Implementing The Internal Peer Review Part II

Professional Interactions – Best Practices Series
Part II: Implementing The Internal Peer Review

By Fred Corbus

This article first appeared in Round-up Magazine, official publication of the Maricopa County Medical Society.

As I said in the opening paragraph of Part I (September issue) '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.'

Comments:
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Part I outlined how to design the internal peer review set of guidelines, the evaluation form, (see Figure 1), and the format for reporting evaluation results. (see Figure 2). If these are developed with everyone's participation, prerequisite front-end buy-in will have been accomplished.

So, now the question is, how are evaluation results discussed in a healthy, constructive, and supportive manner?

First of all, for any roundtable discussion on peer review to be seen as fair and enforceable, it is mandatory that every physician submit an evaluation form and that the form includes, at a minimum, an evaluation on him/herself!

Second, attendance at the roundtable is mandatory. Obviously there are valid excuses, but everyone at the roundtable must understand why a certain person is missing: he/she is new to the practice and therefore doesn't participate yet, or the physician is part-time or phasing out, or he/she has a compelling, legitimate and known personal reason.

During development of the peer review process, an extended effort should be made to develop a purpose statement, such as the following:

1. To define and communicate standards of excellence for the practice.
2. To acknowledge each physician's areas of strength and put in place action plans for supporting the improvement of areas of weakness.

During this development process, it should also be revealed what peer review is and what peer review is not.

QUESTIONS ASKED OF THE INTERNAL PEER REVIEW PROCESS

1. What is the context?
Personal awareness, honest and caring dialogue, personal support.
2. How exact will the evaluation be?
Nothing will be exact; the 'measuring instrument' is designed to record subjective perceptions only.
3. How honest is everyone expected to be?
Honesty is an evolutionary skill and learning process.
4. Will topics be numerically weighted?
By design there isn't any weighting; the form shouldn't imply an exact science.
5. How is the significance of each topic determined?
It is done informally during the review session roundtable open discussion.
6. Are we going to be stuck with the form or the process?
Both the form and the process are always critiqued at the end of each session so that they can be improved for the next time.

As the roundtable discussion begins, the facilitator must review both the purpose statement and the points listed above. Setting the context for a constructive, supportive roundtable can be critical.

From a facilitator's point of view, specific evaluation numbers serve only one purpose, to initiate discussion. This is not a scientific report card. It's full of subjective faults and merely serves as a cue card for discussing differing points of view and perceptions. Putting 'those things that everybody is thinking about, but nobody is talking about' on the table is magic in itself.

Now for the discussion mechanics: to begin with, all of the physicians will want to review as many of their own numbers as soon as they are put in front of them. When this happens, any roundtable discussion is on hold. Therefore, hand out only one page at a time. Since each page will have no more than two to four topics, let everyone look at as many numbers on that page as they want before discussing each topic.

I have found that the most efficient and least painful (if you will) method of leading evaluation discussions is as follows (discuss each topic in sequence):

1. First, acknowledge those few physicians who received an average evaluation from the other physicians in the superior performance category. The truth is, they need to be acknowledged.
2. Next, highlight significant differences between any doctor's own evaluation and the average evaluation of the other reviewees. A significant difference is typically 1.00 or greater. In some cases, the person's own evaluation is greater than the average. In other cases it is less. The point is that you now have fodder for discussing the reason behind the difference in perceptions, and this is one of the main points of the entire review process.
3. Finally, address average evaluations that fall in the unacceptable category range. This will be a tense moment for those few providers who received an unacceptable evaluation. In fact, the entire room will be uncomfortable; after all, the entire room created this result, and the continued endorsement for future internal peer reviews hangs in the balance. Once again, however, the focus is on the reasons behind the perceptions and the purpose of the process, which is to put those things on the table that 'everybody is thinking about, but nobody is (constructively) talking about.' The challenge now is to move the discussion in a supportive manner toward action plans, i.e., 'who, does what, by when,' to overcome the unacceptable evaluation. Many providers can contribute to the improvement plan, but obviously the principal accountability lies with the physician in question. If the trait is easily acknowledged and fixed, the discussion may be over. If the behavior is more serious, a date should then be set for a follow-up discussion to review the improvement progress.

If the unacceptable behavior is extremely serious and difficult to address, the physician manager or medical director may want to schedule a private meeting with the offender; however, the time should be set at that moment so that everyone in the room has confidence that it will actually happen, and there also must be a time set for reporting back to the group on the outcome of the private meeting. This aspect of accountability is another moment of truth for the continuing endorsement of the peer review process.

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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