8 Best Practices for Successful Case Review

8 Best Practices for Successful Case Review

Nov 28, 2022
  • Author:
    Noelle Abarelli

Healthcare organizations juggle a variety of priorities, but the one of most important is patient safety. And one of the main ways to keep patients safe is to ensure the physicians they’re working with are providing the best care. There are many ways to ensure physicians are performing to the best of their ability, and one of those methods is Peer Review. In this post, we’ll go over both Peer and Case Review, and look into strategies for accurately evaluating provider performance.

What is Peer Review?

Healthcare organizations, through their medical staff, are responsible for the quality of care and patient safety. Peer Review is a process that helps healthcare organizations ensure they are providing the highest level of care and patient safety possible. Peer Review involves members of a medical staff within a healthcare organization participating in activities that measure, evaluate, and help to improve the performance of providers within the healthcare organization.

There are both federal and state protections in place for Peer Review.

  • The Health Care Quality Improvement Act (HCQIA) provides qualified immunity to hospitals and members of peer review committees for professional review actions and sets the standards that the professional review actions must meet in order to receive protection.
    • The confidentiality provisions of the act allow eligible entities receiving information from the NPDB to disclose the information to others who are part of the investigation or peer review process, provided the information is used for the purpose for which it was provided.
  • The Patient Safety and Quality Improvement Act (PSQIA) created a framework for healthcare organizations to voluntarily share data regarding adverse events and to encourage the sharing of such data. For peer review documents to qualify, they must be created within a “patient safety evaluation system” and engage with and report to “patient safety organizations.”
  • State statutes have varying degrees of protection.
  • Many states have statutes that provide some degree of peer review immunity.
  • Many state statutes make peer review proceedings privileged and mandate that peer review proceedings be kept confidential.
  • However, Many state statutes do not provide for all three protections of immunity, privilege, and confidentiality.

To claim Peer Review protection, all Peer Review information must be treated as confidential and/or privileged. All documents, such as Case Review documents, must cite confidential and privileged protection. If an organization doesn’t cite protection language on its documents, or they make information available outside the review process, courts may find that the organization has waived its right to protection.

What is Case Review?

Case Review and Peer Review are related as case review is a medical staff–led initiative. Case Review is defined as:

A medical review in which the clinical care is cross checked against a specific set of standards, such as Medical Necessity Criteria. A reviewer (peer or physician) will look at a patient's level of care, intensity of treatment, and other care specifications to ensure that the care that was ordered, or provided by a physician or healthcare organization was appropriate and necessary.

Best Practices for a Successful Case Review

A successful Case Review process usually involves eight best practice steps.

  1. Case identification: The healthcare organization's medical staff will define the criteria that determine when case reviews should occur. There are generally two types of Case Reviews.
    • Routine Case Reviews, which are aimed at assessing overall practice patterns.
    • Triggered Case Reviews which are triggered when a provider meets predefined criteria that indicate an area of concern regarding care provided to a patient.

  2. Pre-review or screening by quality analyst or registered nurse (RN): Pre-review screenings are typically only used for a triggered Case Review, which may involve a case abstract or a pre-review screening questionnaire.
    • The RN or quality analyst will complete and submit the pre-review questionnaire to determine if the case needs to go to a peer or physician for review, as not all cases need to be escalated. The screening documentation looks into the issue type, trigger category, case summary, and case recommendation. That information will determine if a physician review is necessary.
    • If a physician review is deemed necessary, the pre-review form also allows the analyst to provide recommendations as well as any questions they want the physician reviewer to address.

  3. Initial physician review
    • If the pre-review screening determines that the case involves an issue that requires review, a physician reviewer (one or more) is brought in.
    • The physician reviewer will gather details on patient care, interpersonal and communication skills, practice board learning, system-based practice, medical clinical knowledge, professionalism, assessment of complications, documentation, overall patient care rating, actual harm rating, potential harm rating, overall case rating, recommended actions, as well as questions to be addressed by the attributing provider.

  4. Initial committee presentation
    • Once the initial review has been conducted, the results of the physician review must be presented to the Peer Review Oversight Committee. They will scrutinize the report and provide action items. This could also be the final committee adjudication if it is determined that care is acceptable and no opportunity for improvement is identified.

  5. Attributing provider input: This can be requested as either part of the initial physician review (step 3) and/or as a result of the committee presentation (step 4).
    • A best practice Case Review process includes obtaining input from the attributing provider. The physician reviewer or Peer Review Oversight Committee, upon analyzing the case, may want to ask specific questions of the attributing provider.

  6. Final committee adjudication
    • Once the Peer Review Oversight Committee has reviewed the attributing provider’s input and taken that into consideration, along with the physician reviewer’s determination, the committee will make a final decision. This typically includes decisions or ratings for:
      1. Patient care
      2. Documentation
      3. Harm (actual or potential)
      4. Overall case rating

  7. Report results to the attributing provider, the department head, and the MEC.

  8. Final action
    • Depending on the outcome, examples of final action may include:
      1. Collegial conversation with the attributing provider
      2. A referral to a clinical department for educational purposes or to a compliance program
      3. A referral to MEC for:
        1. Recommendation for FPPE for Cause
        2. Recommendation for External Review
        3. Attributing provider appeal

It is quite a monumental task, isn’t it? The good news is, there are ways to streamline the process to ensure nothing falls by the wayside. With VerityStream’s Evaluate, you can view every provider in your health setting, while you measure and monitor their performance and share that data with relevant parties. Learn more about it here, and if you have any questions, we’re always here to help, just reach out.