NAVAPD is a professional organization that is similar to other medical and dental professional organizations like the AMA or ADA. NAVAPD cannot and should not get involved in individual and local disciplinary processes as that is not within the scope of this organization.

While we may be able to provide some resources and answers to questions for practitioners facing disciplinary or peer review processes, this is not NAVAPD’s mission nor purpose.  We are not a bargaining unit, and as such, we have no power to influence, counsel, advocate, or advise in local matters. Other bargaining units such as AFGE or NFFE will be in a better position to provide advice and guidance to those practitioners who find themselves involved in a disciplinary matter or other review process. 

The VA Peer Review Process for Quality Management seems to always be met with fear, anxiety, and consternation for those practitioners who have been notified by VA that a case they were involved in is being reviewed in the Peer Review process.  This process does not have to invoke mind numbing fear.  After taking a breath, it is important to determine if the review is a “Quality Management Review” or a “Management Review”.

The Peer Review for Quality Management is found under the VHA Directive 1190 and is protected under Title 38 United States Code section 5705.  The Directive states the requirements for initiating, conducting, and documenting the Peer Review Process, and as the title suggests, “For Quality Management”, is its driving purpose.  This review is under the auspices of Quality Management.  Its sole purpose is to provide both short-term and long-term improvements in patient care by revealing areas needed for improvement in health care by one or multiple clinicians. This ultimately contributes to organizational improvements and optimal patient outcomes. It is intended to promote confidential and non-punitive assessments of care at the individual clinician level.

Although organizational system issues are sometimes identified, the primary goal is overall improvement in the care provided to Veterans through a thorough review of individual clinician decisions and actions. It is to foster a responsive environment where the clinician and clinical leadership can work together to address any opportunities for practice improvement and stronger organizational performance. The Peer Review for Quality Management may ONLY be used for improving the quality of health care or utilization of health care resources in VA medical facilities. Its primary focus is whether the clinical decisions and actions of a clinician during a specific clinical encounter met the standard of care.

This “Peer review for quality management” should never be mistaken for other activities that are conducted by peers, such as management review process, administrative investigations, FPPE, OPPE or other administrative reviews.  When assessing a specific event or issue, the facility should consider whether a 38 U.S.C. 5705-protected Quality Management activity is the appropriate first step. If it is anticipated that administrative personnel actions such as changes in privileges or terms of employment may be indicated, Peer Review for Quality Management is not the appropriate path, and a Management Review should take place instead. It is important to note that a management review is not protected under 38 U.S.C 5705.

A “Management Review” is a review conducted for purposes other than confidential quality assurance. Management Reviews are not confidential and privileged under 38 U.S.C. 5705 and its implementing regulations and are not considered Quality Management activities. Management review activities include Focused Clinical Care reviews, FPPE and FPPE for Cause, Administrative Investigations, and Ongoing Professional Practice Evaluations or OPPE.

A Peer Review for Quality Management should be discontinued if the need for a Management Review is discovered after the Peer Review for Quality Management has begun. Only the summary of the occurrence or the event source can be communicated to a new reviewer to ensure there is a distinct separation of the protected and non-protected processes. The reviewer who conducted the Peer Review for Quality Management should not participate in the non-protected management review. This is to ensure that the confidentiality of the 38 U.S.C. 5705-protected activity is appropriately maintained, and that the integrity of the process is preserved

A Management Review is a non-protected review. A Management Review process must be used if the purpose is: to provide a basis for an action that may affect personnel status or clinical privileges; to be able to respond to an external inquiry (e.g., Office of the Inspector General or Government Accountability Office); or to provide a review for VA legal counsel in lieu of obtaining a Medical Advisory Opinion (MAO).

If facility leadership determines that they need to have the discretion to undertake administrative action following the review, the review must be initiated as a Management Review. A Management Review must not occur concurrently with or following a Peer Review for Quality Management for the same episode of care. If the need for a Management Review can be anticipated, it is preferable to postpone the 38 U.S.C. 5705- protected activity until the Management Review is completed or cancel the protected activity. All information gathered or used in relation to a Management Review, including use for any type of personnel action, must be obtained in a process that is independent of any 38 U.S.C. 5705-protected activity.

• There are three levels of review for a Peer review for Quality Management:

• Level 1: is the level at which most experienced and competent clinicians would have managed the case in a similar manner.

• Level 2: is the level at which most experienced and competent clinicians might have managed the case differently, but it remains within the standard of care.

• Level 3: is the level at which most experienced and competent clinicians would have managed the case differently.

There are nine Aspects of Care that might be reviewed:

1.     Choice and/or timeliness in ordering of diagnostic tests.

2.     Addressing abnormal results of diagnostic tests.

3.     Timeliness of treatment initiation and/or appropriate treatment choice.

4.     Performance of a procedure or treatment.

5.     Timeliness and/or appropriateness of diagnosis.

6.     Recognition and communication of critical clues to patient’s clinical condition.

7.     Timely initiation of appropriate actions during periods of clinical deterioration.

8.     Health record documentation.

9.     Supervision of health profession trainees.

The essential elements of 5705 protected Peer Review for Quality Management include:

1. Peer evaluation of the care provided by individual clinicians within a selected episode of care.

2. Identification of learning opportunities for practice improvement and any related improvement actions recommended by the peer review process.

3. Confidential communication back to the clinicians who were peer reviewed regarding the results and any recommended actions to improve their clinical practice. This communication cannot include initiation of any administrative actions.

Clinical events that require a Peer Review for Quality Management include:

• Death that was preceded by a change in the patient’s condition when there are questions regarding response to, management of, and/or communication related to the referenced change.

• Death appears to be associated with a health care related incident, adverse event, or a complication of treatment.

• Death within 24 hours of admission (except in cases when death is anticipated and clearly documented, such as transfer from hospice care).

• Death within 48 hours of transfer out of a special care or intensive care unit (unless the transfer was made because death was anticipated).

• Death during or within 30 days after a surgical or invasive procedure including same day surgery/diagnostic procedure unless the death is clearly not related to the surgery, or (if after 30 days) death is suspected to be related to the original procedure.

• The circumstances of death appear to indicate there was a lack of appropriate palliative care.

• Cardiac or pulmonary arrest that may have been preventable.

• All suicides and attempted suicides by inpatients.

• Completed outpatient suicide within 7 days after discharge from inpatient Mental Health treatment or residential care.

• Attempted outpatient suicide within 3 days after discharge from inpatient Mental Health treatment or residential care.

Clinical events that should be considered for Peer Review for Quality Management include the following:

• Unexpected transfer to a special care unit for complications, incomplete management prior to transfer, or premature discharge from the special care unit that resulted in transfer back to the unit.

• Unplanned or partial removal, repair of organ or structure, or injury (laceration, perforation, tear, or puncture) during an invasive procedure.

• Post-op complications on current admission or within 30 days of surgery.

• Neurological deficit that does not present on admission.

• Acute myocardial infarction or cerebral vascular accident within 48 hours following a surgical or invasive procedure.

• Abnormal laboratory, imaging, or other test results not addressed by the responsible clinician.

• Staff supervision not documented in the health record within 24 hours of patient admission.

• Irregular discharges.

• Non-completion of operative consent.

• Patient and/or family issues and concerns that were unable to be resolved.

• VA medical facility incurred patient incident, such as: Falls, Medication errors, Patient injury other than fall.

• Incomplete management in the Emergency Department (ED) or Urgent Care (UC), with or without a return for additional care.

• Completed outpatient suicide over 7 days after discharge from inpatient Mental Health treatment or residential care, or never admitted for inpatient treatment or residential care.

• Attempted outpatient suicide over 3 days after discharge from inpatient Mental Health treatment or residential care.

A clinician who is the subject of a Peer Review for Quality Management cannot be provided with a copy of the actual peer review document, even if redacted, to protect reviewer anonymity. A written summary of the relevant peer review findings and rationale for level assignment should be given to the clinician. Relevant clinical detail must be conveyed in a way that provides a complete and accurate picture of the reviewer’s rationale and conclusions. This allows the clinician the opportunity to accurately address these issues if they choose to provide a response to the Peer Review Committee. No individual shall be permitted access to confidential and privileged quality assurance records and documents unless such individual has been informed of the penalties for unauthorized disclosure. Any misuse of confidential and privileged quality assurance records or documents shall be reported to the appropriate VHA official (e.g., VA medical facility Director, Chief of Staff). 

THE PEER REVIEW COMMITTEE (PRC) AND THE PEER REVIEW PROCESS:

The Peer Review Committee membership must be chaired by the Chief of Staff, and consist of senior members, e.g., service chiefs, section chiefs of key clinical disciplines. The PRC is not required to include a peer of the same subspecialty as the individual being reviewed.

The PRC is responsible for the Final Review and must be completed within 120 calendar days from the date the designation memorandum was signed. The PRC is also responsible for discussing all Peer Review for Quality Management cases within the facility completed by individual initial peer reviewers when the initial level assigned is determined to be a Level 2 or Level 3. The committee also provides evaluation and discussion of the initial review and the episode of care of a representative sample of Level 1 peer reviews. The committee will provide  a final level assignment, in writing, for all cases brought before the PRC.

The PRC provides recommendations for non-punitive, non-disciplinary actions to improve the quality of health care delivered or the utilization of health care resources. The supervisor of the individual who was reviewed is responsible for initiating appropriate action and follow-up.  The supervisor of the individual(s) that was assigned a Level 2 or Level 3 will communicate with the individual(s) in their service and ensure that appropriate action is implemented and must notify the PRC upon completion of the appropriate action and follow up. 

The PRC at each facility defines that facility’s process for the determination of a final level by the committee (e.g., voting, consensus) and will review external peer review audit outcomes as available, including consideration, documentation, and resolution of audits that may have two-level discrepancies between the external reviewer’s level and the peer review committee’s level. All discussions regarding a peer review occurring during PRC meetings are recorded in formal meeting minutes. Documentation relevant to any Peer Review for Quality Management must be maintained in a secure manner.

The Peer Review for Quality Management process consists of an initial review conducted by an individual peer reviewer followed by an evaluation and discussion of the initial review and the episode of care by the facility PRC. This review results in the determination of a Level 1, Level 2, or Level 3 provision of care as assessed against the nine Aspects of Care described above.

The PRC will notify the clinician of the initial peer review level assignment of Level 2 or Level 3. The clinician will be invited to submit written comments or appear before the PRC prior to the committee’s determination of a final level assignment. Clinician participation is documented in the PRC minutes. The clinician is given a summary of the case and rationale for the level assignment. If the clinician has left VA service, the case should still be considered by the PRC if it is an initial level 2 or level 3, however the final level and any feedback are not required to be sent to the clinician. If the clinician has transferred to another VA facility, the clinician may be notified about the initial level and be given the opportunity to provide input to the PRC. If the PRC assigns a final level 2 or level 3, the clinician and the Chief of Staff at the new facility may be informed of the result as a means of improving practice.

Reasonable efforts are made to allow clinician participation by submission of a written statement, attending the meeting in person, or by teleconference. The initial peer review level as determined by the peer reviewer is not modified prior to review by the PRC. Only the PRC has the authority to adopt or assign a different level to the peer review. The clinician may present a response on issues raised by the initial peer review. If the clinician declines to offer feedback to the committee, the PRC makes a final level assignment after case discussion. When the PRC reviews a case that was assigned Level 1 on initial peer review and determines the level needs to be changed to Level 2 or Level 3, the clinician will receive an opportunity to respond to the PRC prior to finalizing the level assignment.

Since the peer review process for quality management is non-punitive, a formal appeal process following final level assignment by the PRC is not necessary nor appropriate.

NAVAPD hopes this information helps alleviate the fear surrounding the peer review process that some of our members may find themselves involved. Any clinician encompassed in a review should seek appropriate guidance from their Supervisors, Human Resources, AFGE or NFFE unions, and others as may be appropriate. We are providing this as a reference to hopefully make the process as transparent as possible. We also want our membership to understand that NAVAPD cannot get involved in 5705 protected reviews or non-protected reviews.

We thank you for your membership in NAVAPD and thank you for caring for our nation’s veterans. Please use the Contact Us feature on the website to reach us and please like us and follow us on Facebookwww.facebook.com/profile.php?id=100070231563454 and LinkedIn.