QUESTION:
The physician group practice that is affiliated with our health system wants to develop a peer review process for outpatient practitioners. Does this make sense and, if so, what are some considerations in setting up such a process?
ANSWER FROM HORTYSPRINGER ATTORNEY CHARLIE CHULACK:
Even though an answer to this question involves an evaluation of the unique circumstances of the group practice, there has been a significant increase in interest in this topic. In our experience, the motivation for wanting an outpatient peer review process makes sense. The groups with which we have worked are interested in enhanced mechanisms and processes to better evaluate clinical care and address conduct concerns for ambulatory care practitioners, rather than solely relying on the human resources/employment process. They are also interested in taking advantage of any available peer review protections under state law that may only apply if there is a peer review structure in place.
An outpatient peer review process can be modeled on the process for your hospital’s medical staff. However, the structure is usually scaled down. For example, Clinical Specialty Review Committees, if being used for specialty reviews and expertise as a part of the Medical Staff peer review process, are generally not needed for outpatient peer review (but, as noted below, you want to reference your state’s peer review statute to confirm that any chosen structure maximizes protections under the law). Instead, you can rely on Clinical Specialty Reviewers or assign a member from the outpatient peer review committee who has the specialty expertise or knowledge to perform the case review.
As noted above, an additional consideration is your state’s peer review statute. If the statute contemplates peer review protections for outpatient peer review, you want to make sure that your process is set up to take advantage of those protections. By way of example, Colorado law discusses “professional review committees” of “authorized entities” (e.g., hospitals and physician groups). These professional review committees may share information with one another – for example, from hospital to group and group to hospital. The committees and their individual members are entitled to certain immunities from liability, and the records of professional review committees are confidential and privileged. However, for these protections to apply under Colorado law, the authorized entity and professional review committee must have statutorily required policies and procedures in place describing, among other things, hearing and appeal rights for practitioners. The professional review committee also has to register with the state. Thus, any peer review policy for an outpatient professional review committee will need to have these requirements addressed to be eligible for the protections in Colorado.
If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com. Also, tune in to The Brave New World of Ambulatory Peer Review, a podcast from Horty, Springer & Mattern attorneys Ian Donaldson and Charlie Chulack will be available on Wednesday, February 25, 2026 for more on this topic.