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LAWRENCE M. SHUER
Chief of staff PEER REVIEW |
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I have attended peer review sessions on a regular basis ever since I came to Stanford University in 1978 to begin my postgraduate training in neurosurgery. At that point in my career I was already impressed with the idea that physicians collegially discussed complications and cases involving mortality. All of us have learned not only from our own experiences but also from those of our colleagues. Much
of medicine is based on this form of shared experiential education. At an institution such as ours, educational peer review sessions are an important tool in the training of medical students, interns and residents, as well
as members of the medical staff. And, yes, there is more to peer review than education. Licensing statutes require us to have true peer review in all of the services. The public expects physicians to "police" themselves in order to protect those who do not have the knowledge to question the practices or treatments of their doctors. Our peer review is designed to help physicians learn how to improve care of their patients. Only when there is a pattern that suggests a practitioner has a distinct problem with his/her care of patients will any disciplinary action be taken, and then only after the practitioner has been given the opportunity to receive due process via a hearing. Within the last year I have taken an active role in the hospitalwide Care Review Committee (CRC), charged with overseeing the peer review of each of the services of Stanford Hospital and Clinics. The CRC helps triage discussions about peer review in cases that cross traditional specialty lines or in which one service feels that another department might have some issues to discuss regarding the care of a patient. When a service-based peer review group believes that the care of a patient has been below standard, the case will be discussed by the CRC to see whether the "grading" of the case seems fair and correct. For a long time we have utilized a numerical grading system where episodes are rated as an unpreventable occurrence within the standard of care (1), or a possibly preventable occurrence within the standard of care (2), or a preventable occurrence with marginal deviation from the standard of care (3), or a preventable occurrence with a significant deviation from the standard of care (4). We have noticed that some physicians come to the CRC arguing about the numerical rating. Some quibble about whether a case should be rated a 1 versus 2, or 2 versus 3, etc. To get away from this numbers game, we have asked the peer review committees at the service level to answer seven questions regarding any incident or case reviewed: - Is there an opportunity to improve care? If so, what is that opportunity? - Could the incident have been prevented? If so, how? - Is there an educational opportunity? If so, what is the topic and who should be educated? - Does a hospital process need to be improved? - Does the case represent a deviation from the standard of care for this patient population, or did an error in judgment occur? - Was the management of the case appropriate after the complication or incident? - Does the case potentially call for risk management? Over the past four to six months we have been working on some peer review guidelines in an attempt to standardize the manner in which peer review is handled at the service level. We hope the medical board will ratify these guidelines soon. To begin with the CRC believes that peer review must first occur at the service level, since that is where a physician's true peers are found. If an issue comes to the CRC before it has been discussed at the service level, then we will refer it back to the service for action. We will invite the individual practitioner to appear before or correspond with the CRC about the specific case. I have found that most of our colleagues who have come before this body have understood the importance and perspective of a care review proceeding. Others, however, seem to be overly concerned with potential fallout and thus vociferously argue against any classification that in any way implies that the doctor might have handled the case differently. The process really encourages peers to evaluate a case and make a judgment in a dispassionate fashion. We intend to have physicians learn from the review and not get caught up in finger-pointing or trying to reject accountability in a particular case. Coming before the CRC should be viewed as an opportunity to explain onešs actions and hopefully to benefit and learn from the broad perspective that the committee offers. If any of you have questions regarding the peer review process, please do not hesitate to contact me at (650) 725-6021, or by e-mail (larshuer@ leland. stanford.edu). |
COLUMNS
Chief of Staff
Fact File: Neuropsychology
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