St. Vincent Peer Review Process for Clinical and Safety Events
Physician and APP/AHP Events
All events must be entered into Safety Net. If you do not have access or do not feel comfortable entering an event on Safety Net, contact the Montana Medical Staff Professional Performance Manager and request that they enter it for you.
Physician and APP/AHP Events follow one of two different pathways in the review process, depending on the event type:
Clinical Events
These events follow the Med Staff Peer Review (MSPRC) Process. Clinical events are reviewed and if determined to need Peer Review are assigned to a Case Reviewer within the Med Staff Peer Review Committee. Case Reviewers complete case reviews by completing chart reviews in Epic, visiting with the Physician/APP/AHP’s and other staff involved in the event and following the Just Culture Algorithm. Once the case review has all the details needed to make a recommendation on the final case rating of the case, the case will be submitted for final approval. The finalized case review will go to the next upcoming MSPRC meeting where it will be reviewed, and a final case rating will be assigned. The case will be assigned one of the following final case outcomes:
No Opportunity for Improvement – No issue with care provided or falls within the Human Error category
Minor Improvement Opportunity – Minor educational opportunities found while reviewing the case. Physician/APP/AHP will receive an educational letter.
Significant Improvement Opportunity – Significant learning opportunities found while reviewing the case. Physician/APP will receive an educational letter.
Inappropriate Care – Inappropriate care was determined.
All final case ratings will be tracked and trended within the Physician/APP/AHP’s confidential file and will have Peer Review Protections.
Quality (Behavior/Professionalism) Events
Events determined to fall under the Quality category follow the Leadership Council Process. The Leadership Council is a subcommittee of the Physician and APP/AHP Wellness and Leadership Council. Events that follow the Leadership Council process are reviewed and if determined to be a minor event will flow to the Department Chair for review. The Department Chair will review the event by completing chart reviews in Epic (if needed), visiting with the Physician/APP/AHP’s and other staff involved in the event. Once the department chair has a resolution for the event, they will share their findings along with any educational opportunities found, process issues, or other areas of improvement or resolution for the case to the Montana Medical Staff Professional Performance Manager. The event will be closed and tracked and trended in the Physician/APP/AHP’s confidential file and protected with Peer Protections. Serious Quality events will go directly to the Leadership Committee. The Leadership Committee will review the event by completing chart reviews in Epic (if needed), visiting with the Physician/APP/AHP’s and other staff involved in the event. A final case outcome will be determined, and appropriate action will be taken as needed. Serious Quality events are tracked and trended in the Physician/APP/AHP’s confidential file and protected with Peer Review protections.
The Med Staff Peer Review Process and Leadership Process are intended to provide learning opportunities for physicians and are not intended to be punitive. Reviewers and Department Chairs should visit with Physician/APP/AHP’s involved in events to ensure that all case details are appropriately reviewed.
Medical Staff Peer Review Committee Chair: Dr. Mario Giovanini
Medical Staff Physician and APP/AHP Wellness Council and Leadership Chair: Dr. Gerri Mournian
Medical Staff Physician and APP/AHP Wellness Council and Leadership Vice Chair: Dr. Tom James
Montana Medical Staff Professional Performance Manager: Jennifer Nicholson, MHA