Who determines when external peer review is needed?

Typically, recommendations for external peer review (EPR) arise from peer review committees that are faced with issues they can't resolve--lack of specialty expertise, conflicts of interest and other potential legal or credibility issues. The board should also have the right to determine whether it needs EPR to answer concerns or protect itself legally even if the medical staff believes it can, or has, conducted a fair review. Although a physician may ask that the committee or leadership request EPR for his or her case, we strongly recommend that your policy not allow for the involved physician to demand EPR. It is the organization's decision whether it can perform peer review fairly. That said, organizations should consider the physician's concerns in making their decision, particularly when dealing with potentially litigious physicians.

Because EPR will often require the use of extra financial resources, the hospital or medical staff leadership should approve the need for EPR. This approval may go through the medical executive committee (MEC) or via a mutual agreement between the medical staff president and an administrative leader, often the vice president for medical affairs or the chief medical officer, if the organization has one. Unless the review is a routine review due to lack of internal expertise, the hospital's counsel should clearly identify and support the precipitating reason for the EPR. For example:

• Was the review initiated because of concern that a potential patient-care problem might exist?
• Was it initiated after an investigation designed to determine whether sanctions are necessary?
• Was it initiated because support was needed for sanctions already rendered?

Answering these questions can make all the difference between an orderly collegial solution and an adversarial fair hearing. No outside evaluation should be initiated without involving legal counsel experienced in healthcare law.