Peer review monthly: Should the medical staff quality committee be responsible for hospital PI?

In helping hospitals design effective medical staff quality committees to oversee their peer review programs, The Greeley Company must often help hospitals define the responsibilities of these critical committees. One area of debate is whether hospital performance improvement (PI) activities should fall under the medical staff committee umbrella.

I want to be clear that no regulations exist to guide hospitals one way or the other, although CMS favors separate reporting of medical staff and quality activities. If you have a single committee doing both functions well, you don’t need to change anything. However, when Greeley consultants are called in to assess why a medical staff is not performing internal peer review effectively, they often find that a combined committe is often at least partially to blame. As a result, Greeley consultants tend to encourage the creation of separate medical staff and hospital quality oversight committees.

The combined committee model is based on the belief that quality is seamless, and greater organizational learning takes place if all aspects of PI are addressed in the same setting. Although often cited as a concern, the real issue is not related to non-physicians being present during peer review discussions. These committees typically excuse most non-physician members before peer review discussions begin.

The main problem with the combined committee model is that managing quality requires authority and accountability. For hospital PI, the medical staff has neither when it comes to improving systems and processes of care. When a medical staff committee accepts PI responsibilities without the real authority necessary to drive change, two things may occur:
1. The medical staff may become distracted from its primary responsibilities: evaluating and improving physician performance
2. The board may fail to recognize that management is responsible for assuring that patient care systems function well

Do we want physicians to participate in hospital performance improvement? Absolutely! However, this leads to the second reason why combined committees often struggle: PI requires a physician who is a system thinker, while peer review requires a physician who can evaluate the competency of his or her peers. This is often not the same person, yet the combined committee requires its physician members to wear both hats. Separate committees are better able to cultivate and select physician members who have the appropriate mindset and interest for the tasks at hand.

Finally, the combined committee is a concern for the long-term protection of peer review information from discoverability. Unless a state law clearly protects PI discussions under the medical staff umbrella, using the medical staff committee to protect those discussions may undermine the fundamental purpose for peer review protection: to allow openness and candor when discussing physician competence.

Can hospitals preserve the desire for organizational learning without a combined hospital PI and medical staff quality committee? Yes, through clear communication between the two committees via a few common members. In addition, both committees should be accountable to each other to seriously address their own individual responsibilities.

Best regards,

Robert Marder, MD
Vice President
The Greeley Company