Peer Review System Manual

If the hospital’s medical staff leadership and administration agree on the need to upgrade the peer review system either through the implementation of the NPRC Peer Review System or modification to the existing peer review system, the NPRC Peer Review System Manual will allow the hospital to promptly achieve this objective.

Designed as a comprehensive, single source for standardizing and streamlining peer review systems, the Manual contains over 100 pages of detailed, unambiguous instructions for performing peer review activities.

The participation of the medical staff and administration in the development process is essential to the successful implementation of the Manual. NPRC meets with the hospital’s key medical staff officers and administration to tailor the peer review system and the Manual to address the recognized problems and accommodate the hospital’s structures, services, data capabilities and political environment.

The Peer Review System Manual provides detailed instructions for performing appropriate and effective peer reviews including:

  • 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 process.

See also:

Peer Review System Evaluation
NPRC Peer Review System