Share this article on:

A Systematic Approach to Clinical Peer Review in a Critical Access Hospital

Deyo-Svendsen, Mark E. MD, FAAFP; Phillips, Michael R. MD; Albright, Jill K. MS, RN; Schilling, Keith A. MBA; Palmer, Karl B. MS, RN

doi: 10.1097/QMH.0000000000000113
Physician Engagement in Quality

Purpose: Clinical provider peer review (CPPR) is a process for evaluating a patient's experience in encounters of care. It is part of ongoing professional practice evaluation and focused professional practice evaluation—important contributors to provider credentialing and privileging. Critical access hospitals are hindered in CPPR by having a limited number of providers, shortages of staff resources, and relationships among staff members that make unbiased review difficult. Small departments within larger institutions may face similar challenges.

Methods: A CPPR process created at Mayo Clinic Health System is described. It involved a case review questionnaire built on the Institute of Medicine “Six Aims for Changing the Health Care System,” a standardized intervention algorithm and tracking tool.

Outcomes: During 2007 through 2014, a total of 994 cases were reviewed; 31% led to provider dialog and education or intervention. Findings were applied to core measure processes with success rate going from 87% to 97%. Changes were adopted in end-of-life care, contributing to a 50% reduction in all-cause mortality rate.

Conclusions: Providing peer review tools to a critical access hospital can keep peer review within a group with knowledge of the individual provider's practice and can make process improvement the everyday work of those involved.

Department of Family Medicine (Drs Deyo-Svendsen and Phillips), Department of Quality and Utilization Resources (Mr Schilling and Ms Albright), Mayo Clinic Health System–Red Cedar, Menomonie, Wisconsin; and Clinical Services, Allevant Solutions, LLC, Mechanicsburg, Pennsylvania (Mr Palmer).

Correspondence: Mark E. Deyo-Svendsen, MD, FAAFP, Department of Family Medicine, Mayo Clinic Health System–Red Cedar, Menomonie, WI 54751 (

The authors declare no conflicts of interest.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

© 2016Wolters Kluwer Health | Lippincott Williams & Wilkins