Professional Interactions – Best Practices Series
Creating Internal Peer Review That Has Buy-In, Part I
By Fred Corbus
This article first appeared in Round-up Magazine, official publication of the Maricopa County Medical Society.
My article on the Best Practice of Internal Peer Review will be in two parts. Part I addresses the development of guidelines, elements of a peer review form, and the format of the evaluation reporting handout for the subsequent roundtable. Part II, which will be in the November issue, will address the implementation of the peer review.
Let’s be honest – the mere mention of “Peer Review” instantly stirs up deeply embedded emotions: the fear of being confronted and the fear of being asked to do the confronting, the anxiety of causing a strain on relationships and the fear of being part of a process that will result in people disliking you. And, in fact, of the hundreds of physicians I have personally worked with, I can’t ever recall being asked to begin my consulting relationship by designing and implementing a peer review. Only after a practice has trust in my method of facilitation and sees value in the other, “safer,” professional interaction documents, is it willing to entertain the idea. I would have to admit, however, that encouraging and coaching physician groups through the development of internal peer review is uniquely satisfying for me as a professional facilitator. The reason is simple: if done correctly it provides a safe, constructive way to talk about the quality of almost any professional interaction. Talk about something valuable!
Within any practice there are literally scores of personal interaction scenarios that carry consequences, and every one has the potential to create an aftermath of discussions among providers. The truth is, every single practice with three or more clinicians already has internal peer review. The trouble is it usually has not been designed to allow safe, honest, constructive feedback that results in accountability and improvement.
So how do you get everyone to create a peer review form and reporting handout that they buy-into?
First, you must allow everyone to input and agree on the guidelines. Providers need to discuss and reach a consensus on the following questions:
- How often will the process take place? (Typically once a year).
- Who will be reviewed? (Usually everyone of the same professional/clinical level after having been with the practice for six months.)
- Will public results be down to the level of the individual provider or will results only be a report card on the practice as a whole? (About 75% of my clients take the results to the individual provider level.)
- If the results will be to the level of individuals, who will calculate individual input to arrive at each physician’s evaluation averages and will therefore be privy to how each clinician rated each of the other clinicians? (In my case it’s part of my role as a facilitator.)
- How long will the actual roundtable for discussing the peer review evaluations be? (Usually one meeting only.)
The next step is to allow everyone to create and agree on the input and reporting forms. Providers will need to decide:
- What topics will be reviewed.
- What evaluation scale will be used.
- What should be on the evaluations handout that will be used for the “public” roundtable discussion.
Each practice has its own list of topics, and in fact, its own definitional nuances for each topic. The following list can be used as a discussion reference for selecting the topics (typically a review form includes 15-20 items).
“TYPICAL” PEER REVIEW TOPICS
- Current Medical Knowledge
- Knowledge of Specialty
- Clinical Judgment
- Clinical Case Management Skills (Hosp.)
- Clinical Diagnostic Skills
- Proficiency with Technical Procedures
- Medical/Surgical Complications
- Willingness to Learn and Practice New Skills
- Charting and Documentation
- Management of Patient Schedule
- Ability to Communicate with Patients
- Communication/Interaction with Clinic Staff
- Interaction with Office Staff
- Communication/Interaction with Hospital Staff
- Follow-up with Referring Physicians
- Teamwork/Relationships with Our Own Physicians
- Expertise and Availability as a Consultant
- Community Relations, Outreach Lectures
- Participation on Hospital Committees
- Completion of Assigned Clinical Tasks
- Completion of Assigned Non-Clinical Tasks
- Research and Publications
- Attendance at Designated Meetings
- Work Ethic, and Economic Effectiveness
- Practice Development
- Time Management
- Punctuality
Each of these topics must then have 4-6 phrases defining the topic in enough detail so that an evaluation can be made. This definition is always unique to the experiences, practices, and values of each group. (See Figure 1)
The evaluation scale is the second design element that must be agreed to. In truth, I’ve never seen any valuation scale such as “Excellent – Good – Fair – Poor” or “Exceed Expectations – Meets Expectations – Fails Expectations” that works. The reason is obvious; evaluations using these scales all end up gravitating to the unrealistically high end of the scale. There is no room for acknowledging the truly magnificent performer, and, on the opposite end of the spectrum, no one wants to record the real evaluation for the poor performer.
An effective scale should provide room for “Unbelievably Superior Performance” on the high end and “Unbelievably Poor Performance” on the low end. This means that most evaluations for most physicians should end up in the middle to upper middle of the “Expected Performance” range. When you think about it, this is a pivotal concept in the creation of an effective peer review form. Together these three broad categories should define a total incremental spectrum of possible performance. (See Figure 1)
Since all doctors are listed under reach topic, each doctor uses only one form for all evaluations on all physicians. (If the decision is for each clinician to evaluate the practice as a whole instead of individual doctors, there needs to be only a single line under the evaluation scale. For reporting purposes, make sure that each doctor records his or her name regardless of which form you use.)
Figure 1
Review form completed by:
TOPIC #1, KNOWLEDGE OF SPECIALTY
Consider the following:
- knowledge/command of current practices - specialty and referring physicians’ respect for knowledge
- knowledge/command of advanced practices - physicians’ perception as an information source
- breadth and depth of specialty knowledge
The last design question is: what should be on the evaluations reporting handout that will be used for the roundtable discussion? In other words, who gets to see what data? I strongly suggest that two data for each provide be displayed: the physician’s own evaluation of him/herself along with the average evaluation given by all the other providers. (If the decision is to evaluate the practice as a whole instead of individual doctors, then each doctor’s evaluation is displayed beside the overall average for the practice.) (See Figure 2)
Not only does this recording make sense from an accountability point of view, these data form the basis for constructive roundtable discussion, as Part II will explain. My next article will carefully outline the need to put the per review process in a supportive context and how to review evaluation results to promote healthy, supportive dialogue, moving the conversation toward personal improvement plans when needed.
If you have any questions about this article, please feel free to give me a call.
The development of documents such as these is an investment of time, requiring meetings where participants listen and understand. Gaining a joyful environment within which to practice medicine makes it all worthwhile!
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