Peer Review Procedure Manual (Grievance Resolution)

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Prologue

The introduction to the Principles of Veterinary Medical Ethics of the AVMA states that "professional organizations may establish ethics, grievance, or peer review committees to address ethical issues." The purpose of conducting and participating in peer review is to provide a forum for veterinarians to resolve disputes with clients or among themselves. This Peer Review Procedure Manual includes principles and guidelines to assist state and local veterinary medical associations that wish to implement peer review.
 

Peer review is intended to be a collaborative process that achieves a fair result for all participants. Peer review is not a substitute for a court of law and should not be engaged where the matter is in litigation. Although peer review is voluntary, participants should abide by the final result. The peer review committee's decision and recommendations are not enforceable in a court of law, but the committee must follow rules to ensure that the process is conducted in an impartial and consistent manner. The peer review committee is often responsible for investigating a complaint, conducting a review, and determining an appropriate resolution to the matter. For these reasons, associations should consider training their peer review committees on how to handle complaints efficiently and competently.

Associations should consult with legal counsel to evaluate and minimize the legal risks involved with conducting peer review. Associations should ensure that state law adequately protects peer review proceedings from discovery in civil lawsuits and, to the extent possible, provides immunity from liability for peer review committee members acting in good faith. Peer review participants must agree to maintain the confidentiality of peer review proceedings. They should agree that statements and documents prepared or disclosed during the peer review process will not be used in any later legal proceedings, and that peer review committee members will not be liable for damages arising from their service. In addition, associations should carry sufficient liability insurance to cover peer review proceedings and committee members.

 

Preface

Veterinarians are expected to be sensitive to uncertainties or misgivings exhibited by clients during treatment of their animals and should be willing to discuss explicit complaints. For professional and personal reasons, veterinarians should be concerned that clients leave their offices well satisfied. As professionals, veterinarians also should be aware of how the public perceives the veterinary profession as a whole and the importance of their role in shaping this perception.

 

Veterinary care delivery has become more complex. Therefore, informal methods of resolving misunderstandings are not always sufficient. Consequently, a more formal method of response has been developed - peer review.

Peer review is a mechanism by which a profession demonstrates the appropriateness and quality of care it renders. The review provides a proficient and credible system for resolving disagreements that cannot be resolved at an earlier, more informal stage. Peer review may be administered by ethics or grievance committees of local or state associations or by more formal boards established by those same associations. All such committees or boards will be discussed as a single entity.

Clients, as well as veterinarians, must be aware of the existence and the availability of the peer review system. The finest review mechanism is worthless, if no one knows of its existence.

Peer review is based on professional expertise. Veterinarians with appropriate professional credentials help conduct the hearings, review the evidence, and make objective decisions and recommendations based on the findings.

The peer review system is credible, because its rules and procedures are clearly established and afford an equal opportunity for each participant to be heard. The presence of a non-veterinarian on the committee may enhance this credibility. Non-veterinarian representatives should serve in an advisory capacity and should evaluate procedures and mechanisms for fair and equitable resolution of disagreements.

Peer review is not a court of law, an adversary proceeding, or a punitive expedition. Peer review exists to educate, adjudicate, and clarify, and to make corrections where necessary.

Peer review is voluntary. However, those using the system should abide by its findings. For peer review to be effective, people should voluntarily seek out the system and then should be willing to abide by the outcome. The strength of peer review is derived entirely from its ability to function effectively and fairly.

A peer review manual is necessary to suggest procedures that can be adopted to ensure success of the system. Because many professional groups are involved in veterinary care, they are potential participants in peer review. Therefore, a reasonable degree of uniformity in the process is needed from community to community and from state to state. (Appendix 1)

The purpose of the peer review manual is to assist component and constituent societies to create a peer review system as quickly and efficiently as possible.

The veterinary profession needs to expand and to perfect its peer review system. The peer review system can demonstrate to the public the excellent care that veterinarians provide to their patients and the initiative that the profession takes to correct problems that may arise.

Purpose

A peer review committee should be established within a local, regional, or state veterinary association to review matters concerning, but not limited to, appropriateness of care and quality of treatment. The committee may act on appropriate requests initiated by clients, veterinarians, or insurance carriers.

Responsibility

The peer review committee should explore, to the extent necessary, all matters referred to it and do so within a period that makes its efforts effective. The committee's means of communication may vary as the situation warrants. The peer review committee has equal responsibility to clients, veterinarians, and insurance carriers.

 

Matters for Review

Appropriateness of Care: The peer review committee shall determine the professional appropriateness of planned or completed treatments that are necessary and consistent with an appropriate diagnosis.

 

Quality of Treatment: Skills with which treatment is provided will be evaluated in light of standards that generally prevail within the profession by those who routinely perform the treatment in question. Evaluation will be done by competent practitioners who are qualified to perform the procedure.

Membership

Peer review committees of veterinary associations should be reasonably uniform in structure and procedure, because the effect of their actions may have regional or national implications.
 

The peer review committee should be composed of licensed veterinarians who are well respected in their professional community. Members should represent a spectrum of veterinarians with respect to age, species expertise, and experience. Veterinary associations are encouraged to include a well-respected non-veterinarian as a resource on their peer review committees.

The size of the peer review committee should reflect the geographic area covered, the veterinary population of the association, and the potential patient/client caseload. In all instances, there should be at least three committee members.

Members should serve staggered 3-year terms to ensure continuity of experience.

Members of a veterinary association body responsible for hearing appeals should not serve on a peer review committee because of the potential conflict of interest in hearing such appeals. If possible, veterinary association officers should not serve on peer review committees.

If the committee believes that additional expertise is needed to render a proper judgment, the chair should appoint additional members to hear that case. Appointed committee members have the same status, as do permanent members.

In instances involving veterinarians with a limited or specialty practice, the chair may convene a panel of other, similarly experienced practitioners from the association membership or from an appropriate specialty organization. In this instance, such panel, together with the chair, vice chair, or designated member, will comprise the peer review committee.

Before the review process, any involved party may inquire as to the identity of members who constitute the peer review committee. Any involved party may submit a documented request that the chair excuse a committee member for due cause. Another member may be appointed to replace the excused member for the deliberation in question. The chair, with the advice of the committee, should be empowered to accept or reject this request, giving reasons for such action.

Geographic Distribution

Cases are heard within the jurisdiction of the veterinary association where the service in question has been or will be performed. If the local veterinary association fails to act on a case within a reasonable period, and the state veterinary association has made every effort to ensure review at the local level, the peer review committee of the state association should hear the case.

Procedure and Limitation

Generally, mediation is the initial step the committee takes to resolve differences. If efforts to mediate prove unsuccessful, the case is deferred to the peer review committee for full review. After that review, the committee reaches a decision based on factual findings and transmits its decision to all participants.

Licensed veterinarians practicing in the state, their clients, insurance carriers, and governmental agencies, should be encouraged to use the peer review system when appropriate.

The peer review committee itself has no disciplinary powers. However, in instances involving habitual offenders, the committee may recommend continuing educational courses. The committee should not consider cases in litigation.

Litigation

A case is considered formally in litigation when a party to a dispute files a complaint instituting civil action in court, or when it is under investigation by the state board of veterinary medical examiners. The peer review committee should not consider cases in litigation. Peer review is designed to resolve complaints or misunderstandings so that civil action may be avoided. For a case to be eligible for consideration by a peer review committee, parties involved should not have initiated formal litigation proceedings concerning aspects of veterinary services to be reviewed.

If a dispute between the veterinarian and the client involves collection of a fee and the veterinarian has initiated litigation for collection of that fee, the peer review committee of the state association should be able to determine whether peer review would be beneficial.

Method for Requesting a Review

Any party wishing to initiate peer review should make a written request to the appropriate local or state veterinary association. A request for peer review should be accompanied by supporting records and pertinent information, stating specific questions to be answered. Such reviews should be conducted at the lowest level association that provides peer review.

If an animal health insurance carrier questions a claim form, the carrier should first contact the veterinarian for clarification. If the problem cannot be resolved between the parties, it can be referred to the peer review committee of the state veterinary association. When the insurance carrier submits the written request, it must include documentation that attempts to resolve the problem have been made without success. After receiving the request, the state or local veterinary association determines if the case is eligible for review, then refers the case to the appropriate peer review committee.

Mediation: When a request for review is received by a peer review committee, the chair should appoint one committee member to act as mediator. The mediator considers the request to determine whether the requesting party has fulfilled its responsibility to attempt to resolve the differences.

The mediator then contacts all parties involved and tries to reconcile differences. The mediator documents all contacts with clients, veterinarians, and carriers. Under no circumstances does the mediator examine the animal patient.

If the case is resolved by the mediator, the mediator submits a written report to the chair, and the case is closed. If mediation is not successful, the mediator informs the chair by written report. (Appendix 2).

Pre-review procedure: If a veterinarian who has a limited or specialty practice is being reviewed, that veterinarian may require that the chair of the peer review committee appoint a panel of at least three specialists from the appropriate specialty organization or three members of the local or state association who have similar experience. (Each specialty organization determines how its panel is to be selected.) The committee chair or designated member joins the specialty panel in reviewing the case. The peer review committee can also request such an arrangement, if the committee does not consider itself sufficiently knowledgeable in the specialty area to make necessary decisions.

Examination of a patient: If the committee believes that an examination of an animal is necessary, the client should be asked to sign a form giving permission for the examination before the review (Appendix 3) (Appendix 4). The client's veterinarian is notified that the examination is to take place (Appendix 5). The findings are not discussed with the client at the time of the examination. If the committee decides that an examination of an animal is necessary to render a decision, but the client withholds permission for the examination, the review is terminated with a written explanation of the reason for the termination given to all parties.

Communications and Record Keeping

Communications: The peer review committee should report its decisions and/or recommendations in writing to all concerned parties within 60 days of the initiation of review. During each step of the review process, all letters and documents should be stamped confidential, and copies should be sent to executive offices of the state or local veterinary association. All phone conversations and informal discussions should be well documented, dated, and retained by the chair of the peer review committee. Contents of all reviews should be kept in strictest confidence.

The committee, in writing, informs all parties involved of their right to appeal its decisions.

A committee report should include comments concerning noncooperation by the involved veterinarian.

How a Review is conducted: The mediator presents the report to the committee and leaves. Each party is then interviewed separately by the committee.

Peer review is intended to be a mediation process. Because peer review is not a court of law, attorneys should not be present at a review, and a verbatim report of the proceedings should not be made. The committee reaches a decision in closed session and writes a report (Appendix 7).

The decision of the peer review committee should be equally fair to all parties involved and should stand on its own merit. A committee decision should not be influenced by what the committee believes a party would be willing to accept, but rather what would be fair and just to all.

 

The Committee's Report

A majority vote constitutes the decision of the peer review committee. Written minority opinions are permitted and should be included with the committee's final report.

 

The committee's report should be specific with respect to the questions raised and should not include extraneous or unnecessary comments.

All involved parties should be notified in writing of the committee's decision and recommendations with an explanation of the right to appeal (Appendix 8). Copies of the committee's report and of all pertinent data should be forwarded to the parent association's executive offices. Contents of all reviews should be kept in strictest confidence and should be retained for the period advised by legal counsel.

Appeal of the Committee's Decision

A decision can be appealed within 30 days, with the party initiating the appeal required to show due cause why an appeal is justified, i.e:, (1) proper procedure was not followed, (2) information has surfaced that was not available at the time of the review, or (3) a decision was made that ran counter to the evidence and testimony presented.

All parties have the right to appeal the committee's decision when any of the aforementioned conditions are alleged.

The request for appeal of the decision of the peer review committee should be sent in writing to the chief elected officer of the parent association. Such requests should specify and document the basis on which the appeal is requested in conformance with the aforementioned reasons for appeal.

Decisions of the peer review committee of the local association will be referred to the peer review committee of the next higher level association within the state. For example, the decision of a peer review committee of a local association may be appealed to a regional association or directly to the peer review committee of the state association.

Appeal of a Decision by a Local Association Peer Review Committee

 

The chief elected officer of the local association will ensure that all documentation necessary for the appeal is present and will forward the request for appeal to the chair of the peer review committee of the next higher echelon veterinary association in the state. The regional or state peer review committee will review the case and the appeal request and will decide whether the appeal is justified. The committee may reject the appeal as unwarranted and allow the original decision to stand, or it may hear the appeal case, offering all parties the opportunity to present information.

 

 

Appeal of a Decision by the State Association Peer Review Committee

If a decision by the peer review committee of the state association is appealed, the chief elected officer of the state association, after receiving the request for appeal, will initiate an investigation of the appeal by the executive board of the state association. The state association's executive board will review all of the facts of the case and the request for appeal and will determine what further action is appropriate, i.e.: (1) appeal is unwarranted and the challenged decision stands; 2) the case is sent back to the peer review committee for re-review, if the initial review is considered inadequate or incomplete; or 3) the executive board agrees to hear the appeal case.
 

Within the peer review system, the decision of the executive board of the state association is final.

Cases Involving Nonmember Veterinarians

Because the state veterinary association has a responsibility to the public and the veterinary profession, veterinarians who are not members of their state or local associations should be notified that they may also participate in the peer review system. This system includes peer review at their request, the request of a client, or the request of a third party. Non-members being reviewed should agree to the review in writing.

 

Peer Review Liability Law

State, regional, and local associations should purchase liability insurance for all members participating on peer review committees.

 

An effort should be made to pass a peer review liability law in each state legislature. The following sample law is a guide, not necessarily a model. However, the sample contains elements that might be included when a law is drafted. Each association is strongly advised to seek legal advice on the appropriate format for its jurisdiction.

SAMPLE LAW

Members of a veterinary peer review committee of a state or local veterinary association shall not be deemed liable for damages to any person for action taken or recommendation made within the scope of functions of such committee, if such committee members act without malice and in reasonable belief that such action or recommendation is warranted by facts known to them after a reasonable effort to obtain the facts as to which such action or recommendation is made.

The veterinary peer review committee and its records shall be exempt from discovery proceedings.

NOTE: Each state association should consult its own legal counsel prior to implementing the Peer Review Procedure.

Appendix 1: Procedural Chart Example (PDF)
Appendix 2: Report of Mediation (PDF)
Appendix 3: Sample Letter of Notification (PDF)
Appendix 4: Permission Form For Examination (PDF)
Appendix 5: Sample Letter Announcing Examination Time (PDF)
Appendix 6: Report of Peer Review Committee (PDF)
Appendix 7: Sample Letter to Accompany Final Report (PDF)
Appendix 8: Peer Review Chair Checklist (PDF)

Disclaimer: This model form/document is published by the American Veterinary Medical Association, 1931 N. Meacham Rd., Schaumburg, IL 60173. It is a sample only, is not specific to the facts of any business or organization, and therefore should not be used or relied upon without the advice of retained legal counsel. This model form/document is not intended to provide legal advice or opinion and should not be construed as such.