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Peer Review Versus Patient Safety Data Reporting (PSDR)

What is peer review? What is Patient Safety Data Reporting (PSDR)? Are they the same? Different? Who may perform peer review? These are just a few of the questions we receive related to these two topics.

What are PSDR and Peer Review?

PSDR is a form of quality control performed by accredited facilities within the outpatient setting. Those participating in the data reporting process create a system-wide culture of clinical quality and demonstrate the positive results of accreditation. PSDR reporting is required for QUAD A facilities participating in Office-Based Surgical, Office-Based Procedural, Oral Maxillofacial Surgery, Pediatric Dentistry, International Surgical, or Medicare ASC programs. Reporting PSDR data is required quarterly, including physician case review. Results of the physician case reviews are discussed during Peer Review meetings.

Peer review is the task of physicians holding one another to the ethical standards of their profession and maintaining the administration of patient safety and quality of care consistent with optimal standards of practice. Peer Review is a separate and distinct process from PSDR. Most physicians are familiar with the peer review process, which is performed at a like-physician-to-physician level. The objective data elements required during the quarterly PSDR submissions, as part of the accreditation process, are specifically intended for medical study and the evaluation and improvement of quality care and reduction of morbidity and mortality. The facility can enter this data before conducting its peer review meetings. Peer review meetings must be held quarterly; or every six months, based on the facility’s monthly case volume.

Who may conduct peer review? What is the definition of a peer?

A peer is someone with the same or similar skills and competencies. American Medical Association (AMA) publishes information regarding the peer review process and describes the composition of the Peer Review Committee as follows:

Peer review is conducted in good faith by physicians who are within the same geographic area or jurisdiction and medical specialty of the physician subject to review to ensure that all physicians consistently maintain optimal standards of competency to practice medicine. Physicians outside of the organization that are convening peer review may participate in that organization's peer review of a physician if the reviewing physician is within the same geographic area or jurisdiction and medical specialty as the physician who is the subject of peer review.

If providers outside your facility conduct your Peer Review process who are not directly hired by your facility, a signed Business Associate Agreement (BAA) is required. If your Peer Review process is conducted by providers directly hired by your facility (not contracted), a BAA is not necessary.

What are the differences between PSDR and Peer Review?

Patient Safety Data Reporting

Peer Review

  • Quarterly online data submission to QUAD A.
  • Must include three random cases per quarter per surgeon.
  • Must include submission of all unanticipated sequela.
  • Required reporting components:
    • Basic patient information
    • Surgical case information
    • Anesthesia information
    • Chart review – Are these components present?
      • Pre‐Op Plan for Treatment
      • Medical History
      • Physical Examination
      • Laboratory Reports
      • Informed Consent
      • Anesthesia Record
      • Operative Report
      • Post‐Op Recovery Record
      • Discharge Instructions
      • Rx Given to Patient
      • Pathology Report
      • Recorded in Surgical Log
  • Quarterly or twice per year (based on facility monthly case load) facility‐based meeting to improve quality and safety of care.
    • To qualify for conducting Peer Review only twice per year, the facility must perform less than 50 cases per month.
    • Facilities performing greater than 50 cases per month must perform Peer Review quarterly.
  • To include, at a minimum, the same random cases and unanticipated sequelae submitted to the Patient Safety Data Reporting portal since the preceding peer review meeting.
  • Performed by a recognized peer review organization or a surgeon other than the operating surgeon unless otherwise specified by state regulations.
  • Required record review components:
    • Adequacy and legibility of history and physical exam
    • Adequacy of surgical consent
    • Adequacy of appropriate laboratory, EKG, and radiographic reports
    • Adequacy of a written operative report
    • Adequacy of anesthesia and recovery records (with IV sedation or general anesthesia)
    • Adequacy of instructions for post‐ operative care
    • Documentation of the discussion of any complications

The relevant QUAD A standards addressing the PSDR process, reporting, and collection of case review data are 1-F-1 and 1-F-2. Evaluation of the case review data occurs during the Peer Review meetings. QUAD A standard 10-B-6 addresses Peer Review meetings.

How is compliance evaluated?

During an onsite survey, the QUAD A surveyor will view evidence of your PSDR compliance and of the periodic in-house peer review. For PSDR, you can show the surveyor the online green status bars on previous periods. For in-house peer review, the surveyor will review your documentation of this process. Methods of documenting peer review include meeting minutes, email chains between peers, etc.

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.