Establish effective oversight of the peer review process

The oversight function of the peer review process involves all the actions necessary to oversee the process to ensure that it is done correctly.

The oversight function is not always familiar to physicians because in many hospitals, the peer review process is not organized to perform it. Medical staff oversight of the peer review process may simply be an afterthought—they may do only what the quality staff tell them to do with regard to measurement, evaluation of data, and so forth, or they may resolve only controversial cases. To create an evaluation process that truly focuses on physician improvement, however, the medical staff must establish an active oversight structure with clearly assigned responsibilities that support the goals of peer review. Such an oversight structure will, for example, select relevant physician measures for all six performance dimensions and prioritize resource use.

Medical staff responsibilities critical to effective oversight of the peer review process include:

• Standardizing and coordinating the case review process to ensure reliability
• Ensuring consistent interpretation of physician performance data
• Selecting relevant physician measures for all performance dimensions or general competencies
• Ensuring that data is systematically collected and analyzed
• Ensuring that identified performance improvement opportunities are addressed
• Ensuring availability of physician performance data for feedback and reappointment
• Prioritizing the use of resources for measuring physician performance