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When Is External Peer Review Required?

4 Situations That May Call for External Peer Review

Ambiguity and litigation are among the reasons an organization may look elsewhere for experts to evaluate a physician’s competence.

This article was originally published on the Credentialing Resource Center, July 6, 2017.

Although external peer review of a physician’s competence is seldom required in most organizations, it is nonetheless important to have a policy in place should the need arise. In many hospitals, the service line or department chair, medical staff quality committee (MSQC), or another designated group will make recommendations on the need for external peer review to the medical executive committee (MEC). The policy must also define the circumstances in which external review will occur and state that no practitioner may require the hospital to obtain external peer review if it is not deemed appropriate by the MEC or the board.

Circumstances requiring external peer review may include but are not limited to:

  • Litigation: When dealing with the potential for a lawsuit.
  • Ambiguity: When dealing with vague or conflicting recommendations from internal reviewers or medical staff committees. Conclusions from this review will directly impact a practitioner’s medical staff membership or clinical privileges.
  • Lack of internal expertise: When no one on the medical staff has adequate expertise in the specialty under review, when the only practitioners on the medical staff with that expertise are determined to have a conflict of interest regarding the practitioner under review, or when the potential for conflict of interest cannot be appropriately resolved by the MEC or board.
  • Miscellaneous issues: When the medical staff needs an expert witness for a fair hearing, for evaluation of a credentials file, or for assistance in developing a benchmark for quality monitoring.

The MEC or governing board may also require external peer review in any circumstances deemed appropriate by either of these bodies.

A policy should also be in place regarding information obtained during an external peer review. If the review was conducted for reasons other than legal concerns or credibility, the report is usually first reviewed by the MSQC or equivalent committee at its next regularly scheduled meeting, unless an expedited process is requested by the MEC or the board. If improvement opportunities are found to exist, they will be handled through the same mechanism as internal peer review unless the issue is already being addressed in the corrective action process.

Peer review policies also indicate that if an external peer review is requested directly by the MEC or the board for legal concerns or credibility, the requesting body determines which committee should conduct an initial review of the report.