INSERT HEALTH CENYER NAME
POLICIES AND PROCEDURES
DEPT/OPS AREA: Quality
Management
POLICY NAME:
POLICY NUMBER: QM XX
PEER REVIEW PROCESS
EFFECTIVE (ORIGINAL) DATE:
APPROVAL DATE:
REVISED DATE:
DATE REVIEWED:
APPROVED BY: Board of Directors
POLICY STATEMENT:
This policy is applicable for all Licensed Independent Practitioners (LIPs) credentialed by the health
center.
Patient safety and quality medical care are the central foci underlying the health center’s peer review
process. All appropriateness of care peer reviews are conducted using evidence-based guidelines, when
available, or practice parameters developed by national medical specialty societies, which have been
vetted and approved by the health center when feasible. Peer reviews are based on appropriateness,
effectiveness and efficiency of services to assure quality medical care. The purpose of peer review is to
proactively examine clinical system processes that may identify opportunities for system improvement
and to address alleged quality of care issues when presented.
RESPONSIBILITY:
The Board of Director’s (BOD) and the Chief Executive Officer (CEO) has ultimate responsibility for
the peer review processs policy. The BOD delegates oversight of this policy to the Quality Improvement
Committee (QIC) to conduct review of peer review results and make recommendations for performance
improvements, when improvement opportunities are identified. The CEO delegates the responsibility to
effectively manage the peer review process to the Medical Director.
All LIPs are required to participate in peer review activities.
IMPLEMENTATION:
Peer reviews for efficiencies, effectiveness, and appropriateness of care are conducted periodically, at
least quarterly, using a proactive systematic assessment process in which a clinician reviews, or
supervises the review process, using a random sample of a charts for quality of care indicators. The
health center may request and/or approve external peer reviewers from time to time to conduct peer
reviews.
A standardized review audit tool is used to conduct each review. At least annually the QIC determines
peer review areas of focus. Relevance is based on previous year peer review performance to threshold,
high cost and/or high volume diagnoses, population demographic. At a minimum peer review addresses
two chronic conditions, preventive health (including immunizations) across relevant population
SAMPLE: Peer Review Process Policy
Quality First Healthcare Consulting, Inc.
Page 1 of 2
DEPT/OPS AREA: Quality
Management
POLICY NAME: PEER
REVIEW PROCESS
POLICY NUMBER: QM XX
lifecycles, and prenatal care.
The minimum threshold for overall peer review performance is 85% per audit. Must-pass criteria may
be established from time to time for critical decision points in the delivery of medical care.
Clinician specific peer reviews may be directed by the Medical Director and/or CEO when quality of
care issues are identified via complaints, adverse incidents, or poor quality of care allegation from other
sources. Any quality of care issue regarding patient care will initially be reviewed by the Director of
Quality or designee with oversight from the Medical Director. Confirmed issues are thoroughly
investigated with results reported to the CEO.
Medical Record Documentation reviews are conducted using the health center’s medical record
standards and may be conducted by non LIPs under the supervision of the Medical Director, or designee.
DOCUMENTATION/MONITORING:
All identifiable peer review results are considered privileged and confidential.
Results are stored and kept secure by the Director of Quality. Peer review results are de-identified and
aggregated results with trended performance over time are presented by the Medical Director, or
designee, to the QIC for review.
Clinicians who fail to meet the threshold on any given review are informed by the Medical Director of
the performance deficiency relevant to the appropriate evidenced-based guideline and encouraged to
implement improvement measures. Repeated failures to meet threshold are reported to the CEO.
Clinicians who consecutively fall below threshold in an area of recognized deficiency will be counseled
by the Medical Director and CEO and may be asked to submit a corrective action plan.
Results of peer reviews are tracked for individual LIPs and incorporated into the LIPs credentialing
renewal process.
REFERENCES:
Section 330(k)(3)(C) of the PHS Act and 42 CFR Part 51c.303(C)(1-2)
Joint Commission Comprehensive Accreditation Manual for Ambulatory Care. HR.02
Program Assistance Letter 2012-04, New Requirements for Deeming under the Federally Supported
Health Centers Assistance Act
SAMPLE: Peer Review Process Policy
Quality First Healthcare Consulting, Inc.
Page 2 of 2