NPRC Peer Review System

The NPRC Peer Review System provides hospitals with a state-of-the-art peer review system without the extensive expenditure of the hospital’s financial and time resources typically required to research, develop and implement an effective peer review system.

If a Peer Review System Evaluation indicates the need for a new or modified peer review system or the hospital’s medical staff leadership and administration agree that the peer review system requires an upgrade, the implementation of the NPRC Peer Review System will promptly achieve this objective.

Working with the hospital to customize the NPRC Peer Review System to the hospital’s structures, services, data capabilities and political environment, NPRC can provide a tailored Peer Review System that is:

  • Established in writing in sufficient detail to provide a comfort level to the medical staff leaders and administrative personnel required to act
  • Supported by an effective centralized control mechanism that monitors cases in the system
  • Enhanced by a multidisciplinary structure
  • Based upon compliance with standards of clinical practice and standards of professional conduct adopted by the medical staff and the hospital administration
  • Operated by participants (medical staff and administration) trained in peer review with an understanding of the legal consequences of peer review activities
  • Conducted uniformly with respect to each member of the medical staff in a timely fashion
  • Conducted with protocols for referral of cases and practitioners into the peer review system
  • Structured with a strong External Peer Review Policy and a fair Policy for Peer Review by Business Associates
  • Conducted with separate protocols for clinical peer review and professional conduct peer review
  • Creating a sentinel effect on clinical performance and professional conduct
  • Integrating peer review data into the recredentialing process
  • Installed as a system and not vulnerable to medical staff rotation or turnover of hospital personnel
  • Operated with an updated information system that provides accurate, meaningful and timely internal and external data
  • Endorsed by a hospital and medical staff leadership who are willing to take decisive action
  • Audited internally and/or externally for system breakdowns

The NPRC Peer Review System provides detailed instructions for performing appropriate and effective peer reviews. Specifically, the NPRC Peer Review System, as set forth in the NPRC Peer Review System Manual, includes:

  • A description and the peer review responsibilities of:
  • All peer review committees
  • All officers of the peer review system, the medical staff and administrative personnel
  • A description of the peer review system infrastructure
  • A description of the protocols for referral into the peer review system
  • Protocols of the peer review system (day-to-day operation of the peer review system), including:
  • How to conduct a clinical peer review and a professional conduct peer review.
  • How to conduct a peer review action that encompasses both a clinical peer review and a professional conduct peer review.
  • When to obtain an external peer review for individual cases and practitioners.
  • The development of Standards of Clinical Practice
  • Standards of Professional Conduct
  • A description of the multidisciplinary peer review data committee
  • Policies for:
  • External peer review
  • Peer review by business associates
  • Right to an attorney in the peer review system
  • Impaired practitioners
  • Confidentiality and handling of peer review documents
  • Discussions with practitioners under review
  • Communications to practitioners under review
  • Access to legal counsel by peer review committee members
  • Training and education for peer review participants
  • Auditing the peer review system

Upon the request of the hospital, NPRC is available to assist with implementing the NPRC Peer Review System and training the peer review participants in its operation. The Peer Review System Manual serves as an effective tool in facilitating this proces.

See also:

Peer Review System Evaluation
Peer Review System Manua