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Use an effective rating system for case peer review

Medical Staff Leader Connection, June 28, 2006

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Flagging individual charts for physician review is just the beginning of the interpretation process; the real interpretation occurs when the physician reviewer looks at the chart. Common concerns are that chart review is subjective and that there is little consistency or inter-rater reliability. Standardizing the review process goes a long way toward addressing this concern.

Using scoring categories helps physician reviewers make efficient and consistent determinations when reviewing a patient chart. It also focuses the committee's discussion of each case in a consistent manner. A scoring system should be based on three principles:

1. Use several pure categories. Rate each aspect of the case using clearly identified individual or pure categories. Doing so makes scoring easier and more reliable for each category. It is better to have separate categories for potential clinical outcomes (e.g., no adverse outcome, major adverse outcome, etc.), and levels of overall physician care (e.g., appropriate, controversial, inappropriate). Likewise, it is important to have separate categories for documentation deficiencies, because they differ from true technical quality-of-care issues.

2. Include a middle level. An example of a middle level of care is "care controversial." Otherwise, even when a physician reviewer disagrees somewhat with the approach taken by the physician under review, the reviewer will score care as "appropriate" because the only other option is "inappropriate."

3. List the reasons why care might not have met expectations. For example, the list of physician performance issues typically includes concerns about technical skills, judgment, or knowledge. Systematically defining the basis for the physician's actions allows the medical staff to begin to get to the root cause of physician performance concerns. It also allows staff to identify patterns of performance issues despite differences in the disease, procedures, or circumstances of the individual case.

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