Tip: Define meaningful case review indicators and criteria

General case review indicators should represent significant clinical outcomes or critical processes for which physicians are partially or completely responsible and therefore represent potential improvement opportunities. It is important to make sure that the general review indicators cover all important outcomes, such as mortalities, complications, readmissions, missed diagnoses, or misdiagnoses impacting the patient’s care and patient safety events. It is also important that these indicators are specialty-specific when appropriate.

So what makes for a good case review criterion? A good case review criterion goes beyond the general issue or outcome (e.g., unexpected death) in two ways. First, it defines what clinical situations should be included for physician review because of a likelihood that a physician care issue may have contributed to that outcome. Second, it defines what clinical situations do not need physician review because it is obvious that the review would say the care is appropriate (e.g., death of a patient admitted for palliative care).

Often, these criteria are in the head of an experienced peer review coordinator. Getting them down on paper for medical staff approval and improvement will reduce the perception of bias and increase interrater reliability. A good way to organize this is with a table that shows in a series of columns the general indicator, the inclusion criteria, and the exclusion criteria. In addition, one can add columns describing the relevant departments for a given indicator, and the case identification source. Table 1 provides a set of review indicators using this approach.

Source: Effective Peer Review, Fourth Edition

Table 1: Sample case review criteria

Indicator Inclusions Exclusions
Unanticipated death: Surgical/
Peri-procedural mortality or death within 30 days of initial procedure; deaths with a risk of mortality MSDRG ROM score of 1 or 2 Unless identified by another review indicator: Procedure for palliative care; intracranial patients presenting with GCS ≤5; patients with ASA class 5 or 4E with appropriate procedure indications; urgent/emergent surgery for aortic disease unless surgeon non-availability; patients requiring surgical exploration with intraoperative findings indicating an unsalvageable condition.
Unanticipated death: Medical Inpatient deaths for conditions where death is not typically
anticipated; deaths with a risk of mortality MSDRG ROM score of 1 or 2
Unless identified by another review indicator (e.g., missed diagnosis): Admissions for palliative care; frail patients with multiple comorbid conditions and documented poor prognosis; patients presenting in shock (cardiovascular, hypovolemic; septic); patients presenting to ED in cardiopulmonary arrest; deaths from PE or of patients on appropriate prevention and therapeutic protocols with multiple other comorbidities; deaths due to stroke in patients placed on stroke protocol.
Unanticipated death: OB/neonatal Maternal death, newborn or intrapartum fetal death with gestational age greater than 28 weeks Infants with severe congenital anomalies

Note: This table provides examples of how common generic review indicators can be refined by the medical staff through explicit inclusions and exclusions to ensure consistency and fairness in the case screening process and reduce the number of unnecessary reviews. This list is meant to be illustrative and does not represent a complete set of review indicators. Also, each medical staff needs to decide whether the inclusions or exclusions are acceptable for its peer review program.​