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Hospital Fair Credentialing and Peer Review

RESOLVED, That the North Carolina Medical Society supports the following guidelines and encourages other affected organizations to support them as well:

  1. Peer review functions are distinguishable and separate from risk management functions within a hospital. Peer review is a process of the medical staff, governed by the medical staff bylaws and applicable federal and state law. Risk management is a function that would normally involve hospital administration and may involve medical staff.
  2. The process of choosing “indicators” or “monitors” of physician performance should be overseen by a quality committee at the medical staff level, provided, however, that all metrics should be thoroughly vetted at the department or specialty level. The composition of this committee should represent the diversity of the medical staff, including “economic diversity.” This diversity requirement should be clearly explained in the medical staff’s policies. Oversight of this process should lie within the Medical Executive Committee, which should approve the variance criteria (indicators/monitors) chosen.
  3. Physicians whose cases are chosen for peer review should be notified of this occurrence. They should have an opportunity to provide written input that can be considered by any peer review committee and that becomes part of the peer review file. The physician under review should also be informed of any decisions that may lead to recommendations for individual remedial action or corrective action, and the physician should have an opportunity to respond, in person or in writing, to the underlying quality concerns before the recommendations are implemented.
  4. When data is traced for trends, threshold criteria should be established for defining where a trend exists that needs further evaluation. This responsibility should lie with a medical staff quality committee. Peer review should be based on objective process and outcome metrics as monitored by the local institution and as defined by the department in question.
  5. The North Carolina Medical Society recommends that medical staffs use care in labeling certain aspects of their peer review activities. The term “investigation” should be reserved for a formal review of data that is anticipated to lead to corrective action, since this term has implications for reporting to the NPDB (National Practitioner Data Bank). Initial reviews of data should be labeled using other terminology, e.g., “quality review,” “focused study,” “peer review evaluation,” etc. The purpose is to avoid unnecessary or inappropriate reporting to the NPDB, which may harm physicians who have no reportable quality concerns.
  6. The North Carolina Medical Society recognizes the important value of External Peer Review (EPR). Where EPR occurs, selection of external peer reviewers should be submitted in advance to the physician under review, and he or she should have an opportunity to object to any particular individual. Such objections should not rise to the level of veto power, which could obstruct the process. In general, EPR should be reserved for circumstances in which internal review has raised the possibility of a restriction or reduction of privileges or where objectivity of internal peer review may have the appearance of being compromised because of medical staff demographics. A physician under review always has the option to request external peer review prior to a final decision implementing corrective action.
  7. Medical staffs should adopt a mechanism that affords protection to physicians who, acting in good faith and the best interest of quality of care concerns, report concerns to the peer review committee, under the protection of a medical staff policy.
  8. Fair hearing panels should be selected with good faith effort where practical to include representation similar to that of the physician under review (i.e., with regard to race, gender, ethnicity, training, etc.). Physicians under review should have an opportunity to voice good faith objections to inclusion of any members of a Fair Hearing Panel. Such objections should not rise to the level of veto power, which would obstruct the process.
  9. Medical staffs should be informed about the uses of mediation and arbitration in resolving disputes around credentials and privileges.
  10. The North Carolina Medical Society should facilitate educational programs to help ensure that members of hospital boards, medical executive committee, credentials committees, and quality committees are knowledgeable about proper practices regarding peer review, performance improvement and appropriate credentialing and privileging. To maximize availability, a variety of tools may be used to promote this education (e.g., video tapes, Internet tools, retreats, grand rounds, computer education tools, continuing medical education, etc.).
  11. Approaches should be developed to promote the sharing of successful practices that exist in member hospitals and medical staffs with regard to peer review/performance improvement activities.

(Report G-2002, adopted as amended 11/17/2002)
(Report J-2010, Item 3-7, adopted 10/24/2010)
(technical corrections, Board Report-2018, Item 82, adopted 11/3/2018)