241112 A Medical Staff Peer Review System in a Public Teaching Hospital An Internal Quality Improvement Tool

Tuesday, November 1, 2011

LInda S. Chan, PhD , Los Angeles County University of Southern California Medical Center, University of Southern California Keck School of Medicine, Los Angeles, CA
Manal Elabiad, MS , Biostatistics and Outcomes Assessment, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
Ling Zheng, MD, PhD , Biostatistics and Outcomes Assessment, Los Angeles County University of Southern California Medical Center, Los Angeles, CA
Brittany Wagman, BS , Biostatistics and Outcomes Assessment, Los Angeles County University of Southern California, Los Angeles, CA
Nicholas Testa, MD , Associate Medical Directory, Quality Improvement Department, Los Angeles County University of Southern California, Los Angeles, CA
Stephanie L. Hall, MD , Chief Medical Officer, Los Angeles County University of Southern California Medical Center, Los Angeles, CA
Peer review of the quality of care of the medical staff in a healthcare delivery system is an essential mechanism for evaluating physician judgment and performance in the provision of patient care. Properly executed and utilized, peer review can bring about change that improves the quality of patient care, enhances overall clinical performance and augments physician education. While all health care facilities are mandated to conduct peer reviews the process of how it is conducted, analyzed, reported and utilized varies widely. Our institution, a large public teaching hospital that trains approximately 1,500 medical professionals per day, including more than 870 medical residents in nearly all medical specialties, has developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system with a computer-based tracking system and created a database of all peer review documents that can be easily queried. The database improves the quality of care by allowing prompt analysis of all peer reviews and serves as a repository for outcomes and corrective actions. MS-PRS specifically a) provides accurate data on outcomes to both clinicians and hospital administration, b) monitors outcome and process measures over time by individual provider and/or clinical department/division, and c) tracks the adequacy and timeliness of corrective actions taken. We have observed improvements in educational opportunities and practice patterns of the medical staff, in the delivery of health care, and in hospital environment and policy. Further, MS-PRS has brought together the fragmented peer review activities throughout the healthcare network and allowed peer reviews from all departments to be centralized, standardized and quantified as a whole. In this paper we will present the development, implementation, and management of MS-PRS as well as the challenges encountered and lessons learned.

Learning Areas:
Administration, management, leadership
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs

Learning Objectives:
Describe the development of a computerized medical staff peer review system in a large public teaching healthcare network and discuss the challenges encountered and lessons learned.

Keywords: Health Care Quality, Quality Improvement

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am director of the Biostatistics and Outcomes Assessment Unit of the Quality Improvement Department and work closely with the Chief Medical Officer and Quality Improvement Clinical Director of the institution.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.