate in peer reviews.

The California legislature framed its statutes so as to allow that a peer review can be found in court to have been improper due to bad faith or malice, in which case the peer reviewers' immunities from civil liability "fall by the wayside".

Many medical staff laws specify guidelines for the timeliness of peer review, in compliance with JCAHO standards.

Some physicians allege that sham peer review is routinely conducted in retaliation for whistleblowing, although a study of the phenomenon did not support this charge.

Cases of alleged sham peer review include Khajavi v. Feather River Anesthesiology Medical Group, Mileikowsky v. Tenet, and Roland Chalifoux.

Defenders of the Health Care Quality Improvement Act state that the National Practitioner Data Bank protects patients by helping preventing errant physicians who have lost their privileges in one state from traveling to practice in another state. Physicians who allege they have been affected by sham peer review are also less able to find work when they move to another state, as Roland Chalifoux did. Moreover, neither opponents or supporters of the NPDB can be completely satisfied, as Chalifoux' case shows that just as physicians who were unjustly accused may be deprived of work in this way, those who have erred might still find work in other states.