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Small Hospital Challenges Monthly

Medical Staff Leader Connection, June 18, 2008

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Financial constraints, increased regulation, and heightened scrutiny from the general public are posing problems for all hospitals, but small hospitals, defined as those with less than 200 beds, have some unique challenges. Small hospitals often face challenges in the following areas:

• Peer review
• Leadership
• Recruitment and retention
• Budgets
• Information technology
• Medical care and bed capacity

Over the next several months, we will explore each of these areas. Let’s start with barriers to effective peer review. Many factors can impede effective peer review, including lack of knowledge, lack of appropriate infrastructure, and bias. Of all these barriers, bias, is particularly difficult to overcome in the small hospital environment.

Peer review has traditionally translated to physicians reviewing each other’s patient charts to assess competency. Today, peer review has a much broader definition: the review of practitioner competency against a performance framework (whether defined as The Greeley Company's Dimensions of Performance or The Joint Commission’s Six Core Competencies). To gather this type of information, medical staffs need to look at the quality of care (technical quality and patient safety) and the environment in which it is provided (relationships, resource use, service quality, etc.).

Medical staffs cannot collect this type of data through traditional chart review alone, partly because it is subject to bias. For example, even when evaluating quality of care, medical staffs that rely on chart review alone only see a small portion of practitioners’ activities. They should also look at the rates at which certain events occur and at the rules of practice physicians are expected to follow. Rate and rule indicators are less susceptible to bias because they are data driven.

For routine peer review, The Greeley Company has seen more small hospitals work with larger hospital systems or develop networks of other small hospitals to conduct peer review cooperatively. Smaller hospitals working with a larger hospital system can access other smaller hospitals to do peer review for common specialties and the larger hospital system’s specialists as needed. Small hospitals that are not working with larger systems are forming collaborative business agreements to do routine peer review. Many small hospitals enjoy such collaborative arrangements: they are finding it easier to peer review individuals they do not know personally, and the results seem objective.

Regards,
Mary Hoppa, MD
Senior consultant
The Greeley Company

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