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Administrative (Non-Clinical) Policy
As of July 1, 2017, this administrative policy applies to the operations and staff of legacy UWHC.
Effective July 1, 2015, the legacy operations and staff of UWHC and UWMF were integrated into the
University of Wisconsin Hospitals and Clinics Authority (UWHCA). All administrative policies are being
transitioned to apply UWHCA-wide, but until future revision to this policy #8.39, it applies only to the
operations and staff of legacy UWHC.
Policy Title: Peer Review for All Individuals Holding Clinical or Professional
Effective Date: August 10, 2017
Chapter: Patient Care
To assist the Senior Vice President Medical Affairs and the clinical chairs in carrying out their
responsibilities for the continuing surveillance of the professional performance of all individuals who
hold clinical or professional privileges in their respective departments. The clinical chair may wish to
delegate these activities to other designated medical staff while retaining ultimate responsibility.
A. Peer Review
1. The term "peer review" includes:
a. Peer review by medical staff members of the qualifications and performance of
medical staff colleagues.
b. Peer review of other clinical professionals with professional privileges by their peers
and broader peer review of some of their findings and/or recommendations. This
includes anyone providing a medical level of care.
c. Peer review of applicants to the medical staff and applicants for professional
d. Peer review resulting from (a) or (b) above that reviews some of the findings and/or
recommendations of this primary peer review and/or approves final actions. This peer
review can also be conducted by the Corrective Action Peer Review Committee,
Credentials Committee, Medical Board, or other committees. Thus, this policy does
not address subsequent actions and appeals as defined in Articles IX and X of the
Bylaws of the Medical Staff.
e. There is also institutional peer review that reviews institutional processes and/or the
activities of non-privileged individuals who are not subject to this policy. These other
peer review functions and the applicable committees are not subject to this policy.
2. Peer review for the purpose of this policy is the process of synthesizing objective data,
extant literature, evidence-based medicine, medical ethics, medical community standards
for the care of patients, and other information in order to evaluate the quality of care
provided by individuals who hold clinical or professional privileges. When evaluating the
quality of care of an individual member, this process must solicit participation by the
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member under review prior to any formal determination finding the practice of the member
under review to be deficient.
3. Cases may be identified for peer review through a variety of methods, including but not
limited to, referrals from medical staff committees, members or hospital departments; chart
review; event reporting; requests by external agencies or payors; patient/family complaints;
or routine reports (e.g., mortality reports).
4. Peer review will generally be conducted by a department Quality Improvement/Peer
Review Committee. However, peer review for purposes of this policy also includes the
review of activities of medical staff members and other clinical professionals for the
purpose of improving the quality of health care. For example, peer review activities may
include, but are not limited to, case conferences or case reviews, critical incident review or
M&M, and all such activities used for peer review are confidential.
For the purpose of this policy, peers include members of the medical staff and other clinical
professionals. When physicians are being reviewed, peers are limited to other physician members
of the medical staff who by virtue of training, certification, licensure, or experience have
sufficient understanding of the aspects of care under review to be able to assess the propriety of
that care. This would include members in the same specialty or related specialty or general field
of practice as the member under review. Peers do not have to be in the same field of practice.
When non-physician members of the medical staff or other clinical professionals with
professional privileges are being reviewed, peers would include members of the same profession
or physicians who sufficiently understand the care under review to be able to assess the propriety
of the care. Peers also include outside consultants who are not members of the medical staff who
are involved in the process under (III)(C).
C. Peer Review Committee
For the purpose of this policy, a peer review committee is a committee of peers constituted to
conduct peer review. Peer review committees may be formally constituted by the Medical Board,
Senior Vice President Medical Affairs, by a clinical chair. Such committees may include hospital
or departmental administrative staff, or allied health professionals in advisory and support roles,
but not as voting members if the committee takes action by voting for purposes of judging the
clinical competence of individuals who hold clinical or professional privileges. Only physicians
can vote on individuals with clinical privileges. Physicians and those with professional privileges
can vote on individuals with professional privileges.
A. Each clinical chair appoints a quality chair and/or standing peer review committee or committees
which may also function as a quality improvement committee, to review the clinical competence
of individuals who hold clinical or professional privileges in their respective department. These
committees are involved in Ongoing Professional Practice Evaluation of privileged practitioners
(see Section IV-Ongoing Professional Practice Evaluation), and may be responsible for Focused
Professional Practice Evaluation of privileged practitioners. (See Section V-Focused Professional
Practice Evaluation). Committees charged by a clinical chair with peer review responsibilities
should be documented as such in their department's annual report to the Peer Review Committee,
or in hospital administrative policy, such as Administrative Policy 4.40-Reporting Unexpected
Events & Determination of Sentinel Event Status.
B. Each departmental quality improvement/peer review Committee is staffed by a Quality
Improvement Specialist, who is a member of the Quality, Safety and Innovation Department. The
Quality Improvement Specialist provides support and consultation regarding the departmental
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performance improvement plan and quality monitoring and improvement activities, including
peer review, assisting in preparation of reports for the Quality Improvement/Peer Review
Committee, and collecting and maintaining reappointment data.
C. The Senior Vice President Medical Affairs and the clinical chairs may appoint additional peer
review committees to review inter-departmental issues or other matters that in his/her opinion
requires institutional level review.
D. When a Quality Improvement/Peer Review Committee takes action by voting, Committee staff
not meeting the definition of a "Peer" may not vote on decisions regarding the clinical
competence of individuals who hold clinical or professional privileges (see section II.B. above).
E. In circumstances where the UWHC Medical Staff cannot provide more than one "Peer"
(as defined in section II.B. above) to review the clinical practice under review, the Senior Vice
President Medical Affairs or the department clinical chair may seek one or more such peers from
outside institutions. The hospital shall not be responsible for the cost of such external peers unless
they are approved by the Senior Vice President Medical Affairs.
F. All discussions, documents, minutes, and reports generated by a quality improvement /peer
review Committee, or as part of any peer review activity, are confidential and are protected from
disclosure in accordance with Wisconsin statutes 146.37 and 146.38. Only authorized persons
have access to peer review information. Authorized persons include, but are not limited to,
medical staff leaders, Medical Staff Affairs personnel, UWHC administration, and Quality,
Safety and Innovation personnel.
G. The Quality Improvement/Peer Review Committee contributes to the departmental Performance
Improvement Plan, which is reviewed and approved annually.
IV. Ongoing Professional Practice Evaluation (OPPE)
A. The Quality Improvement/Peer Review Committee establishes methods of evaluating and
monitoring the clinical practice of individuals who hold privileges in the department. Data is
made available to the Quality Improvement/Peer Review Committee on an ongoing basis by
various departments and committees to assist in this review. All individuals with clinical or
professional privileges will be reviewed at least every six months as part of OPPE. The data is
summarized and reported to the clinical chairs during the medical staff reappointment process for
use in making appointment/privileging decisions.
B. In fulfilling its role in monitoring the quality of the care provided by the members of its
department, the Quality Improvement/Peer Review chair routinely reviews volume information
related to requested privileges and other quality indicators as identified by the hospital and/or
department where applicable. The departmental Quality Improvement/Peer Review Committee
assures compliance with Hospital Administrative policy 8.48-Operative, Invasive and Other
Procedures and The Joint Commission (TJC) requirements. Monitors selected should include
measures of performance or outcomes as deemed appropriate to the procedure by the
clinical department. The Quality Improvement/Peer Review Committee may also review data as
presented by other committees or departments, such as pharmacy and therapeutics, blood and
tissue utilization, health information management, or risk management.
Department Chairs also receive additional data from other committees and departments on a
regular basis. Examples include medical record documentation audits, patient complaints and
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V. Focused Professional Practice Evaluation (FPPE)
FPPE is required for all new privileges meaning all privileges for all new applicants and all new
privileges for individuals with existing clinical or professional privileges. The initial FPPE review will
occur at six months after the new privilege begins. However, this time frame could be extended by the
clinical chair for privileges with low volume. FPPE may also be used when a question arises regarding a
currently privileged practitioner's ability to competently provide safe, patient care.
The FPPE process may include chart review, monitoring clinical practice patterns, simulation, proctoring,
external peer review, or discussion with other individuals involved in the care of each patient
(e.g., consulting physicians, assistants at surgery, nursing or administrative personnel). The criteria for
performance evaluation will be identified by the Quality Improvement/Peer chair.
Relevant information resulting from the focused evaluation process is integrated into performance
improvement activities and this policy which are intended to preserve confidentiality and privilege of
A. Use of FPPE when questions arise regarding currently privileged practitioners:
1. The Departmental Peer Review Committee may require FPPE in cases where questions
arise about a privileged practitioner's ability to provide competent safe, high quality patient
2. Triggers for FPPE review of a currently privileged practitioner include any indicators that
fall outside of our standards of care. Some examples include:
a. Complaints by patients, families, hospital or medical staff
b. Medical Record completion discrepancies
c. Lack of adherence to UWHC policies
d. Results of ongoing peer review that identifies non-standard care
e. Hospital wide indicators (measures that trigger review)
f. Other triggers as identified by the department
3. Once a case has been identified as meeting the criteria for review, the departmental Quality
Improvement/Peer Review Committees will initiate that review within 90 days, and will
strive to complete the review within 180 days. There may be a rare exception where it may
take additional time to complete the review, such as in situations where meeting that
deadline would unreasonably inhibit the ability of the member under review to receive a
fair review by his/her peers.
4. Cases included in FPPE may come from a variety of sources, both internal and external.
The Quality Improvement/Peer Review Committee may define those circumstances, such
as a significant negative patient outcome, that automatically prompt review. The review
mechanisms employed should be consistently applied when conducting FPPE to ensure the
review is not unreasonable when applied to certain individuals. However, in some cases,
the committee may need to deviate from the routine FPPE mechanism to focus its review
on individuals who, by the nature of the care they provide, the outcomes of previous cases
reviewed, or identified practice patterns, are considered at higher risk for significant
negative patient outcomes. The Committee may use its discretion to define the cases it
reviews in order to achieve the most effective surveillance commensurate with the patient
care provided by its members. It should, however, review every case referred by a credible
source where a specific deviation from accepted practice is identified or credibly suggested.
5. When warranted, the committee recommends action and evaluates the impact of the actions
taken. The Committee should report any significant variation in practice to the clinical
chair for educational or other appropriate interventions with the practitioner. Any concerns
should also be shared with the practitioner so they have an opportunity to provide
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input. The committee may also recommend to the Senior Vice President Medical Affairs or
to the clinical chair that an issue be referred to another committee, such as the Medical
Staff Health Committee or Medical Staff Behavior Committee, or recommend that
corrective action be considered under the Medical Staff Bylaws. The Clinical Chair will
notify the Chief Nursing Officer (CNO) (or applicable senior leadership with oversight of
the practitioner or service involved) when actions taken outside of the department are
needed or changes in professional privileges are being considered. Further proceedings
would be followed per the Medical Staff Bylaws.
B. Reports of new privilege FPPE evaluations
At the end of the first six months of practice at UWHC, or request for new privilege, the Quality,
Safety and Innovation Department will generate summary data and forward to Medical Staff
Affairs. The Medical Staff Affairs office will then generate a review form along with a list of
privileges to be reviewed. These items will be forwarded to the Clinical Chair for determination.
Clinical Chairs have the authority to extend FPPE evaluation, when necessary, to demonstrate
competency in one or more of a privileged practitioner’s requested privileges (due to low volume,
lack of demonstrated competency) or if there has not been improvement in performance of the
trigger(s) (see –V.A.1-5 above) that resulted in a currently privileged practitioner undergoing
FPPE. Completed FPPE forms are expected to be returned within 14 days to the Medical Staff
Office, 2639 University Ave. Madison, WI. If the FPPE evaluation results are marked as
“unsatisfactory” at the conclusion of the FPPE evaluation, the Medical Staff Credentials
Committee will review and recommend action as outlined in UWHC Medical Staff Bylaws.
Senior Management Sponsor: SVP, Associate Chief Medical Officer
Author: Director, Quality and Patient Safety
Review/Approval Committee(s): UW Health Administrative Policy and Procedure Committee;
UW Health Chief Administrative Officer
Ann Sheehy, MD
UW Health Medical Board Chair