Summary of Vermont Statewide Peer Review Physician Pool

Last updated October 24, 2014

Vermont Peer Review Physician Pool
 I.  Purpose
A priority of Vermont’s hospitals is to enhance and improve the peer review of the medical staff of hospitals.  Peer review includes the routine review of patient charts for performance evaluation, education and reappointment as well as the review of potential quality concerns.
 
Vermont hospitals have found that their peer review committees are frequently challenged to find peers to review the quality of the services provided by their Medical Staff members.  Many hospitals have physicians on their active staffs for whom there is no peer, or the only available peers have a conflict of interest such as being in practice together.
 
In an effort to make peers more widely available to Vermont hospital peer review committees, Vermont’s hospitals and the Vermont Program for Quality in Health Care hereby agree to establish a statewide peer review pool from which they may all draw physicians to conduct or assist peer review.

II. Vermont Program for Quality in Health Care (VPQHC) Physician Pool – Operations
Members of the physician pool will be nominated annually by the president of the medical staff in accordance with the criteria described below, in consultation with the chair of the medical staff executive/peer review committee or other appropriate medical staff.  The nominations will be approved by the CEO of the hospital (or designee).
 
The physician pool list will be housed on the Peer Review section of the VPQHC website and maintained by VPQHC with annual updates.  The physician pool list will include the name of the physician, the hospital with whom the physician is affiliated and the specialty of the physician.
 
Hospitals will call physicians from the pool directly and negotiate individual contracts with each reviewer. A contract template will be available on the VPQHC website.  All contracts will be signed by the hospital, the physician reviewer and VPQHC.  The contract shall include language providing for the disclosure of individually identifiable patient information in accordance with current law.
 
Each hospital will provide the physician reviewer with a format for his or her comments.
 
III. Criteria for Physician Participation in the Statewide Physician Pool
All members of the physician peer review pool shall be:

  • An active member of the medical staff of a participating hospital (no provisional medical staff)
  • Board certified in the specialty for which the physician will be a reviewer
  • Nominated by the president of the medical staff in consultation with the chair of the medical executive/peer review committee or other appropriate medical staff.  The nominations will be approved by the CEO of the hospital. 

IV. Peer Review Protection
Under 26 V.S.A. §1443, proceedings, reports and information shared as part of a peer review committee’s activity shall be confidential and privileged and shall not be disclosed in any court proceeding or otherwise unless authorized by the peer review committee.  It is the intention of VAHHS and VPQHC and each Hospital signatory to this memorandum to conduct all activities related to the statewide peer review pool under appropriate peer review committee procedures to maintain the confidentiality and privilege of the peer review process as provided by Vermont statute, 26 V.S.A. §1441-1443.  
 
Peer review committee confidentiality protection shall be invoked in two ways.  The work convened by VPQHC in establishing a statewide physician pool, and maintaining a data base shall all be conducted as part of VPQHC’s statutory authority as a peer review committee organization.  All physician participants shall sign a confidentiality agreement as a member of the VPQHC statewide physician peer review committee and shall enter into a separate peer review committee contract with any individual hospital with whom he or she contracts to provide specific peer review services.  All contracts between hospitals and individual physician pool participants shall be structured such that the physician pool participant shall receive and report information to the appropriate hospital peer review committee thereby invoking that hospital’s peer review committee protection.  
 
V. Confidentiality – Agreements between Hospital and Physician Reviewer
A template peer review committee participant agreement between a hospital and a physician reviewer will be available on the VPQHC website.  This agreement shall define both the peer review committee confidentiality of the information to be shared between the hospital and the reviewer and shall establish the physician as a business associate to the hospital for the purpose of compliance with the federal HIPAA privacy regulations.  Each physician reviewer shall receive only the minimum amount of patient identifiable protected health information necessary for the peer review committee activities.