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Multi-specialty Peer Review

Patient Safety Quality Monthly, July 15, 2005

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Dear Colleague,

As we work with medical staffs to redesign peer review, we are finding more often that physicians accept the concept of multi-specialty peer review committees. However, there also remain many medical staff leaders uncomfortable with the idea that physicians outside their own specialty are allowed to review their cases. They often express this concern as an issue of fairness in the peer review process.

Ironically, while no case review model can completely do away with bias, the primary reason for using multi-specialty peer review is its ability to reduce bias and increase the fairness and credibility of the process. Today I thought we might discuss why.

There are two types of bias that can affect peer review:

• Individual bias is the concern that a given individual's relationships or values may affect the evaluation. This is simply a fact of human nature. That is why our courts use the jury system. The judgments of twelve individuals can cancel out the bias of each individual. Applying this to peer review models, when a medical staff uses the department chair or medical director as the sole initial reviewer for peer review, it places that individual in a difficult position because of the potential perception of individual bias.

• Group bias is when an entire group's values or relationships may affect the evaluation. One form of group bias, specialty bias, arises when the opinion of a department may not reflect that of the medical staff as a whole. The way to reduce group bias is to include the views of individuals outside the group, just as the jury model reduces individual bias. This is why multi-specialty review is ultimately a fairer process.

So why are so many physicians convinced that only a physician in the same specialty can perform peer review? It starts with the perspective that when an adverse event occurs, it must be due only to a technical quality issue that requires a specialist to evaluate. If instead you start with the perspective that the issue might be related to a number of physician performance areas (e.g. communication, follow-up etc.), then multi-specialty review begins to make sense. For those issues, there is no reason why a physician in a given specialty or department has to be evaluated by other physicians in that specialty or department. And in those in situations where the case hinges on specialty or department specific clinical issues, the appropriate specialty review can be requested.

Why not start with the specialty review and get help for the other issues when they arise? That is where group bias comes into play. Because of its mindset, the group often does not even recognize the issues at hand or doesn't realize that its perspective on the issue differs from others. That is why we reverse the process so that the general review is first and the specialty review follows if necessary.

Remember, like any group bias, specialty specific bias is often not intentional. It is simply a fact of human nature. So as humans, we need to put in place systems that help us overcome our flaws.

Regards,

Bob Marder, MD
Practice Director, Quality and Patient Safety
The Greeley Company

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