To ensure consistent, impartial and professional evaluations of care, transplantation services will be subject to peer review in all cases that meet the following criteria:
- Mortality (elective admission, within 48 hrs of OR, unexpected)
- Delay in diagnosis
- Readmission within 3 days
- Unplanned return to the operating room
- Procedural events (e.g., surgical injury, anesthesia injury, pneumothorax related to intravascular catheters; unintentionally retained foreign bodies)
- Variations in standards of care as identified by regulatory agencies (e.g., New York State Department of Health Patient Occurrence Reporting and Tracking System)
- Variations in standards of care defined by transplant services
All cases for peer review are prepared in conjunction with a Quality Management Coordinator. Surgical care is reviewed by the appropriate departmental peer review committee, and will include peers with experience with these procedures. The primary surgical (or medical) provider whose care is being reviewed is not involved in the review. If non-surgical care is questioned, cases are referred to other Peer Review Committees (Cardiology, Medicine, Nursing, etc.) Extramural expertise may be sought to review cases for which internal peers are limited.
Attributions and findings made as a result of this process will be summarized and reported to the Peer Review Board, and incorporated into the recredentialling processes. The Peer Review Board reports to the Montefiore Quality Council per Medical Center Policy. Based upon the above reviews, the departmental committee chairperson may determine that some cases require more focused reviews. Each program may also elect to further discuss peer review cases in interdisciplinary morbidity and mortality teaching conferences.