There are many competent and capable consultants and resources out there that can guide organizations on formal restructuring of their peer review and QA/PI programs. But we have to keep in mind that there are regulatory and accreditation challenges – and they all speak in some form to how we address quality within our organizations.
In some respects they’re fairly flexible and in others, not at all. But keep in mind, the majority of these laws were written in the early 1980s and they have not taken into consideration the new healthcare paradigm shift, so any restructuring or emphasis around a quality program that wants to share information around a system that uses a centralized system based determination on quality metrics and processes may have a problem with the Medicare CoP, state hospital licensing requirements, and the state peer review statute. For example, many state peer review statutes do not contemplate the role of a centralized quality system and how that information can be shared.
There is a mindset within many organizations related to how risk adverse they are (ie: in litigation, etc), and if you increase your standards and expectations, you will identify more quality issues. And how do you address these? The answer to that question will implicate the corrective action and fair hearing processes. In some cases, that could implicate your compliance program activities if you’ve reported quality one way and there is a quality adjustment reimbursement related to it and that you know your data’s bad and so you have to correct that report. The obstacle is in improving your quality programs within your organizations.
There are also risks with: malpractice and cost, negligent provider credentialing, political concerns, and compliance.
Let’s not forget that a lot of providers and payors are on different pages. If you have an aging medical staff and you have a younger hospital C-suite, they start to view things a little bit differently; this is a generational challenge. For example, payors may be much more aggressive than providers are willing to be at certain times. And really, it doesn’t matter how successful you’ve been for the past two or three or four years if those ideas don’t align.
When it comes to quality activities, many healthcare facilities have poor communication and engagement because it’s hard to get the same folks participating in the process and to get people motivated around those activities. And this if oftentimes due to limited leadership resources. Think about this: medical staff leaders do not take a class in self-governance in medical school, they learn on the job. So we often see a strained application of medical staff membership when it comes to quality issues.
The bottom line is that many credentialing, privileging, and quality assurance performance improvement activities just get by.
Here is something to think about as you start to reshape and re-emphasize your efforts on quality review in peer review activities: When we come to the point of trying to influence success and change for peer review activities, remember a fundamental truth – we can’t avoid it. You’re paid for the delivery of sufficient quality healthcare. We know that’s the direction and start by just accepting it.
The professional staff of an organization (whether it be the medial staff of a hospital or or AFC, or leadership of a nursing home) have supporting resources uniquely positioned to be the central point to how we deliver healthcare and tackle credentialing, privileging, quality monitoring, quality improvement, and peer review. This role should focus on being efficient by providing training, avoiding an overcomplicated peer review construct, focus on systems of care, and set expectations for quality within the organization. And finally, keep in mind that the future is a moving target and we always need to be ready to bob and weave accordingly.