•Peer review - essential tool for evaluating and improving medical staff’s quality of care •Recent requirement by Joint Commission - Ongoing Professional Practice Evaluation

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

CHALLENGES ENCOUNTERED

RESULTS – MORTALITY PEER REVIEWS

•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

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 reviewsCultural 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

MEDICAL STAFF PEER REVIEW SYSTEM

LESSONS LEARNED

•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

PURPOSE OF THE STUDY

•Present the development, implementation, and management of an electronic Medical Staff Peer Review System (MS-PRS) as well as challenges encountered and lessons learned

RESULTS – MEASURE OF POTENTIAL IMPACT

LAC+USC MEDICAL CENTER

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 departmentsConfidentiality of Peer Reviews•Only accessible to quality improvement staff •All names are kept confidential through out review processStaffing•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

INTRODUCTION DISCUSSION

•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)

RESULTS – IMPROVEMENTS TAKEN

Opportunities for Improvement (OFI)

2007 2008 2009 2010

# mortalities reviewed# Had OFI (Level 1 review)

84144

78534

72330

73718

# OFI status not finalized# Had OFE (Status finalized)

012

2 14

3 5

5 1

Improvement Actions Taken, 2007-2010

0

5

10

15

20

25

30

35

40

45

50

Nu

mb

er

of

Imp

rovem

en

t A

cti

on

s

Number of Medical Malpractice per 100,000 Patient Encounters

0

20

40

60

80

100

120

Nu

mb

er

of

Me

dic

al M

alp

rac

tic

es

pe

r 1

00

,00

0