Normative Clinical Peer Review Database Project

Scope

Hospital-wide medical staff peer review activity

Exclusions

Pathology and Diagnostic Radiology reviews

Definitions

Pre-Review Case Screening
A process to determine whether to send a question related to one specified patient episode of care for peer review
Case Review
A peer review of one specified patient episode of care by one committee or department. If the same patient episode of care is independently reviewed by a separate committee or department, count it as a separate case. Count a readmission review as 1 case review.
Learning Opportunity
A broad view of the potential for improvement, both individual and organizational, to be gained from the peer review process.
More than 1 learning opportunity may be identified in any single case review.
Reason for Review
Whatever criteria or screens are used in your organization to identify cases for peer review. They may differ across departments or committees. A comprehensive taxonomy is available on request.

Data Collection Periods

  • October 1 – March 31
  • April 1 – September 30

Note: All measures apply to the time period being reported.

Required Program Measures

  1. Total number of cases identified/referred for review
  2. Total case review volume
  3. Total hospital admissions
  4. Total count of instances of recognition of excellent performance by a member of the medical staff
  5. Total count of Learning Opportunities discovered in peer review (sum of a-c)
    1. System issues
    2. Group education
    3. Individual education

Optional Program Measures

  1. Breakdown of Total number of cases identified/referred for review
    1. Number of cases self-referred for peer review
    2. Number of cases identified/referred by medical staff involving other clinicians
    3. Number of cases indentified/referred by other clinical staff (do not include referrals by those whose defined role is to identify cases for peer review)
    4. Number of cases identified by all other means
  2. Breakdown of Total number of cases reviewed by committee or service. For example,
    1. Total number of Medical cases reviewed
    2. Total number of Surgical cases reviewed
    3. Total number of Other cases reviewed
  3. Breakdown of Total hospital admissions corresponding to #2. For example,
    1. Medical admissions
    2. Surgical admissions
    3. Other admissions
  4. Number of cases identified/referred by reason for review
  5. Number of cases closed via pre-review screening process (sum of a-c)
    1. Number screened by a physician
    2. Number screened by non-physician clinicians
    3. Number screened by non-clinicians
  6. Number of cases reviewed by reason for review
  7. Number of cases reviewed by level of harm (AHRQ Common Format harm score preferred)
    • 1 = Death: Dead at time of assessment
    • 2 = Severe permanent harm: Severe lifelong bodily or psychological injury or disfigurement that interferes significantly with functional ability or quality of life. Prognosis from time of assessment
    • 3 = Permanent harm: Lifelong bodily or psychological injury or increased susceptibility to disease. Prognosis from time of assessment
    • 4 = Temporary harm: Bodily or psychological injury, but likely not permanent. Prognosis from time of assessment
    • 5 = Additional treatment: Injury limited to additional intervention during admission or encounter and/or increased length of stay, but no other injury. Treatment since discovery, and/or expected treatment in future as a direct result of event
    • 6 = Emotional distress or inconvenience: Mild and transient anxiety or pain or physical discomfort, but without the need for additional treatment other than monitoring (such as by observation; physical examination; laboratory testing, including phlebotomy; and/or imaging studies). Distress/inconvenience since discovery, and/or expected in future as a direct result of event
    • 7 = No harm: Event reached patient, but no harm was evident
    • 8 = No Event: Case selected for review for reasons other than an adverse event or near miss (not on AHRQ list)
  8. Average turn-around-time for case review, measured in days, from date of the event which ultimately gave rise to the review until the date of final decision on the case, for cases in which the final decision is made during the period
  9. Reviewer meeting attendance – average percent attendance for the time period
  10. Average cases reviewed per reviewer per meeting
  11. Breakdown of System issues identified in the peer review process
    1. Clinician to Clinician or Interdepartmental issues
    2. Other system issues
  12. Learning opportunities discovered by type vs. reason for review – a pivot table with Excellence and the 4 types of learning opportunities as columns (Excellence, Clinician to Clinician Issue, Other System Issue, Group Education, Individual Education) and the Reasons for Review as rows.
  13. Measures of medical staff perception of the peer review program (as may be in use)
    1. Multiple choice items: provide report with counts of responses for each response option for each survey item
    2. Free text response items: provide summary of findings

Have Questions or Need Clarifications?

Contact Marc T. Edwards, MD, MBA: marc@QAtoQI.com or 860 521-8484