Peer References and TJC Requirements

One area of constant confusion and struggle for hospital medical staffs is peer references. With the Joint Commission’s (TJC) emphasis on Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), hospitals should focus on evaluating all performance data collection and analysis and not just peer references. As a result, except for initial application, hospitals have the opportunity to wean themselves off of peer references at reappointment except in those cases when the hospital does not have access to performance data due to low or no patient volume. (You should pause here and consider whether these practitioners should continue to maintain medical staff membership!) In fact, MS.07.07.03 Element of Performance 2 states that you only need to get and evaluate peer recommendations at reappointment if you have insufficient practitioner-specific data. Many facilities, however, continue to rely heavily on peer references as a means of collecting quality information.  Is this reliance based on fact or habit? Let's examine TJC's current peer reference requirements.

First, who may be a peer? This question comes up frequently and there is great variation in the answer even among our hospital clients. According to the Joint Commission, a peer is someone from the same discipline with essentially equal qualifications.  For example, a nurse practitioner’s peer reference would ideally come from another nurse practitioner who is familiar with the individual’s actual performance, either from within the same organization or outside the organization.TJC continues:

“However, in situations where there is no nurse practitioner, physician’s assistant, psychologist, or social worker who could provide a peer reference it is acceptable for a physician or D.O. with essentially equal qualifications, who is familiar with the allied health practitioner’s performance, to provide the reference.  For example, an anesthesiologist could provide a reference for a nurse anesthetist, and a psychiatrist could provide a reference for a psychologist and a psychologist with similar responsibilities could provide a reference for a social worker.”

From http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs/MS/Peer_References.htm

Please note, too, there is no TJC requirement that a physician must be in the same specialty to serve as a peer evaluator.  Any requirement that peers much be in the same specialty is voluntary – and beyond actual TJC accreditation requirements.  For small hospitals or facilities in rural areas, it may be impossible to find another specialist, particularly one who is not in direct competition, who can comment on the physician’s actual clinical knowledge, technical skills, judgment, interpersonal skills, communication, and professionalism.  Also, a thoughtful peer evaluation of a surgeon might come from an anesthesiologist who personally witnessed the surgeon’s surgical skills in the operating theater than a partner or other member of the surgery department who does not have this direct knowledge of the surgeon’s skill and judgment.  Again, the decision regarding who may serve as a peer reference is within the medical staff’s discretion.

How many references do you need to collect?  Here again, there is a strong preference for three references at initial appointment and three at reappointment.  Interestingly, there is no current stated requirement in TJC hospital standards mandating three references at initial application.  Three is a magical number based on custom, history and habit.  Particularly for the reappointment process, if you determine you need peer evaluations, consider lowering your requirement to two references.  It will help keep you on task as you focus on getting medical staff members reappointed on time.

My best advice is to give yourself breathing room if you struggle with obtaining peer references, particularly at reappointment.  Remember the actual requirements and don’t box yourself into a corner by defining high and arduous peer reference standards through your bylaws and policies.  Save your energy and focus on getting the performance data from within your hospital QI and PI departments or from other area hospitals!

March 18, 2010