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Greeley Peer Review Monthly: Don't let the peer review process be held hostage by an incomplete discharge summary

Medical Staff Leader Connection, June 3, 2009

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I recently attended a peer review committee meeting, during which I learned that the quality improvement staff delayed a case review by several months because the attending physician under review had not dictated a discharge summary. Although the case was referred because of a serious concern, the quality improvement staff did not feel they should initiate the review without a completed record because it would put an undue burden on the nurse and physician reviewers. In fact, some medical staffs have a policy requiring that the physician complete the discharge summary before a review can proceed.

This scenario presents an interesting dilemma because it pits two key principles of a good peer review system against each other: effectiveness and efficiency. On the one hand, for peer review to effectively improve patient care and physician competency, it must be timely. If peer review is delayed, so are the medical staff’s opportunities to educate physicians and prevent future errors.

On the other hand, for peer review to be efficient for the physician reviewer and quality staff, they shouldn’t waste valuable time trying to piece together the patient’s clinical course without the benefit of the discharge summary. After all, no one has an abundance of resources for this activity.

The irony in this case was that a potential clinical improvement opportunity in the patient care competency was not being addressed by a second competency area—interpersonal and communication skills—because of non-compliance with medical staff completion policies.

Some might say, “But discharge summaries are only a regulatory compliance issue and not a patient care concern.” Yet the peer review committee’s willingness to put off physician improvement while waiting for the discharge summary is just an example of how tolerating delinquent discharge summaries can affect patient care. What if the patient was readmitted and there was no discharge summary to assist other physicians?

While the best solution is for the medical staff to seriously address the issue of delinquent discharge summaries (which is beyond the scope of today’s column), I suggest an alternative to address the issue for the purposes of peer review:

If the case identified for peer review lacks a discharge summary or any required document, such as an operative report, the medical staff peer review committee notifies the attending physician immediately and requests that he or she complete the document within a defined period (usually two to five days). If the physician does not complete the document within that time frame, the physician is penalized. If the physician does not complete the document within two weeks, continue with the penalty but review the chart without the document.  

What should the penalty be? Many medical staffs find that suspending physicians is not typically effective. If that is the case for your medical staff, I suggest imposing a daily monetary fine until the physicians complete the record. If the physicians do not pay the fine by the time they complete the discharge summary, they continue to pay the fine when they apply for reappointment or the application will not be accepted.

An alternative (or additional) penalty might be to require the physician to appear at a meeting with the chair of the board and the president of the medical staff.

Robert Marder, MD, CMSL, is the vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.

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