The act states that its notice and hearing requirements are not the only way to
provide adequate due process for peer review. The courts, however, will tend
to regard these statutory requirements as minimums. These requirements
were developed in court cases against governmental medical care institutions.
The effect of the act is to require private institutions seeking immunity to
comply with the same due process requirements as public institutions. Since
most private hospitals already meet this standard, this should not require
substantial changes in hospital procedures. It will require other medical care
entities, such as private clinics, to use formal, hospital- style proceedings
rather than the informal procedures that are the norm in these environments.
The act only covers peer review activities carried out in a reasonable belief that
they will improve the quality of medical care. The best evidence of a proper
review decision is a written set of standards that explain what is expected of a
physician practicing in the entity. These should be detailed and straightforward.
They must be intelligible to jurors and physicians, as well as to attorneys. For
hospitals, most of the relevant standards are already in force as part of the
Joint Commission requirements. The problem is that few physicians are
familiar with these requirements. These standards must be made available to
members, and prospective members, of the medical staff. Adherence to these
standards must be an explicit condition of medical staff privileges.
It is critical that the medical care entity enforce all standards uniformly. There
cannot be a double standard based on economic performance or personal
relationships. If, for example, delinquent chart completion is used as a ground
for the termination of staff privileges, then the hospital must ensure that all
members of the medical staff complete their charts on time. Disparate
enforcement of standards is less defensible than having no standards.
The only way to provide even-handed enforcement of standards is to shift from
exception-oriented review to review based on statistical and population
analysis. In some areas, such as completion of medical records, the hospital
keeps data on every physician. The data can be compiled into profiles to
establish the norm and standard deviations for chart completion. Physicians
exceeding a set deviation would be flagged and counseled. If their
performance did not improve, they would be terminated. In other areas, such
as surgical complications, indirect measures are much less effective. These
require that a random sample of charts from every physician be reviewed for