Published on March 4, 2014
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 P R O V ID E R -R E LA T E D T O TA L E du V er ca ba t io C lc on n ou t in ns uo el us in m g W on ri t it o te rin n Im co g S pr Y un S ov se TE ed li n M su g -R pe E LA rv G is TE io en Im n D er pr at T ov ed O ed TA ne ho L w sp po Im it a l ic pr le ie ov nv s ed iro co nm In cr m en ea m t un In se c ic d at IC rea io se U n d be st A ds cq af fi n or ui re g O d R ne ro C w om la ri eq fie s ui d pm ex en is t in ts g po M lic ad ie e s ne w fo rm 0 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
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APHA 09.30.11 - MSPRS 1. A Medical Staff Peer Review System in a Public Teaching Hospital – An Internal Quality Improvement Tool Linda S Chan PhD, Manal ...