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Hospital Peer Review Consultation

Doctors sitting around a white table

The Institute for Medical Quality helps medical staffs conduct peer review by offering both a review of individual cases and a comprehensive evaluation of a physician’s practice. These consultation services are entirely independent from any IMQ accreditation or certification program. Consultation services are customized for each medical staff, group or clinic, and fees are based on the scope of the services provided.

Clinical Case Review

Through off-site patient chart review, an IMQ Clinical Case Review consultation provides a skilled and objective evaluation of the clinical practice of one or more physician members of a hospital medical staff, physician group, or ambulatory care practice through peer review of selected cases. IMQ's involvement is especially helpful when an organization will benefit from expert review of one or more patient cases, but needs physicians of the appropriate specialty who have no real or perceived conflicts of interest.

Reviews are performed by physicians in active practice in the clinical specialty or sub-specialty of the case selected for the peer review.  IMQ selects two physicians to conduct an off-site review of individual clinical cases and outcomes and creates a report detailing their findings and recommendations. The IMQ report is a confidential document intended solely for use within the organization’s peer review program.  

Comprehensive Peer Review

IMQ’s Comprehensive Peer Review consultation is custom-designed to assess the overall quality of care and services provided by one or more physicians who practice at a hospital or clinic or in a group-practice setting. The physician(s) who is the focus for the peer review must consent in advance to the consultation.

This consultation is intended as a helpful adjunct to a facility’s or group’s quality assessment and improvement processes and is most appropriate under the following circumstances:

  • When a medical staff peer review body has performed peer review, but requires assistance in determining the quality of care and/or means of achieving quality improvement provided by a physician or physicians on staff;
  • When the physician whose care has been reviewed feels that he/she has legitimate disagreement with the conclusions of the peer review body;
  • When the number of physicians practicing in the same specialty or sub-specialty on the medical staff is deemed insufficient to perform objective peer review;
  • When physicians practicing in the same specialty or subspecialty on the medical staff feel they cannot objectively conduct peer review.

Each consultation is customized to fit the environment and needs of the facility or group, but at a minimum involves two physicians of the relevant specialty who practice in another geographic area. Generally, the consultation begins with an on-site review of medical records selected by the organization and by the consultants, and continues with interviews with the involved physician(s), appropriate medical staff or group leadership, and key employees of the organization. The consultants also assess relevant credentials documents and quality-related data.

Following the on-site visit, the consultants prepare a report of their findings. This confidential report is sent to the Chief of Staff and the physician(s) whose care is being reviewed. The report is designed to provide information that can be factored into ongoing peer review activity. Thus, IMQ consultations are most effective in the early evaluation of a concern about physician’s performance.

IMQ treats the fact that a peer review has been performed by IMQ as confidential. Additionally, the report prepared by IMQ after the consultation, as well as all information contained in the report, are held strictly confidential by IMQ.  Such information may be released to a third party by IMQ only with written approval of the Chief of Staff and the physician involved.

For further information about the Peer Review and Medical Staff Consultation programs, please contact Leslie Anne Iacopi at (415) 882-5167.