Definitions:
- Peer Review: The process of evaluating, supporting and enhancing, on a peer-to-peer basis, the clinical quality and performance of the members of the DaVita Medical Staff.
- Credentialing and Peer Review Committee (CPRC): The OCMO committee that oversees credentialing and peer review activities at the direction of the facility Governing Body (GB).
Physician behavior issues like these are appropriate for peer review:
- Rude, loud or intimidating behaviors
- Patient safety concerns
- Patient or teammate solicitation in the facility
- Violation of patient privacy
- Sexual harassment or other offensive conduct
- Physician impairment (e.g., drug or alcohol)
- Deteriorating cognitive or health issues with potential to interfere with practice
- Documentation and rounding issues
- Breaches of law, ethics or policy
Management-driven responsibilities like these are not appropriate for peer review:
- MDA contractual obligations
- Oversight of facility staff
- Operational issue
If I see an issue* with a medical staff member, what do I do?
1. Consult with your other GB members about the confidential issue and, if the matter requires, speak with the provider directly. Document the discussions in a confidential, peer review privileged file.
- As the medical director, you should send a peer review privileged letter to the physician outlining the issue and expectations based on DaVita bylaws, policies and procedures. Contact the peer review coordinator for a template to help you with this process.
- If there is potential that you may be seen as conflicted due to a personal or competitive relationship with the physician, the letter may need to come from the ROD or GMD.
- If there is an immediate patient safety concern, contact your ROD.
2. Consult with Peer Review Coordinator if:
- The situation does not improve or is serious enough that you believe immediate action is needed
- You may be conflicted due to a personal or competitive relationship
You will be asked to provide:
- Basic facts underlying the complaint
- Key documents (written complaint, notes, medical records, correspondence, etc.)
- Key witnesses (another physician, ROD, teammates, patients, etc.)
- Steps the GB has taken to address this matter
- Be sure to promptly respond to any additional requests from the peer review coordinator or CPRC member.
3. Remember, the peer review process is privileged and confidential. All documents should be clearly marked “Peer Review Privileged” and maintained in a separate peer review file. The issue should not be discussed with anyone outside the Governing Body.
For more information or help, contact physicianpeerreview@davita.com