What makes peer review punitive?

Nothing turns physicians off from participating in peer review than a punitive peer review process. Although peer review is a regulatory requirement, each medical staff must decide how to approach it at its own institution. If your medical staff perceives peer review as punitive, you need to determine why.

Whether you have explicitly decided to use more punitive methods or have simply settled into an approach because “we have always done it this way,” you have made a cultural choice. But like any choice, you can change if you understand how your organization’s culture influenced it.

So how do you move to a non-punitive peer review culture? Although there are a number of factors that affect how physicians perceive a peer review program, a key factor is fairness. Having a fair peer review process means having a consistent process that allows for appropriate input and treats everyone equally. In The Greeley Company’s work with peer view programs across the country, we have found several practices that can affect the perception of fairness in a peer review program.

The first factor is consistency. Have clear policies and procedures and apply them as they are written. Physicians often perceive that peer review is unfair and that the medical staff has multiple peer review committees that follow different procedures. Many medical staffs have moved to a central multi-specialty peer review committee to eliminate that variability and lend the peer review process consistency.
However, a single multi-specialty committee can still be unfair if the committee does not follow its own procedures. It is not uncommon for physician leaders to ignore or be unaware of peer review procedures and revert to “common sense,” which means different things to different people, and is therefore inconsistent. Similarly, peer review support staff may lapse into old practices and lose focus on keeping the committee on track with their current procedures.

Whether you have a single committee or multiple committees, it is critical to look at your peer review policies and procedures and make sure that your practice matches them. Not only will this help your peer review culture, but it will protect you from potential legal issues related to peer review.
The second factor that affects how physicians perceive peer review is whether the peer review process allows for appropriate input. Every physician feels that he or she deserves a day in court when the medical staff starts questioning his or her care. Get the physician’s input prior to the final committee decision. This is a vital cultural choice for reducing physicians’ perception that the peer review process is punitive. Rather than the committee making a decision and then allowing the physician to respond if he or she disagrees, we recommend that committees first ask the physician the key questions that have raised concerns in the first place. The committee should withhold any discussion and decision about the severity of the case until it has received the physician’s input within an appropriate timeframe. In return, the physician should be fair to the committee and respond within a reasonable time frame. If the physician fails to respond in a reasonable time frame, the committee may then retract the physician’s right to offer input.

The committee should also seek input from the initial reviewer. Requiring the reviewer to provide content-based opinions regarding whether the care is appropriate is critical to avoiding under- and over-scoring of case reviews. It allows the committee to examine the initial review and pinpoint its questions for the physician in question.

The last aspect of fairness is equality. Conflict of interest is a major issue that often creeps into every medical staff’s culture at one time or another. Peer review committee members must be aware of and disclose all potential conflicts of interest prior to reviewing a physician’s performance. If those conflicts are substantial, the member should not be present during committee discussions and voting. If a peer review committee member’s performance is being evaluated, the committee should not treat him or her any differently than a physician who is a non-committee member.

Finally, once you've created clear policies and procedures and implemented them consistently, there's one more step that can help: transparency. Educate your medical staff about the peer review process and how your medical staff is striving to make it better. Doing so can go a long way to reducing the perception of unfairness and therefore engage physicians more fully in the peer review process. 

Robert Marder, MD, CMSL, is the vice president of The Greeley Company, a division of HCPro, Inc., in Danvers, MA.