The primary purposes of the peer review process are to:
Monitor the individual clinical performance of providers.
Review the effectiveness and appropriateness of modalities and procedures.
Examine member grievances and satisfaction reports to determine necessity or corrective action.
Review the quality, content and completeness of medical records to include an evaluation of legibility and problem-oriented progress notes (concurrently and retrospectively).
Review the appropriate use of the formulary and documentation of instructions to Members.
Make recommendations to the Quality Improvement Committee chairman regarding provider outcomes of care. Initial remedial actions must be submitted as a formal recommendation to the Corporate Quality Improvement Committee Chair and may be in the form of in-service education.
Organization
Physician practitioners (with non-physician medical providers’ participation, when indicated) conduct peer view. The suggested format for peer review evaluation is attached.
The physicians at each primary care site are responsible for supervising non-physician medical
Quality Improvement Program Description
practitioners. Letters documenting this relationship are kept on file at each primary care site and Medical Group office and at Community Health Group.
The minutes of the Peer Review sessions are kept confidential in the Quality Improvement process.
Quality of care concerns identified via the Quality Improvement process are categorized for assessment, intervention, and resolution as follows:
Level 0 - No quality of care issue.
Level 1 - Pertains primarily to the art of caring and communication issues.
Level 1a - Surgical complications - Untoward surgical or post surgical events, which are not determined to be due to negligence or poor technical ability.
Level 1b - Pertains to minor systems problems including documentation issues.
Level 2a - Pertains to systems problems with potential for adverse outcome to member or cases, which demonstrate adverse effect on the member.
Level 2b - Pertains primarily to clinical issues and/or clinical judgment directly impacting member's care with the potential for mild to moderate adverse effect on the member or for cases, which demonstrate mild adverse effect on the member.
Level 2c - Clinical issues which reflect the potential for significant to serious adverse effect on the member or for those cases which demonstrate moderate adverse effect on the member.
Level 3 - Medical mismanagement with significant adverse effect on the member. "Significant Adverse Effect" is defined as:
1) Unnecessarily prolonged treatment, complications, or readmission; or
2) Health care management that results in anatomical or physiological impairment, disability or death.
Once the significance of the identified quality issue is determined, the Credentialing Sub-Committee members select the appropriate corrective action. Corrective action plans are categorized by the choices listed below. This breakdown allows a method for tracking the different types of corrective action interventions that are implemented, and provides a standardized method for determining the most appropriate course of action to take.
Notification
Education
Intensification
Coordination with licensing and accreditation bodies
Sanction plan corrective action process to be initiated, and a time frame in which to implement and/or complete the corrective action. An explanation on how to appeal the Committee's decision or submit further explanatory information is included in the notification letter that is sent to the provider and/or other involved parties.
Education
Educational methods are used as a corrective action when it appears that an educational deficit may be causing the identified problem. Educational corrective actions may include:
Telephone and/or one-on-one discussion with the responsible parties
Quality Improvement Program Description
Letters or notices defining case specifics and the appropriate action plan
Suggested clinical literature reading
Self-education courses
Continuing clinical education course recommendation
Monitoring by another physician
Intensification/Focused Review
Intensification includes focused review of all care or cases involving the particular provider in question, for a limited period of time. The provider is then re-evaluated by the CorpQIC, based on the findings of the cases reviewed since the initial problem was first identified. The purpose is to determine if the issue in question was an isolated event or follows a pattern or trend.
Coordination with Licensing and Accreditation Bodies
Information regarding significant adverse outcomes determined to be the fault of a contracted provider is coordinated with regulatory agencies such as the National Practitioner Data Bank and the California Medical Board. The types of cases that would be reported must demonstrate severe, persistent patterns of inappropriate practice after the provider in question:
has been provided the opportunity to present his/her views on the matter to the CorpQIC,
failed to break the pattern after corrective action has been repeatedly requested, and
has exhausted his/her appeal rights.
Sanction Plan
The CorpQIC and/or Board may recommend sanctions for cases where a practitioner fails to alter a behavior after repeated reminders. However, these sanctions do not always result from identification of adverse outcomes. For example, cases where a physician is repeatedly not following Community Health Group’s guidelines for obtaining prior authorization for a referral to a specialist may also fall into this category. The quality of care may not be affected in this instance, but the provider is considered to be consistently non-compliant with guidelines. A letter from the Board warning the provider of possible dismissal from the provider network if cooperation is not obtained may be a sanction used in this particular situation.
If a more severe sanction is recommended by the CorpQIC, such as actual dismissal from the plan, and reporting to the National Practitioner Data Bank is indicated, the Board is immediately notified of the specifics and requested to provide recommendations and make the final decision to terminate a contract with a practitioner.
Other Interventions
Based on the uniqueness of each situation, interventions for corrective action may be indicated that do not necessarily appear in the guidelines. For these situations, the CorpQIC members, under the direction of the Chief Medical Officer, may determine the most appropriate corrective action to formulate.
Corrective Action Requirements
Regardless of the type of corrective action selected for use by the CorpQIC, certain parameters are followed for developing the implementation plan. These are as follows:
Quality Improvement Program Description
Date the corrective action is to begin, how long it will be in effect, and when it will be re-evaluated are clearly defined.
Responsible parties for ensuring implementation and monitoring of the corrective action plan are identified.
Anticipated outcome is identified.
Objective goals must be incorporated into the plan to provide effective measurement tools.
Re-evaluation of the identified quality problem is included in the plan to determine its success.
Subsequent action plans are developed and initiated using the same parameters as the first.