Hospital Quality of Care Review
The American Medical Foundation assists Hospitals in reviewing their quality and peer review systems and then works closely with administration, physician leadership and the governing body to guide them, where necessary and appropriate AMF works with an institution’s legal representatives to insure that their reviews are appropriately protected in the implementation of strategic modifications to improve these systems.
The AMF Teams dedicated to this endeavor have developed specific methodologies to evaluate a Hospital’s existing processes for Medical Staff Peer Review, Medical Staff Credentialing and Privileging, Medical Staff Discipline, and Quality of Care Methodologies and Metrics including OPPE and FPPE. The process seeks to explain any identified deficiencies in a detailed systems review, work with all parties to seek appropriate solutions for that institution and guide the revised methodologies through the implementation process.
Members of the Team can serve as mentors, if requested and required, throughout the implementation process to insure effective systems which will accomplish their purpose and assist the institution to remain compliant with accreditation and state and federal laws. This process has been effective in obtaining physician understanding and acceptance and approval from administration, the governing body and legal counsel.
AMF has developed a unique approach to this process and has also served as the Institutional Review Organization (IRO) for institutions that have been the subject of OIG Corporate Integrity Agreements which are focused on quality and peer review issues.
The AMF Team provides its strategic services through direct observation and interaction on site to understand the operation of the facility, its culture and the relationship between the medical staff and the administration and governing body. Without direct observation, it is impossible to understand whether the peer review processes, quality assurance mechanisms and credentialing and privileging are operating in an appropriate manner to insure quality of care and patient safety. Without the ability to examine operations on site, it is virtually impossible to make an appropriate assessment and then develop a plan that is acceptable to the institution which will accomplish its purpose in an efficient and effective manner. Upon completion of its evaluation, the AMF Team prepares a Systems Review Report which includes the findings and supporting rationale regarding the strengths and weaknesses of the peer review policies and procedures, medical staff credentialing, medical staff training and discipline, and the quality systems as well conclusions and any recommendations to improve any of these systems, operations and processes.
A thorough and systemic analysis includes the gathering and analysis of quality assurance data including the core measures and departmental and divisional clinical criteria. It includes the review, analysis and appropriate incorporation of that information to improve patient care, maximize patient safety, compare and assess individual and aggregate physician performance, identify physician outliers, recommend remedial action, and take corrective action. This process includes the credentialing of new practitioners, the re-credentialing of existing medical staff members and the delineation of specific privileges for each member of the medical staff and ancillary staff practicing within the facility and the OPPE and FPPE processes.