Clinical Peer Review Program Self-Evaluation

Evidence-Based Tools for Healthcare Improvement

Notice: Out-Dated Version

This inventory was retired when the results of the Longitudinal Clinical Peer Review Effectiveness Study completed in March 2016 were accepted for publication in the International Journal of Quality in Health Care, published by Oxford University Press. Please see https:/qatoqi.com/php/self-assessment.php for the current version.

The associated methodological notes were simultaneously updated and can be found at: https://qatoqi.com/self-assessment-methodology.htm.

Archived Version

This brief questionnaire returns a QI Model Score measuring the extent to which your clinical peer review program conforms to evidence-based best practices.

For technical background on the Self-Evaluation Tool see: Clinical Peer Review Program Self-Evaluation Tool Overview

Answer the following questions as they apply to the entire peer review program at your hospital, not just within a single department. Your score will display after you submit your responses.

If you wish to receive a copy of the results and analysis, please be sure to enter your correct email address. All information entered will be kept confidential. We do not sell or share our contact lists.

Identifying Information (Optional)
First Name
Last Name
Title
Organization Name
Mailing Address
City
State (2 letters)
Zip Code
Phone
email
	Please contact me

1)	Standardization of Process
	Peer review process is highly standardized. An oversight group 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
	The process is not really standardized - autonomous behavior predominates
2)	Clinical Performance Measurement During Case Review (see examples below)
	The findings from case review are essentially undocumented
	Case review may be documented, but no measures of clinical performance are recorded
	Clinical performance is summarized with an overall score, which may capture a few key dimensions (Example A)
	Clinical performance is measured on multiple dimensions using a single template common to all medical care (Example B)
	Clinical performance is measured on multiple dimensions that vary according to the specific type of clinical activity being reviewed (e.g., surgery vs. medicine vs. OB)

Example A: Commonly Used Overall Rating Method

This assessment, limited to an overall score, classifies the review decision, but does not measure clinical performance.

It has 10 options, but only captures 3 levels of management quality (Appropriate - Varied from Standard - Unacceptable).

Example B: Sample Methodology and Rating Scale for Measuring Clinical Performance

Multiple elements of clinical performance are rated on a 5 point scale from Best to Worst. Page one of several.

cf: Rubin HR et al. Guidelines for Structured Implicit Review of Diverse Medical and Surgical Conditions. RAND; 1989 N-30066-HCFA.

Common overall unstructured rating method

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
4)	Governance of Process
	The medical staff leadership gives little or no attention to governance of the peer review process and its aggregate outcomes
	There is regular review of data involving the process and its aggregate outcomes, with little or no discussion
	There is regular review of 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)
5)	Rating Scales for Case Review (see examples above)
	We don't use rating scales
	We rate elements of clinical performance primarily on Yes or No type scales (e.g., a check box for documentation issues)
	We rate elements of clinical performance on scales that have at most three or four intervals from best to worst (Example A)
	We rate elements of clinical performance on scales that have five or six intervals from best to worst (Example B)
	We rate elements of clinical performance on scales that have seven or more intervals from best to worst
6)	Reviewer Participation
	Which statement best describes the level of participation by Reviewers in the Peer Review process?
	Excellent
	Very Good
	Good
	Fair
	Poor
	Very Poor
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
8)	Improvement Opportunities
	In each case review, we look for process improvement opportunities including clinician to clinician issues, in addition to evaluating individual clinical performance
	In each case review, we do little more than ask, "Was the standard of care met?"
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 the episode of care
	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 Case Review
	Pertinent diagnostic images or recordings (e.g., CT, MRI, ultrasound, fetal heart tracings, etc.) are routinely examined along with the medical record
	Only the medical record and the reports of pertinent diagnostic studies are examined
13)	Adverse Events
	Trends in adverse event rates (either globally or by event type) are monitored in the context of peer review outcomes by committees, departments or governance
	Adverse event rates are measured, but trends are not monitored in the context of peer review outcomes
	Adverse event rates are not measured
14)	Self-Reporting
	Medical staff members frequently report adverse events, near misses and/or hazardous conditions affecting their own patients for peer review.
	Strongly Agree
	Agree
	Somewhat Agree
	Somewhat Disagree
	Disagree
	Strongly Disagree
15)	Committee Discussion of Case Reviews
	What proportion of case reviews are presented and discussed in a committee prior to final decision-making?
	<25%
	25-49%
	50-74%
	75% or more
	Unknown
16)	Quality of Case Review
	Rate the general quality of case review activity on the following scale:
	Relatively superficial and lax
	..
	...
	....
	.....
	Extremely thorough and rigorous

Submit responses to see your QI Model Score Security Phrase: Enter both words separated by a space (required)

Clinical Peer Review Program Self-Evaluation Tool

Evidence-Based Tools for Healthcare Improvement

Notice: Out-Dated Version

Archived Version

Identifying Information (Optional)

1)

Standardization of Process

2)

Clinical Performance Measurement During Case Review (see examples below)

Example A: Commonly Used Overall Rating Method

Example B: Sample Methodology and Rating Scale for Measuring Clinical Performance

3)

Recognition of Excellence

4)

Governance of Process

5)

Rating Scales for Case Review (see examples above)

6)

Reviewer Participation

7)

Relationship to Performance Improvement Activity

8)

Improvement Opportunities

9)

Board Involvement

10)

Performance Feedback

11)

Case Review Volume

12)

Documents Examined During Case Review

13)

Adverse Events

14)

Self-Reporting

15)

Committee Discussion of Case Reviews

16)

Quality of Case Review

© 2012-23 Marc T. Edwards

QA to QI Consulting Posted: December 18, 2013 Last modified: July 13, 2018