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Peer review serves as an important adjunct to other hospital quality and safety programs. Despite its importance, the available literature contains virtually no guidance regarding the structure and function of effective peer review committees. This Clinical Perspective provides a summary of the purposes, structure, and functioning of effective peer review committees. We also discuss important legal considerations that are a necessary component of such processes. This discussion includes useful templates for case selection and review. Proper committee structure, membership, work flow, and leadership as well as close cooperation with the hospital medical executive committee and legal representatives are essential to any effective peer review process. A thoughtful, fair, systematic, and organized approach to creating a peer review process will lead to confidence in the committee by providers, hospital leadership, and patients. If properly constructed, such committees may also assist in monitoring and enforcing compliance with departmental protocols, thus reducing harm and promoting high-quality practice.

Purpose: To provide an overview of the development and implementation of a peer review process for advanced practice nurses (APNs) based on critical incidents that provide meaningful evaluation of practice and meets the needs of APNs across multiple care specialties and practice situations. Data sources: A review of the literature and evaluation of the existing peer review process currently in place at a large tertiary care facility. Conclusions: Peer review is central to self-regulation and professional practice for APNs. It has been proposed that APNs of similar rank and clinical expertise should participate in peer review. APN peer review and evaluation have traditionally existed as a component of performance evaluation, evaluation of practice patterns, and compliance monitoring, and to evaluate quality indicators. We found no examples of peer review in the context of evaluating a critical incident in the literature. The APN Peer Review Committee and the review process were developed at our institution to provide peer input and communication to all credentialed APNs in incidents regarding appropriateness of care and scope of practice. Implications for practice: APNs must assure that they have a voice in the peer review process. Representation by peers of similar specialty and rank is an important component in the peer evaluation process. The establishment of the APN Peer Review Committee served this purpose for our institution.

Purpose:In conjunction with curricular changes, a process to develop integrated examinations was implemented. Pre-established guidelines were provided favoring vignettes, clinically relevant material, and application of knowledge rather than simple recall. Questions were read aloud in a committee including all course directors, and a reviewer with National Board of Medical Examiners (NBME) item writing and review experience. This study examines the effectiveness of this process to improve the quality of in-house examinations. Methods:Five hundred and twenty items were randomly selected from two academic years for initial comparison; 270 from 2000 to 2001, and 250 from 2001 to 2002. The first set of items represented the style, content and format when courses and tests were departmentally/discipline based, assembled by course directors, and administered separately. The latter group represented similar characteristics when courses and tests were organ-system-based, committee-reviewed and administered in an integrated examination. Items were randomized, blinded for year of origin, and rated by three NBME staff members with extensive item review experience. A five-point rating scale was used: one indicated a technically flawed item assessing recall of an isolated fact; five indicated a technically unflawed item assessing application of knowledge. To assess continued improvement, a follow-up set of 250 items from the 2002 to 2003 academic year was submitted to the same three reviewers who were not informed of the purpose or origin of this set of test items Results:The mean rating for items from 2000 to 2001 was 2.51 ± 1.27; analogous values for 2001–2002 were 3.16 ± 1.33, (t = 5.83; p < 0.0001), and in 2002–2003; 3.59 ± 1.15 (t = 10.11; p

The multidisciplinary trauma peer review process collects, reviews, discusses, and collates all morbidities and mortalities of injured patients to institute corrective action in a timely manner. The resultant remedial activity may include professional education, physician counseling, restriction of privileges, or changes in the trauma care system. Effective corrective action necessitates timely data input from the postmortem examination. Faced with an inordinate delay, skimpy reports, and expense in obtaining such reports from the medical examiner's office, the chief medical examiner was invited to become a member of the peer review committee. During a 12-month interval as a full-fledged member of the peer review process, the medical examiner was able to provide complete verbal reports on all deaths resulting in a synergistic benefit to the peer review process and to the medical examiner office. Two of 53 nonpreventable deaths were reclassified as possibly preventable in one and preventable in the other. Four of 15 possibly preventable deaths were reclassified based on the medical examiner report. In turn, the physician members of the team were able to augment the medical examiner's knowledge in certain areas that were critical for his analysis of accidents or homicide. Based on these findings, the medical examiner is recommended as a participating member of the trauma peer review committee.

Guidelines for the protection of privacy in the conduct of medical research have been issued by the National Health and Medical Research Council, approved by the Commonwealth Privacy Commissioner, and gazetted on 1 July 1991 (Commonwealth of Australia Gazette No. P19) to remain in force until 30 June 1994. This paper examines the guidelines and seeks to inform researchers, institutional ethics committees and the institutions those committees represent of their content. Responsibilities are placed upon those engaged in the conduct of research and those involved in undertaking ethical review who now have to decide that the public interest in conducting the research substantially outweighs the public interest in privacy. There is also an emphasis on the requirement for surveillance of research projects by institutional ethics committees which has not previously been apparent. Questions are posed to assist in deciding whether a particular research protocol is subject to the guidelines.

I have presented a variety of methods of helping practitioners evaluate products. It does not appear that the frustrating challenge of product evaluation will become less complex. Practitioners should use all of the concepts enumerated in this article to aid in their selection of products and be thankful that we have the freedom to select the products that we believe, after due consideration, are best for our patients.

Good research does not occur in isolation. The researcher should choose one or more reviewers to serve as quality monitors of the process. The reviewer(s) should be carefully chosen, and the relationship should be nurtured. When the research is not enhanced by the relationship, new reviewers should be sought even if this delays the research process. A good study has enough glory to share with all reviewers, and a poor study is a heavy burden to bear alone.

To determine if rank position on the match list of a maternal-fetal medicine (MFM) fellowship program predicted applicant academic success.The Thomas Jefferson University MFM fellowship program rank order lists and the results of the match were reviewed for 1991-2002. Evaluation of candidates includes an application, 3 letters of recommendation, curriculum vitae and interview upon invitation. Career success of graduated fellows was defined as MFM board certification, number of peer-reviewed publications and of Society for MFM (SMFM) abstract publications.Applicants ranked higher tended to have more peer-reviewed publications per applicant (9.2 vs. 4.7 vs. 4.4, p = 0.5) and more abstracts presented at SMFM (7.6 vs. 8.0 vs. 3.8 p = 0.5) as compared to lower-ranked applicants. Ranked applicants had a higher probability of being MFM board certified (74 vs. 22%, p = 0.005), having more peer-reviewed publications (6.8 vs. 1.4, p = 0.005), and more abstracts (7.1 vs. 2.1, p0.0001) as compared to nonranked applicants.MFM fellowship applicants who were ranked higher were more likely to publish as compared to lower-ranked applicants. Ranked applicants were more likely to publish and be MFM board certified as compared to nonranked applicants.

Like all medical schools, Northeastern Ohio Universities College of Medicine (NEOUCOM) has an elaborate committee system for academic review and promotions (ARP). Little research exists locally or nationally on this system.E-mail invitations to all 420 NEOUCOM currently enrolled students were sent seeking their participation in a qualitative study that involved interviewing students who had appeared before an ARP committee at any time for any reason to understand how they experienced the process.NUD*IST software was used to analyze the data generated by the interviews.The invitation drew 19 volunteers from the pool of 84 students who, at the time of the messages, had appeared before an ARP committee at least once. Themes were discovered surrounding students' perceptions of the committee's purpose, their experience of it, their beliefs about students' honesty when appearing before the committee, how they felt about themselves after a committee appearance, and how they would improve the process of academic review.

In two recent papers, a radical change of the review system for medical ethics review committees was proposed. The current systems in Great Britain and Australia were described and it was suggested that the extended roles and responsibilities of the medical ethics review committees could not be fulfilled by the present committees. It was proposed that professional medical ethics committees be established with full time members who would receive an appropriate honorarium. The Netherlands has a decentralised system of medical ethics review, which is based on peer review. A radical change of the current system of medical ethics review is not warranted. There is however a need for further improvements to the current peer-review system. An important aspect of this improvement is an honorarium for the members as well as a budget for training and for the adequate scientific and administrative support of the committee by a secretariat. The fees levied for reviewing each protocol could in part finance the committee and its secretariat. However, these fees will probably not meet all of the costs. Therefore the centres involved in medical research should consider supporting their committees. It is in their interest to demonstrate their wish to protect those persons who consent to participate as research subjects. This will maintain the confidence of both the public and future participants in clinical trials. Furthermore, an efficient and adequate system of ethical review will support a balanced view towards medical research with human subjects and will also contribute to a positive image of the centre also as an attractive environment for medical professionals.

Many people have an interest in the quality of medical education. Students have the right to as good an education as possible, and the public has the right to well-educated and well-trained general physicians and specialists. Therefore, a medical school or faculty must ensure its quality and is accountable for the quality of the training it provides. This paper emphasizes that the best way to ensure quality is by continuous attention to it. Quality depends not on measurement instruments and tools but rather on the spread of quality awareness among faculty, staff, and students. A tool for safeguarding quality is the design of a well-functioning quality assessment system, based on two pillars: a system of internal quality control and external assessment by peers. The connection between the internal and external assessments is the self-evaluation by the school. On the one side, this self-evaluation is a critical self-analysis and an agenda for improvement. On the other side, it contains information for the external reviewers. The peer review also provides input for the process of improvement.

The revelation that data obtained for the US-based National Surgical Adjuvant Breast and Bowel Project (NSABP) from subjects enrolled at Hôpital Saint-Luc in Montreal was falsified has eroded public trust in research. Institutions can educate researchers and help prevent unethical research practices by establishing procedures to monitor research involving human subjects. Research monitoring encompasses four categories of activity: annual reviews of continuing research, monitoring of informed consent, monitoring of adherence to approved protocols and monitoring of the integrity of data. The authors describe characteristics of research projects that may call for monitoring procedures in each category. The form taken by such monitoring depends on the nature of the protocol. Although appropriate research monitoring requires substantial investment of personnel and financial resources, it is required under guidelines regulating research involving human subjects in Canada. Research monitoring is a step forward in re-establishing public confidence in medical research.

Many randomized clinical trials include a data and safety monitoring board (DSMB) that is responsible for reviewing accruing data, monitoring performance of the trial, assuring safety of the participants in the trial, and assessing the efficacy of treatment. The DSMB often makes recommendations about continuation of the trial or alteration of the protocol. Although such boards are very influential in both the conduct and interpretation of randomized clinical trials, there is no standard mode in which DSMBs operate nor do they routinely report publicly about their deliberations. This paper describes the composition of DSMBs as well as their functions. It concludes with a series of questions that needs to be addressed to ensure that the DSMBs operate effectively.

How do you objectively evaluate physicians at reappointment. How do you establish a common ground for the evaluation process that still acknowledges acceptable differences in performance? Perhaps one physician has some difficulty with documentation and attendance at meetings, but has no quality problems clinically. Another physician may have good documentation and meeting attendance, but has some quality problems. Another physician has a behavior pattern that is disruptive, a few documentation problems, but excellent quality. Yet another physician is a marginal practitioner with major problems in several areas, including quality. Reappointment of these physicians might be extremely difficult, especially if the credentials committee is recently appointed and not familiar with the details of the performance data.

The Graduate Training Committee at Memorial Sloan-Kettering Cancer Center developed procedures for comprehensively reviewing the 32 graduate training programs at our institution. The methods used to carry out this review, the problems encountered, and the results of this review are presented. As this type of program review is now mandated by the Accreditation Council for Graduate Medical Education (ACGME), our method and experience should prove useful to other institutions planning a similar review process.

This article reviews the general principles of quality assurance (QA) in an imaging department, with emphasis on nuclear medicine. The various steps taken during the development of the QA program reflect the response of the QA committee as it came to a better understanding of the components of QA. Accrediting and regulatory bodies have had important roles in providing guidance. Quality control of instrumentation and radiopharmaceuticals opened the gateway to monitoring in high-volume, high-risk areas; however, QA expanded this concept into better generic and clinical monitoring. Encouragement of the use of quality of care referral forms resulted in greater participation by all members of the department. Examples of physicians' QA activities include double reading of images and sending of code cards. Experience with other forms of physician QA activities is also included. The QA committee provides a forum for five steps of QA: identify problems, assess the causes, implement action to prevent them, monitor effects of the actions, and document these activities. These steps should lead to improvement in the standards of patient care.

In 1983, The Methodist Hospital of Houston, Texas--the largest private nonprofit acute care hospital in the United States--revised its quality assurance (QA) program to integrate Joint Commission standards with the mission of the hospital. The revised QA program includes the medical staff, hospital departments, management, and a Caring Through Service Task Force, which evaluates services from the patient's perspective.

Peer Review Committees (PRCs) that aid insurance companies in evaluating chiropractic treatments and fees have been the focus of recent court challenges. Some practitioners have argued that PRC activities constitute price fixing in violation of the Sherman Antitrust Act. PRCs have been successful thus far in claiming an exemption from antitrust scrutiny as a “business of insurance” within the meaning of the McCarran-Ferguson Act. This Note contends that PRCs are not exempt from antitrust regulation; since PRCs do not spread risks and are involved in inter-rather than intra-industry agreements, their activities do not fall within the narrowly defined “business of insurance” exemption.The Note then analyzes the merits of the price fixing allegations under both the “per se” standard and the “rule of reason.” First, the Note concludes that the unique nature of the health care market and the legitimate functions served by peer review make the application of a per se standard inappropriate. Second, under the rule of reason, the Note indicates that peer review encourages efficient and innovative health care practices while it deters the escalation of health care costs. The Note concludes that the net effect of peer review is not anticompetitive, especially since PRCs lack the coercive power to compel compliance with the recommendations.

The paper discusses the medical origins of the peer review legislation and its adaptation to community mental health. Three models of peer eview are presented which could be used in community mental health centers. They are the problem model, the sequential model, and the Psychiatric Utilization Review and Evaluation Project (PURE) model. All three require a review of records by a committee of respected clinical staff, regardless of profession.

The lack of a precise definition as to what unnecessary surgery really means continues to be a significant problem. The most accurate statement of the problem appears to be that unnecessary surgery exists, but its true scope is yet to be determined. Further research on health services must be devised before all of the questions concerning unnecessary surgery can be answered.