Peer Review.  It has been a topic of conversation for years.  In the Health Resources & Services Administration (HRSA) world, peer review is talked about by Federally Qualified Health Centers (FQHCs), FQHC Look-A-Likes (LAL) and Primary Care Associations (PCAs). Peer review is talked about at state and federal conferences, during training sessions and webinars, and during HRSA Operational Site Visits (OSVs).  Unfortunately, the reason peer review is talked about so frequently is because there are so many unresolved questions.  What does HRSA require?  How many charts must be reviewed?  How frequently must charts be reviewed? And even, why are we doing this?   

The standards for peer review are outlined in Chapter Five, Clinical Staffing, and Chapter Ten, Quality Improvement/Assurance of the HRSA Compliance Manual (Chapter Five, Chapter Ten).  Chapter Five discusses the need to consider the results of peer review/performance improvement activities in the reappointment process for credentialing and privileging, while Chapter Ten discusses the need for the completion of quarterly QI assessments.  What the Compliance does not do is provide specifics, such as:

• Who – What individuals should peer reviews be completed on and who should be completing them?
• What – What tool(s) should be utilized to complete peer reviews, and should the same tool be used for all peer review?
• When – When and how frequently should peer review be completed? How many charts should be reviewed for each provider?
• Where – Does peer review need to be completed for all sites in the health center’s scope of project?
• Why – Why is peer review being completed? Is it being completed only to maintain compliance with HRSA expectations, or is it being utilized as a mechanism to truly evaluate performance and mitigate risk?

Health centers are expected to have a process in place for conducting peer review on a “routine and regular basis,” although there is minimal guidance from HRSA on how to do this.  Health centers should utilize the responses to the “Five W’s” below as guidelines to not only ensure compliance with HRSA expectations, but as a means of emulating the best practices demonstrated by high performing health centers:

• Who – Peer review should be completed for all services in the health center’s scope of project, between providers within the same specialty, who are similarly credentialed.

• What – HRSA does not mandate that a specific tool be used to complete peer review, although the tools used should contain criteria that is appropriate to the specialty being reviewed.  For example, the tool used to peer review an OB/GYN provider will contain different criteria than the tool used to peer review a Family Practice Physician.  Resources for Peer Review can be found at ECRI.  This resource is free to health centers and provides support for Quality Improvement (QI) and Risk Management (RM) initiatives. 

• When – Chapter Five of the HRSA Compliance Manual states the results of peer review/performance improvement activities must be considered in the reappointment process, which is typically a minimum of every two years.  Using the HRSA Health Center Program OSV Protocol (OSV Protocol Clinical Staffing), the Clinical Reviewer must validate the health center considers the results of peer review/performance improvement activities in the reappointment process.  Likewise, Chapter Ten of the HRSA Compliance Manual states Quality Improvement/Assurance assessments must be completed on a quarterly basis.  Using the HRSA Health Center Program Site Visit Protocol (OSV Protocol Quality Improvement Assurance), the Clinical Reviewer must validate the health center conducts quarterly QI assessments. Peer review is a key component of a health center’s Quality Assurance/Improvement Program and is considered a QI assessment; therefore, health centers should complete peer review a minimum of quarterly to identify trends and address areas of risk.  HRSA does not specify the number of charts that must be reviewed.  Industry standard best practices demonstrates the completion of a minimum of five charts per provider per quarter.  The key is to complete enough reviews to adequately evaluate the performance of your providers and quickly address issues.  The health center does not want to find out a provider is placing patients or the health center at risk after it is too late. 

• Why – The purpose of completing peer review is to evaluate performance, mitigate risk and ensure the delivery of high-quality care to patients.  The HRSA Health Center Program Requirements are the floor and not the ceiling.  The health center needs to decide whether the goal is to simply maintain compliance or to take the quality initiatives of the organization to the next level.  

The best process for implementing peer review is often organization specific. There is no “one-process fits all.”  Some health centers complete peer reviews during quarterly provider meetings to ensure timely completion, while others have providers complete reviews during administrative time. Regardless of what process is used, the threshold for performance should be clearly defined and understood by the provider.  Additionally, results must be shared with providers.  The health center cannot expect a provider to improve if they are not aware there is a problem.