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AHLA Peer Review Guidebook (AHLA Members)

Peer Review Guidebook is a comprehensive resource for understanding the peer review process and disciplinary proceedings involving physicians. Includes Health Care Quality Improvement Act (HCQIA) analysis.
Publisher: AHLA
eBook :epub
5th Edition
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ISBN/ISSN: 9781522116745
Publisher: AHLA
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Book Edition: 5E

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The Fifth Edition of Peer Review Guidebook is a comprehensive resource for understanding the peer review process and disciplinary proceedings involving physicians.

Peer review in the health care setting has numerous elements, and while there are few fixed definitions, the essence of the process addresses physician credentialing, privileging, and professional evaluation, both ongoing and focused practice evaluation. Health care entities conduct peer review for multiple reasons, including improvement of care, protection of patients from harm, and improvement of physician performance. While the initial process begins when a practitioner applies to be a member of the medical staff or gain privileges at a hospital or other health care provider, latter elements can include potential reduction or denial of privileges to those under review. The critical guidance for peer review is found in the Health Care Quality Improvement Act (HCQIA), which offers immunity from monetary damages for those individuals and institutions that participate in an adverse professional review action relating to the competence or professional conduct of a physician, provided that its procedural requirements are followed.

Edited by Barbara Blackmond, Charles J. Chulack, Joshua A. Hodges, Lauren M. Massucci and Daniel Mulholland, this edition contains information about HCQIA and its impact on the peer review process, suspension of privileges, injunctive relief from peer review actions and the effect of the privacy rule of the Health Insurance Portability and Accountability Act on peer reviews. The title also provides a multitude of citations to cases, regulations, and other sources. In addition, the appendices include a listing of cases in which physicians have alleged violations of the American Disabilities Act, cases dealing with physician-behavior issues, a list of exclusive-contract case law, cases decided under HCQIA , and numerous others that address the peer review process.

The eBook versions of this title feature links to Lexis Advance for further legal research options.

Published August, 2016.

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Table of contents


Chapter 1—Threshold Issues

1.1  What Is "Peer Review"?

1.2  Why Peer Review?

Chapter 2—Characterizing the Nature of the Concern

2.1  Determining the Nature of the Concern

2.2  General Categories of Concerns

2.3  Reasons That Justify Professional Review Actions

Chapter 3—The Health Care Quality Improvement Act

3.1  Assessing Where the Entity Is in the Process

3.2  Hospital and Medical Staff Bylaws

3.3  HCQIA

3.4  State Peer Review Statutes

3.5  Practicalities of Dealing with the Medical Staff

Chapter 4—Process for Initiating an Investigation

4.1  Introduction

4.2  Bylaws Provisions Relating to Investigations

4.3  Notifying Physician of Investigation

4.4  The Investigating Body

4.5  Maintaining Confidentiality

4.6  The Implications of Investigations or Reporting Requirements

4.7  Form of the Investigation Report

Chapter 5—Use of Informal Resolution in Peer Review

5.1  The Value and Need for Informal Resolution

5.2  What Is Informal Resolution?

5.3  When Should Informal Resolution Be Used? And When Should It Be Avoided?

5.4  What May Be Resolved Informally?

5.5  Informal Resolution Approaches and Tools

5.6  Documentation and Impact of the Informal Process on Formal Investigation

5.7  Disposition of Records of Informal Process

5.8  Reporting Requirements

5.9  Authority to Supervise the Process

Chapter 6—Summary Suspension of Physician Privileges

6.1  Grounds for Summary Suspension

6.2  Legal Authority to Impose Summary Suspension

6.3  Personnel Authorized to Impose a Summary Suspension

6.4  Procedures for Implementing Summary Suspensions

6.5  Procedural Rights Triggered by Summary Suspensions

6.6  Reporting Requirements for Summary Suspensions

Chapter 7—Automatic Relinquishment of Clinical Privileges

7.1  Grounds for Automatic Relinquishment

7.2  Procedural Rights Triggered by Automatic Relinquishment

7.3  Federal and State Reporting Requirements

Chapter 8—Notice

8.1  General Rules

8.2  Specificity of Statement of Reasons

8.3  Hearing Rights and Procedures

8.4  Witness List

8.5  Waiver of Hearing Rights

Chapter 9—Pre-Hearing Discovery

9.1  Background

9.2  Legal Requirements

9.3  General Criteria to Use in Deciding Whether to Disclose Documents to the Practitioner

9.4  Practical Considerations

Chapter 10—The Hearing Officer or Panel

10.1  Selection of a Hearing Officer or Hearing Panel Chairperson

10.2  Competence and Competitive Position of Panel Members

10.3  Objections of Practitioner at Beginning of Hearing Process

10.4  Utilization of Panel or Hearing Officer

10.5  Practical Considerations

Chapter 11—Role of Legal Counsel

11.1  Levels of Involvement

11.2  Right to Counsel

11.2.2  State Law

11.2.3  Tactical Considerations

11.2.4  Right to Assistance of Counsel

11.2.5  Representation by a Non-Lawyer

Chapter 12—Presentation of the Case

12.1  Burden of Proof

12.2  Required Evidentiary Standard

12.3  Evidentiary Issues

Chapter 13—Making a Hearing Record

13.1  Form of the Record

13.2  Special Considerations for Public Hospitals

Chapter 14—Hearing Panel Report

14.1  Legal Requirements

14.2  General Suggestions

14.3  Content of the Written Recommendation - Elements

14.4  Disposition of Hearing Panel Report

14.5  Action on Hearing Panel Report

Chapter 15—Appellate Review and Final Board Decision

15.1  Internal Appellate Review

15.2  Final Board Decision

15.3  Additional Evidence

15.4  Standard of Review

15.5  Inconsistent Findings

15.6  Mandatory Reporting Requirements

15.7  Technical Violations of Bylaws

Chapter 16—Injunctions Challenging Peer Review Actions

16.1  Peer Review Actions Subject to Judicial Review

16.2  Bases for Injunction Actions Challenging Peer Review Actions

16.3  Practical Considerations

Chapter 17—Special Considerations for the Peer Review of Employed Physicians

17.1  Risks Associated with "Ad Hoc" Approach to Peer Review of Employed Physicians

17.2  Options for the Peer Review of Employed Physicians

17.3  Coterminous Provisions in Employment Contracts

Chapter 18—Using a Patient Safety Organization to Protect Peer Review Information

18.1  Using a Patient Safety Organization to Protect Peer Review Information

Chapter 19—Allied Health Professionals

19.1  Allied Health Professionals

Chapter 20—HIPAA Privacy Rule Considerations

20.1  HIPAA Privacy Rule Considerations

Appendix A—Cases Where Practitioners Alleged Violations of the ADA

Appendix B—Cases Dealing With Behavioral Issues

Appendix C—Exclusive Contract Cases

Appendix D—HCQIA Cases

Appendix E—Bases for Professional Review Actions

Appendix F—Illustrative Summary Suspension Cases