HRSA Site Visit Protocol Chapter 10: QI/QA

Peer Review Definition and Requirements

• Peer review is a systematic evaluation of clinical staff performance by their colleagues to ensure quality of care and adherence to standards.
• HRSA requirements stipulate that peer reviews must be based on established quality indicators and clinical standards.

Conducting Peer Reviews

• Peer reviews are conducted by qualified clinical staff members within the organization.
• Best practice involves using a structured framework or form to standardize evaluation criteria and feedback.

Peer Review Options in Smaller Organizations

• Smaller organizations may opt for a cohort approach, where peer reviews are conducted across a small group of providers to share insights and feedback.

Staff Considered as 'Providers'

• Generally, 'Providers' include licensed independent practitioners (LIPs) and other clinical staff who deliver direct patient care.

Recommended Chart Review Frequency

• Recommended review is a minimum of 5 charts/service dates for each LIP and other licensed clinical personnel (OLCP) every quarter.

Data Collection Expectations

• HRSA seeks comprehensive data collection during peer reviews, including performance trends and compliance with clinical practice guidelines.

Caution about Peer Review Exchange

• Health centers are often cautious about peer review exchanges owing to concerns over confidentiality, competitive practices, and varying standards between organizations.

Downsides of Evaluation by Department Director

• A downside of having the department director evaluate all Behavioral Health providers is the potential for bias or conflicts of interest, which could affect the fairness of evaluations.

Purpose of Sampling Files

• Reviewing a sample of files for current clinical staff ensures that credentialing and privileging processes are documented and compliant with regulations.

Required Response for Documentation Issues

• If clinical staff files lack up-to-date documentation of licensure and credentialing during site visit findings, a corrective action plan must be formulated and submitted to HRSA.

Up-to-Date Documentation Requirements

• Current clinical staff files should include up-to-date documentation related to licensure, credentialing, and any supervisory or performance evaluations.

Key Requirement for Contracted Providers

• Contracted or referral providers must adhere to the same credentialing and privileging criteria as in-house clinical staff members.

Competency Assessment for Contracted Providers

• The competency of contracted or referred providers is typically assessed using a combination of credential verification and performance evaluations.

Contract Review Prioritization Criteria

• One prioritization criteria for reviewing contracts with provider organizations includes evaluating the quality and scope of services provided.

Basic Life Support Training Requirement

• Clinical staff are required to maintain current basic life support (BLS) training as part of their credentialing process.

Aspects of Privileging Procedures

• Privileging procedures address qualifications, competencies, and scopes of practice for clinical staff, ensuring they provide care within their expertise levels.

Method for Verifying Clinical Competence

• Current clinical competence during initial privileging is suggested to be verified through a combination of direct observation, chart reviews, and peer feedback.

Process for Privilege Modifications

• The process for denying, modifying, or removing privileges is based on consistent evaluations, performance records, and adherence to established clinical guidelines and policies.