August 29, 2013

Question: Our peer review committee is struggling to keep up with its workload.  Committee members want to do a good job of communicating, so the committee is constantly drafting letters to Medical Staff members regarding the status of case reviews, requesting input, or providing helpful information.  Is there anything we can do to be more efficient?

Answer: Yes!  Valuable physician time can be conserved by having the Quality Department or Medical Staff Office be empowered to generate “informational letters.”  Physicians on the peer review committee could first identify situations for which physician review is not required.  Examples include the failure to complete medical records in a timely manner, clear violations of Medical Staff rules, or the failure to follow protocols that have been approved by the Medical Staff.  The key point is that these situations must be readily identifiable through objective criteria.  When these objective criteria exist, the Quality Department or Medical Staff Office could generate an informational letter for signature by an appropriate Medical Staff leader.  Physicians who receive an informational letter would not be required to take further action or respond to it, though they would be free to prepare a response if they wanted.  If the number of informational letters sent to a practitioner suggests that a pattern has developed, the matter would be reviewed more closely through the peer review process.

Also, hospitals should have a complete set of pre-drafted, template letters for various situations the peer review committee may face.  For example, there should be template letters for requesting input from a physician, inviting a physician to a meeting, seeking an external review, and so on.  Having these letters allows committee members to take advantage of the experience and wisdom of those who served before them.

If you’re interested in other peer review best practices, please join us at The Peer Review Clinic.