AHLA Peer Review Guidebook (AHLA Members)
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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.
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Published August, 2016.
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
3.4 State Peer Review Statutes
3.5 Practicalities of Dealing with the Medical Staff
Chapter 4—Process for Initiating an Investigation
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
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
9.2 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