Medical Staff

Peer review vs. risk management review: What's the difference?

Medical Staff Leader Connection, March 10, 2009

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Recently, while helping a medical staff redesign its peer review program, someone asked whether the medical staff peer review committee should conduct risk management reviews. The discussion started when a risk manager asked what to do with cases identified when a plaintiff’s attorney contacts the hospital with an intent to sue for malpractice. The hospital assumed that the peer review committee would evaluate risk management reviews so that the risk management department could better understand whether care provided by the physician in question was appropriate and defensible.

As the discussion ensued, some of the physicians at the meeting became concerned, and even irritated, that risk managers asked the peer review committee to review these cases, especially because many of these cases involved patients who were discharged more than a year ago.

The issue was not that risk management was sending cases to the medical staff peer review committee, but that they wanted the committee’s opinion. I believe the physicians who raised concern over reviewing the cases had the right idea: the medical staff peer review committee is not the place for medical-legal reviews.

Peer review should focus on physician improvement independent of legal consequences. There is a difference between meeting a standard for legal purposes and finding opportunities to improve care in the future. Risk management reviews should be performed by physicians with clinical expertise and familiarity with legal matters, but not by a medical staff committee.

However, this doesn’t mean that individual physicians on the medical staff shouldn’t work with risk management. Consider establishing a hospital risk management review committee, separate from the medical staff peer review process, made up of physicians selected specifically for this purpose. Physicians in medical director roles often can do this well.

Another concern is the timeliness of these reviews. Reviewing cases from one to two years ago places the medical staff in the difficult position of evaluating care long after the improvement opportunity has passed. This sends a negative message to medical staff members when they receive letters from the peer review committee asking them to explain ancient history.

What about gaining discoverability protection? Fear of discoverability should not prompt the risk management department to ask the medical staff peer review committee to conduct risk management reviews. Risk management reviews based on patients’ intent to sue that are performed outside of the peer review system are most likely protected by attorney-client privilege. Also, when the peer review committee sends its findings back to the risk management department, it weakens peer review discoverability protections because it gives the appearance that the peer review system is engaged in efforts to protect the hospital from legal damages rather than improve the quality of physician care. 

How should the peer review cases flow from risk management to peer review committees? Think of how blood flows from the heart to the aorta, unidirectional with a valve to prevent backflow.

Robert Marder, MD, CMSL
Vice president
The Greeley Company



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