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Overview

Medical peer review is the process by which a professional review body considers whether a practitioner’s clinical privileges or membership in a professional society will be adversely affected by a physician’s competence or professional conduct. The foremost objective of the medical peer review process is the promotion of the highest quality of medical care as well as patient safety. From American Medical Association, http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/medical-peer-review.page.

Policy

Because the healthcare entity is ultimately responsible for the quality of healthcare provided at its facilities, and can be directly liable to patients if it allows unqualified or incompetent physicians to practice in its facilities, it is important that the healthcare entity continually monitor practices of medical staff members and take appropriate actions to protect patients from substandard care. Adversely affected physicians often bring suits alleging: (i) antitrust claims, (ii) breach of contract claims, (iii) discrimination claims, (iv) defamation claims, and (v) other claims under various tort and contract theories. However, [the Health Care Quality Improvement Act] HCQIA provides a limited shield against such potential liability if the requirements of HCQIA are met. HCQIA was designed to encourage good faith peer review activities to improve the quality of healthcare and protect patients.

Authority

To be entitled to HCQIA protection, the four standards set forth in Section 11112(a) of HCQIA must be satisfied. Specifically, the professional review action must be taken:

1. in the reasonable belief that the action was in the furtherance of quality health care;

2. after a reasonable effort to obtain the facts of the matter;

3. after adequate notice and hearing procedures are afforded to the physician involved or after such other procedures as are fair to the physician under the circumstances; and

4. in the reasonable belief that the action was warranted by the facts known after the exercise of such reasonable efforts to obtain facts and after meeting the requirements of paragraph (3). See 42 U.S.C. § 11112(a).

Excerpt from Karen S. Rieger, Eric S. Fisher, and Stephanie A. Russo, The Fundamentals of Medical Staff Issues: Minimizing Risks and Maximizing Collaboration, Fundamentals of Health Law (American Health Lawyers Association Nov. 2011).