II.T QUALITY ASSURANCE PEER REVIEW PROCESS

Effective Date: 
Mon, 02/24/2014
Reviewed: 
Wed, 02/26/2014
Revised: 
Fri, 02/03/2017
Policy: 

Subject: Quality Assurance Peer Review Process for CAPS clinical staff, an overview with reference to specific CAPS policies and procedures for counseling and psychiatry chart reviews.

I. PURPOSE

To identify the mechanism and process for the active, organized, and ongoing peer review process for CAPS clinical staff.

II. POLICY

 A. Counseling and Psychological Services (CAPS) is responsible for the quality of care provided by CAPS clinical staff.  Ongoing peer review is performed on a regular basis to evaluate Clinical Staff within their scope of practice in an educational, non-punitive manner.

 B. The CAPS Director is responsible for regular reports to the Executive Director on the performance of all Mental Health staff functions.  The CAPS Director may delegate to one or more of the CAPS Associate Directors appropriate roles and responsibilities in the Mental Health Staff appointment, reappointment, re-credentialing, privileging, and peer review processes. The CAPS Director retains oversight and authority for any responsibilities delegated to the CAPS Associate Directors.

 C. Peer Review is consistent with CAPS Policies & Procedures and UCSC Human Resources Policies & Procedures.

 D. Quality Assurance Peer Review is provided through monitoring important aspects of care.  Individual and aggregate clinical staff performance is measured through quality improvement, risk management, and peer review. Data related to established criteria are collected in an ongoing manner and periodically evaluated to identify potential trends or occurrences that affect client/patient outcomes.

 E. Quality Assurance Peer Review must be conducted by a member(s) of the clinical staff in good standing, of the same or similar specialty service and at least equal in education and training as the individual whose performance is under review (i.e., nurse practitioners may not peer review psychiatrists, and psychiatrists may not peer review psychologists, etc.).

 G. Clinical staff participate in the development and application of evidenced based criteria used to evaluate the care they provide.

 H. The results of peer review activities for clinical staff are reported to the CAPS Director.

 I. The results of Peer Review are used as part of the process for granting clinical staff reappointment.

 J. Quality Assurance Peer Review activities for mental health staff are coordinated by the CAPS Quality Assurance Peer Review Committee (QA), which is protected under California State Evidence Code §1157.

 K. All members of the clinical staff are reviewed in the Peer Review process.

III. DEFINITIONS

Allied Health Professions:  Allied Health Practitioners are defined as those licensed health care professionals, other than physicians, podiatrists, and psychologists, who are authorized to make independent patient care treatment decisions by virtue of their appointment or professional licensure.  At CAPS these providers are psychiatric mental health nurse practitioners, licensed clinical social workers, and licensed marriage and family therapists. 

Clinical Staff: Includes Medical, Mental Health, and Allied Health Practitioner Staff.

Mental Health Staff Peer Review:  Review of specified cases of Mental Health Staff by a peer member of the same or similar specialty service.

Mental Health Staff:  Includes Psychiatrists, Psychologists, Licensed Marriage and Family Therapists, Postdoctoral Fellows, Psychology Interns, and Licensed Clinical Social Workers

Ongoing Provider Performance Measures:  Provider performance reviews based on comparison with accepted professional guidelines and benchmarking. 

Peer: A member of the clinical staff in good standing, of the same or similar specialty service as the individual whose performance is under review.

Procedure: 

IV. PROCEDURES FOR CLINICAL STAFF PEER REVIEW

 A.  Standard Individual Client/Patient Record Review Process (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to standard peer review for counseling and psychiatry, respectively)     
   1. 
Medical staff who are not CAPS staff are directed to the relevant Policy & Procedure manual for medical services provided outside of CAPS.
   2. Mental Health Staff (members of CAPS staff)
     a. Mental Health Staff will conduct individual Case Record Reviews at least once per academic year
     b. At least fifteen (15) cases per individual provider are reviewed every three (3) year appointment period.
     c. Individual Case Record Reviews are chosen at random or other criteria as deemed appropriate by the CAPS Director or delegated CAPS Associate Director (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to peer review for counseling and psychiatry, respectively).
     d. All cases in which a recommendation for review by the CAPS Quality Assurance Peer Review Committee is identified in the overall rating will undergo review and discussion at by CAPS Quality Assurance Peer Review Committee. If the provider(s) whose review is being discussed is a member of the CAPS Quality Assurance Peer Review Committee, they will be asked to excuse themselves from the discussion.
         i. The provider whose review is being discussed may be contacted for comment and/or clarification. 
         ii. Conclusions and recommendations will be referred to the CAPS Director for review.
         iii.  CAPS Director and the provider’s supervisor will review, and the supervisor will provide feedback to the provider whose review is being discussed.
     e.  The provider’s peer review results will be included as a component of performance appraisals/evaluations.
     f. Copies of all reviews will be given to respective Mental Health staff member with originals filed in the individuals’ confidential personnel/credentialing file for re-credentialing assessment, after all prior steps have been completed.
 
 B.  Special Case Reviews (see the form “Special Referral Cases for CAPS Quality Assurance Peer Review Committee” for a checklist of procedures)

   1. Cases are identified through multiple sources such as:  CAPS Director referral, CAPS Management Team member referral, sentinel events, adverse events, incident reports, chart review findings, client/patient complaints, negative patient care outcomes, legal/risk management issues, provider concerns, and provider self-referral/request for case review.

   2. Issues identified for possible case review are submitted to and evaluated by the CAPS Quality Assurance Peer Review Committee Chairperson.  Issues may be submitted verbally or in writing. 

   3. Providers involved in a referred case are informed by the CAPS Quality Assurance Peer Review Committee Chairperson and informed they may present the case (in writing or person) to the CAPS Quality Assurance Peer Review Committee and the date of the review, allowing sufficient time to review the electronic health record.  If the provider is a member of the CAPS Quality Assurance Peer Review Committee, that provider is excused from the CAPS Quality Assurance Peer Review Committee reviews and discussions.  If the provider is the CAPS Quality Assurance Peer Review Committee Chairperson, the CAPS Quality Assurance Peer Review Committee Chairperson is excused and a temporary chair is appointed by the CAPS Director. 

   4. All members of the CAPS Quality Assurance Peer Review Committee are notified a case has been referred for review prior to the committee meeting. Review date is indicated with sufficient time to review the chart. 

   5. The CAPS Quality Assurance Peer Review Committee reviews/discusses the case as a group.

   6. CAPS Quality Assurance Peer Review Committee reaches a consensus.  Individual care management, educational issues, and appropriate training /systems issues are identified, if relevant.  A summary of important findings/recommendations is gathered by the CAPS Director on a quarterly basis, which is then shared with the Student Health Services Quality Management (QM) Committee.

   7. The CAPS Director determines appropriate department-level follow up and notifies the CAPS Quality Assurance Peer Review Committee, and Providers involved, as appropriate.

 D. Findings of the Peer Review Process are placed in a secure file in the CAPS Director’s or delegated CAPS Associate Director’s office.