American Public Health Association 2011: Medical Staff Peer Review System

1. A Medical Staff Peer Review System in a Public Teaching Hospital –
An Internal Quality Improvement Tool
Linda S Chan PhD, Manal Elabiad MS, Ling Zheng MD PhD, Brittany Wagman BS, Garren Low MS, Roger Chang, MA, Nicholas Testa MD, Stephanie L Hall
MD
Los Angeles County + University of Southern California Medical Center, Los Angeles, California
INTRODUCTION
2009
2010
# mortalities reviewed
# Had OFI (Level 1 review)
841
44
785
34
723
30
737
18
# OFI status not finalized
# Had OFE (Status finalized)
0
12
2
14
3
5
5
1
RESULTS – IMPROVEMENTS TAKEN
Improvement Actions Taken, 2007-2010
50
45
35
30
25
20
15
10
5
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MEDICAL STAFF PEER REVIEW SYSTEM
Number of Medical Malpractice per 100,000 Patient Encounters
120
Technical Challenges
•Lack of a electronic medical record
•Lack of universal access to the hospital
intranet .Procedural Challenges
•Uneven distribution of peer review workload
•Timeliness in processing peer reviews
Cultural Challenges
•Variable degree of acceptability and seriousness
• The “punitive” nature deterred unbiased reviews
Institutional Challenges
•Inadequate staffing, inadequate funding for
computer hardware and software
•Poor medical records system
•Slow implementation of corrective actions
LESSONS LEARNED
100
80
60
40
20
-1
-3
20
11
-1
1
11
20
20
10
-7
-5
-9
20
10
0
10
20
20
1
-3
-1
10
20
10
20
-9
-1
1
-5
-3
-7
09
20
20
09
20
09
20
09
-1
09
20
-9
-1
1
20
09
20
08
-5
-3
-1
-7
08
20
20
08
20
08
20
08
-1
1
20
08
20
07
-7
-9
20
07
20
07
-3
-5
0
-1
Number of Medical Malpractices per 100,000
RESULTS – MEASURE OF POTENTIAL IMPACT
20
07
Peer Review Levels and Bodies
•1st level: discharge department
•2nd level: Small Peer Review Committee (SPRC)
•3rd level: Executive Peer Review Committee
(EPRC)
Feedback and Reporting
•Weekly operational reports
•Quarterly summary trend reports
•Letters to accountable providers and departments
Confidentiality of Peer Reviews
•Only accessible to quality improvement staff
•All names are kept confidential through out review
process
Staffing
•A full-time computer engineer
•A half-time coordinator
•A half-time programmer analyst.
•Assistance from Quality Improvement Managers
(QIM) and QI support as needed
•Number of cases requiring improvement has
decreased
•Significant decrease in medical malpractice claim
rate could be related only in part to MS-PRS
•Direct impact of MS-PRS is difficult to measure
as it is an integral part of the quality improvement
effort of our institution
•MS-PRS scored about 70% using a published
self-evaluation tool (mean 45%, range: 0 to 86%)
(Edwards MT. Peer Review: A New Tool for
Quality Improvement. Physician Exec.
2009;25:54-59)
CHALLENGES ENCOUNTERED
40
07
LAC+USC MEDICAL CENTER
•Largest public teaching hospital in the west
serving the indigent population
•Licensed for 724 beds; transferred to its new
state-of-the-art facilities in November 2008
•Trains about 1,500 medical professionals daily of
which 870 are medical residents
2008
20
•Present the development, implementation, and
management of an electronic Medical Staff Peer
Review System (MS-PRS) as well as challenges
encountered and lessons learned
DISCUSSION
2007
20
07
PURPOSE OF THE STUDY
Opportunities for
Improvement (OFI)
Number of Improvement Actions
•Peer review - essential tool for evaluating and
improving medical staff’s quality of care
•Recent requirement by Joint Commission Ongoing Professional Practice Evaluation
RESULTS – MORTALITY PEER REVIEWS
•Must have adequate staffing, adequate
infrastructure, electronic medical records system,
universal web entry, continuous in-service,
monitoring and improvement
•All clinical departments must support the process
•The peer review instrument and process must be
improved to reduce the variation and bias
•Culture of peer review must be changed from a
punitive to a rewarding philosophy