Peer Review Program Self-Evaluation Items
For each multiple-choice item, please check the one response that most generally applies at
your organization, according to your knowledge.
1)
Standardization of Process
Peer review process is highly standardized.
The oversight committee approves all variation
The process is greatly standardized, but there
may be some unapproved variation
The process is standardized, although there may
be significant variation
The process may be somewhat standardized, but
variation is substantial
Unknown
2)
Clinical Performance Measurement (see examples above)
Case review outcome is classified as to standard of care or is undocumented
Case review is documented by an overall score with or without event classification, harm score, error analysis, etc. (Example A)
Case review is documented using a single
template to rate multiple elements of clinical performance common to all medical care, possibly
including an overall score, a case analysis, etc. (Example B)
Case review is documented by rating multiple
elements of performance on a template selected to match the specific type of clinical activity
being reviewed (e.g., surgery vs. medicine vs. OB), possibly including an overall score, etc.
Unknown
3)
Recognition of Excellence
We have a method to
identify and regularly provide recognition for outstanding clinical performance
We occasionally recognize outstanding
performance
Seldom or rarely, if ever, do we recognize
outstanding performance
Unknown
4)
Governance of Process
An oversight committee regularly reviews data
involving the peer review process and its outcomes, with meaningful discussion directed toward
ongoing improvement of the process (irrespective of discussions about individual performance
issues)
There is regular review of data involving the
process and its aggregate outcomes, with little or no discussion
There is little or no attention to the process
and its aggregate outcomes
Unknown
5)
Rating Scales (see examples above)
Rating scales are either not part of our
process, have less than five intervals, or only score deviation from the standard of care (Example A)
We use scales with five or six intervals from
best to worst (Example B)
We rate elements of an individual’s clinical
performance using scales with seven or more intervals from best to worst
Unknown
6)
Reviewer Participation
We have excellent participation by reviewers in
the peer review process
We have very good participation by reviewers in
the peer review process
We have good participation by reviewers in the
peer review process
At best, reviewer participation is only fair
Unknown
7)
Relationship to Performance Improvement Activity
Peer review is highly interdependent with the
hospital’s Performance Improvement (Quality/Safety Improvement) process
Peer review is at least fairly well-connected to
the hospital’s PI process
At best, peer review is only somewhat connected
to the hospital’s PI process
Unknown
8)
Improvement Opportunities
In each review, we look for process improvement
opportunities including clinician to clinician issues, in addition to evaluating individual
clinical performance
In each review, we do little more than ask, “Was
the standard of care met?”
Unknown
9)
Board Involvement
Trustees periodically receive information about
peer review activity beyond that which would be reported in relation to an adverse action
Trustees are only provided information in
relation to adverse actions
Unknown
10)
Performance Feedback
Cases are reviewed and opportunities for
improvement are communicated on average within 3 months of an occurrence
On average, more than 3 months is required
Unknown
11)
Case Review Volume
The total annual volume of cases reviewed is at
least 1% of hospital inpatient volume
The total annual volume is less than 1% of
hospital inpatient volume
Unknown
12)
Documents Examined During Peer Review
Pertinent diagnostic studies are routinely
examined along with the medical record
Only the medical record and the relevant
diagnostic reports are reviewed
Unknown
13)
Adverse Events
Trends in adverse event rates (either globally
or by event type) are monitored as an outcome measure of peer review activity by committees,
departments or governance
Trends in adverse event rates are not monitored
in the context of peer review outcomes
Unknown
Optional Tool Development Items
14)
Self-Reporting: Medical staff members frequently report adverse events, near misses and hazardous conditions affecting their own patients for peer review.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
Unknown
15)
Leadership: If we found compelling reasons to change our peer review process, we would not be hampered by a lack of leadership.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
Unknown
16)
Resources: If we found compelling reasons to change our peer review process, we would not be hampered by a lack of resources or administrative support.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
Unknown
17)
Resistance to Change: If we found compelling reasons to change our peer review process, we would not be hampered by general inertia and resistance to change.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
Unknown
Submit your responses to see your score