Physician Peer Review in a Just Culture
In order to effectively manage physician actions inside a Health Care Organization
(HCO) it is necessary to have the following policies and practices.
1. Physician Health Policy
2. Disruptive Physician Policy
3. Physician Peer Review
It is important to realize that Physician Peer Review does not replace the managerial
responsibilities of the HCO.
The following Flow Chart attempts to show how Physician Peer Review is integrated into
the management of the organization.
ISSUE
RESOLVED
no further
action
Yes
ETHICAL CONCERN
Discuss Directly
Not Resolved
Unable to discuss directly
TAKE ISSUE TO SUPERVISOR/MANAGER/
ADMINISTRATOR
ISSUE
RESOLVED
no further
action
Yes
Not Resolved
TRIAGED BY
SUPERVISOR/
MANAGER/
ADMINISTRATOR
STAFF CONCERN
BEHAVIOR/
PERFORMANCE
PHYSICIAN PRACTICE/BEHAVIORAL CONCERN
SUPERVISOR/MANAGER/ADMNISTRATOR CONTACTS APPROPRIATE SECTION
CHIEF, CMO, OR CHIEF OF STAFF TO COMMUNICATE TO IN WRITING
HUMAN RESOURCES
BUSINESS ETHICS CONCERN
CORPORATE COMPLIANCE OFFICER
CLINICAL ETHICAL CONCERN
ETHICS COMMITTEE
SECTION CHIEF/CHIEF OF STAFF INITIATES INVESTIGATION
ISSUE RESOLVED
No further action
No
FURTHER INVESTIGATION REQUIRED - REFER TO MEC SUBCOMMITTEE OR
MPOC
SUBCOMMITTEE RESOLVES ISSUES AND/OR MAKES RECOMMENDATION TO MEC
REPORT SENT TO MEC FINAL RESOLUTION OR MC BOARD
July 2003
The conceptual basis of integrating Physician Management into the Health Care
Organization is outlined below.
PEER REVIEW
Preamble
The effective, efficacious, appropriate and safe delivery of medical care in a timely and
respectful fashion in the 21st century is an undertaking of unprecedented complexity.
Managing this degree of complexity requires an organization that is able to perform with
not only a high degree of reliability but also to flexibly react to the changing
environment. In the parlance of Complexity Theory this is a Complex Adaptive
Organism (CAO).
The Medical Staff and its members are necessary players but by themselves cannot
achieve this goal. Likewise the Organization cannot achieve its Mission alone. Therefore
both parties, in a collaborative fashion, must actively manage this partnership with the
goal of providing effective, efficacious, appropriate, respectful, timely and safe care.
An effective partnership must use a common language and uniform process when
designing care delivery procedures. Likewise investigation of Adverse Events, Errors,
System Design and the Individual’s Behavior Choices must be congruent whether
involving the Medical Staff or the Organization’s Employees.
Thus it is necessary to instruct and engage the Medical Staff in the Principles and
Practices of the Just Culture paradigm.
ESSENTIAL CHARACTERISTICS OF A CAO
I.
ACCURATE, TIMELY INFORMATION
The first essential characteristic of a CAO is acquiring accurate, timely information. This
means that there must be tripwires to alert the CAO that a change has occurred that
requires a response (henceforth referred to as a finding). Information for and about the
Medical Staff comes from a variety of sources.
 Provider specific issues identified from aggregate data analysis.
o CMS disease state management indicators, as well as other Performance
Indicators are examples.
 Provider specific issues identified during an event analysis.
o Incident/Occurrence reports
o Quality Concerns identified by staff
o Risk Management audits
o Sentinel Events/Root Cause Analysis
o Patient/Family/Staff complaints
Audit tools/Aids available include: Model HR policies
Model Quality Concern policies
Model Risk Management policies
Model Root Cause Analysis procedures
Model Incident/Occurrence reporting policies
And_____________________________________
II.
THE RESPONSE
The second characteristic of a CAO is the formal response mechanism to findings.
The essential questions to be answered are:
1. Did the Provider set himself/herself and the Patient up for failure?
2. Did the System set the Provider and the Patient up for failure?
3. Was the outcome within the range of expected events by virtue of how care is
delivered?
There should be two parallel lines of analysis of the finding before answering the
preceding 3 questions.
o Evaluation of the Provider for the following issues:
o Health issues which impair performance of the provider or the
organization
 Provider Health policy
o Behavior issues which impair performance of the provider or the
organization
 Disruptive Provider policy
o Knowledge and Skills of the provider
 Training assessment
 Competency assessment
o Evaluation of the quality of the decisions made by the Provider with a
formal determination of whether the decision was human error, at risk
behavior or reckless behavior
 Duty to avoid Harm or Unjustifiable Risk
 Duty to produce an Outcome
 Duty to follow a Procedural Rule
o Evaluation of the System for the following issues:
o Is this result what we designed the system to deliver
o What are the performance shaping factors
o What are the barriers to a poor outcome
o Is there redundancy in the system
o How is recovery fostered
o Is there a perception of high risk
Audit tools/Aids available include: Model Disruptive Provider policy
Model Provider Health policy
Algorithms for the 3 duties
Event Investigation Rules
Job description of a safety/systems engineer
State Peer Review statutes for protected professions and
processes in order to preserve the shield of peer review
And _________________________________
III.
DESIGN
The third characteristic of a CAO is how Care Delivery is designed. There are Formal
and Informal mechanisms.
o Formal Mechanisms for the Medical Staff and the Organization to work together
o Committee structures
o Medical Directorships
o Departmental structures
o Board of Director membership
o Quality Model
 TQM, CQI, FACRAE, PDCA???
o Informal Mechanisms for the Medical Staff and the Organization to work together
o Teams
o Work Groups
o Manager engagement
Audit tools available include: Assessment of resources allocated to Quality
Strength of the Medical Staff in enforcing rules
Information flow to/from the Medical Staff
Dollars/Training allocated to the Medical Staff
Decision making steps on Capital Expenditures
And____________________________________
IV.

FLEXIBILITY
The fourth characteristic of a CAO is ability to perceive subtleties and also
nimbleness of response. The measure is whether or not the organization is flexible
in modifying the policies and processes to the unique circumstances of each
Patient’s situation.
This equates to the organizational assessment of and response to Social Utility in
deviations from policy and procedure.
Audit tools available include: Review of disciplinary files
Patient Complaints
Interviews of Front Line Staff and Providers.
And ____________________________________