Peer Review Monthly: Why use a scoring system for peer review?

Dear Medical Staff Leader,

At a recent Greeley Company national seminar, a physician leader asked me why peer review committees should use a case review scoring system. She had attended another organiation’s program, which advocated eliminating final case scoring and simply classifying cases with care issues as “referrals.” When the physician leader asked the previous speaker to justify this approach, the speaker in turn asked why one would use a scoring system in the first place.

The Greeley Company has consistently advocated for scoring case reviews, but we are certainly open to new ideas that may help medical staffs perform effective peer review. In that spirit, I thought it would be useful to review our justification for using our scoring system to be sure it is still relevant. This scoring system is based on following three action points:

1. Rate each case using categories that focus on a single aspect of evaluation. Doing so makes scoring easier and more reliable. It is better to have one category that evaluates the potential clinical outcomes and a second category that evaluates the appropriateness of  physician care rather than a single category that tries to combines both (e.g., a category such as “Moderate effect on the patient but no physician care issues”). Likewise, it is important to have a separate category for documentation deficiencies because they are different from technical quality of care issues.
2. To rate appropriateness of care, use at least three levels:
   • Appropriate
   • Questionable (or controversial)
   • Not appropriate

   Otherwise, even when a physician reviewer disagrees somewhat with the approach taken by the physician under review, the reviewer will score care as “appropriate” if the only other option is “not appropriate.”

3. Define the reasons why care might not have been viewed as appropriate. The Greeley Company uses a separate category to identify physician care issues (e.g. skills, knowledge, judgment, communication, planning, etc.). Systematically defining physician care issues at the time each case is decided allows the medical staff to get to the root cause of physician performance concerns and identify patterns for improvement despite differences in the diseases, procedures, or circumstances of the individual case.

The main reason for using a scoring system for case reviews is fairness. A scoring system lends itself to more clearly defined thresholds for focused review and allows the medical staff to set prospective targets and address different levels of concerns. As a result, scoring systems make the decision to look more closely at physician performance less arbitrary and more fair. Typically, a medical staff will set a threshold to automatically review a physician’s performance if more than two cases per year are rated inappropriate or four cases per year are rated questionable or inappropriate.

An additional benefit of using a categorical scoring system is that it lends itself to database tracking and easier pattern recognition. Leaving cases rated as referrals requires going back and defining the issues that were apparent on the initial review.

There may be reasons for eliminating scoring based in legal concerns to minimize documentation for peer review. However, to do fair and effective peer review, we believe case scoring is still well justified if a good system is used.

Regards,
Robert Marder, MD, CMSL
Vice president
The Greeley Company