Play a supporting role in peer review

It’s important to remind those outside the profession of all the important work MSPs do every day. For example, while credentialing and privileging might be considered job one for MSPs, the medical staff services department is more involved in quality and peer review processes than ever before.

The medical staff services department is expected to develop incident reporting systems related to medical staff behavior or noncompliance with rules, and to collect this data as a part of the peer review process. The Joint Commission and Healthcare Facilities Accreditation Program (HFAP) have standards for ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) processes. Variations of these processes (with different names) are in place in facilities that aren’t accredited by these groups.

MSPs support many levels of peer review committee activity. For example, an MSP may establish clinical indicators and coordinate with other hospital departments to gather and monitor peer review data and identify trends and patterns within it. Cases are referred to the peer review committee from different sources. Referrals may come from members of the medical staff, the quality department (cases identified through root cause analysis), individual department case reviews, morbidity and mortality conferences, and trended data. If the committee determines none of its members are capable of conducting a thorough and unbiased review, it can identify members of the medical staff with the expertise necessary or can enlist external expertise for an outside review. The committee might also send a case out for external review if it determines that those with expertise could be viewed as inherently biased or as a competitor. Data supplied by the medical staff services department can help with this determination as well.

In addition to providing peer review committee support, MSPs work with chairs of other committees. In certain cases, they might also support the pharmacy and therapeutics committees, the medical records committee, and others to ensure that medical staff committee membership is diverse and that the committee members are appointed according to the medical staff governing documents. MSPs may coordinate meeting agendas, take minutes, and follow up to ensure that action items are completed.

Editor’s note: This post is adapted from an excerpt from The Medical Staff Office Manual: Tools and Techniques for Success.