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Based on interview, and document review, the critical access hospital (CAH) failed to ensure peer review was conducted according to CAH policy and medical staff bylaws for 1 of 2 medical doctors (MD-B) reviewed for the peer review process. In addition the peer review was requested but could not be provided for an additional 6 of 9 outreach physicians.

Findings include:

MD-B received a letter dated 1/9/15, from the CAH, which notified MD-B that he had been granted provisional privileges for surgery under the category of an active staff member. The privilege period granted was 1/15/15, through 7/14/15. On 7/9/15, MD-B received another letter which indicated MD-B had been granted privileges for surgery under the category of an active staff member. The privilege period granted was 7/15/15, through 7/14/17. The privileges granted were subject to all the terms and conditions of the medical staff bylaws, rules and regulations, and CAH policies.

On 9/13/16, at 2:10 p.m. the chief operating officer (COO), and the the quality director (QD) were interviewed and confirmed the CAH had obtained a verbal agreement with an outside physician from Cuyuna Medical Center with comparable skills to complete the peer review for MD-B and 45 records were sent for peer review. The COO further stated that the physician from Cuyuna Medical Center who agreed to complete the peer review for MD-B had not completed the review and returned the medical records. The QD and COO confirmed that only 2 of 9 outreach physicians had peer reviews completed. The COO stated that she was not aware that all of the outreach physician's peer review needed to be completed by the date identified on the facilities plan of correction.

Bylaws of the Medical Staff, last revised 2008, indicated active and courtesy staff would be responsible for participation in the review and evaluation of patient care, utilization review, quality improvement and other monitoring activities. In addition under article IV, section B. 2 - functions and responsibilities of the Executive Committee included:
- Effectively implement the medical staff's responsibility for the CAH's quality assessment plan as it related to medical staff functions
- Review and evaluate qualifications of each applicant for initial appointment, reappointment and modification of appointment and for clinical privileges. Information from the quality, risk and utilization management processes would be taken into account during the reappointment process
- Review the overall practice of medicine at the CAH

The policy for Medical Staff Peer Review on 3/1/01, and revised 12/15, indicated the Chief of Staff was responsible for ensuring that reports from the results of peer review are submitted to the Medical Executive Committee on a regularly scheduled basis. The report should include any patterns and trends or recommendations for focus reviews, performance improvement activities or broader education initiatives as a result of the findings.






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