Peer review (medical & surgical)

PEER REVIEW

STATEMENT OF WORK (SOW)









Contract Title



Peer Review (Medical & Surgical)

Provides Peer Review services for selected medical and surgical cases.

Background

Medical and surgical cases are required to be reviewed by other doctors (peers). In order to be a peer and qualified to complete the review, a doctor must have the same or similar qualifications. If a medical center does not have redundant staffing a case has to reviewed by on outside doctor. There is a charge associated with the review. A review is more costly as complexity increases.

Scope



This contract is for the Department of Veterans Affairs, Veterans Health Administration, VISN 19. Currently only Grand Junction Veterans Affairs Medical Center, CO and Eastern Colorado Healthcare System, Denver, CO are participating.



Specific Tasks



The VISN 19 has a need for a Peer Review Contract.

Peer review will determine the medical necessity and appropriateness of medical treatment, to evaluate the quality of care, and to otherwise determine if the care provided to the patient met the expected standard of care for the type of case and setting of the service. This contract will be for a base year plus four (4) option years. The total contracted period will be five (5) years if all options are exercised. All services provided will be completed at the contractor's location.



The Government will provide the redacted records to be reviewed to the appropriate individuals.

All records will be reviewed initially by a nurse screen. The nurse review results will determine the Level of Care and or the type of Peer Review required (Level 1, Level 2 or Level 3).



The requested peer review will be completed by a board certified, active physician in the same or similar specialty of the case being reviewed. The contracted peer physician will examine the medical record and will prepare a written summary of the case which may include findings, suggestions, or recommendations for further review.



Standard Peer Reviews will be completed in 30 days or less. Reviewer must submit a request in writing a request for approval if more than 30 days are required to complete the review. Expedited Peer Reviews will be completed in 10 days or less.



The Government requires Category 1, Category 2, Category 3, Category 4 and Category 5 Peer Reviews.



The following Categories of review are defined as:

" Category 1: Most experienced competent practitioners would have managed the case in a similar manner.

o Limited in scope, number of issues and complexity of issues to be reviewed

o Limited duration of care episodes to be reviewed

o Limited providers and/or services involved in episode of care needing to be reviewed



" Category 2 : Most experienced competent practitioners might have managed the case differently

o Increased complexity of case but limited in number of issues needing to be reviewed.

o Multiple issues/providers/services but limited complexity and scope

o Case review involves more than one visit or involves outpatient as well as inpatient care settings.



" Category 3: Most experienced competent practitioners would have managed the case differently

o Complex scope involving multiple providers and/or services

o Case involved multiple episodes of care and/or longer length of time involved in issue being reviewed



" Category 4: Most experienced competent practitioners would have managed the case differently

o More complex scope, involving multiple providers and/or services

o More length of time involving multiple visits and care settings



" Category 5: Most experienced competent practitioners would have managed the case differently

o Extremely complex scope, involving multiple providers and/or services

o Extreme length of time involving multiple visits and care settings

The following should be addressed in the review as a minimum:

" Choice of diagnostic test and timeliness of ordering of the test

" Performance of a procedure and or treatment

" Addressing abnormal results of diagnostic tests

" Timeliness of diagnosis and appropriate treatment

" Adequacy of technique during procedures

" Recognition and communication of critical clues to patient's condition during the period of critical deterioration

" Timely initiation of appropriate actions during periods of clinical deterioration

" Medical record documentation

" Supervision of health profession trainees.

" Other relevant aspects of care.

The contractor will submit the case summary with comments and recommendations in writing (typed) as appropriate to the requesting individual.

The written case summary should include the following:

" Education suggestions

" Recommended protocols

" Other improvements



The contractor will

" Submit a copy of peer review by mailed paper copy to the Peer Review Program Manager

o The mailed report will be sent registered mail

o The completed review will be double wrapped

" The contractor will return reviewed file to the requesting VA Medical Center by registered mail or other trackable means (Fedex, UPS, USPS, Etc…)

A peer reviewer must have the following qualifications:

" Possess the relevant clinical expertise necessary to make accurate judgments about the decisions being reviewed

" Possess knowledge of relevant current standards of care

" Be formally trained regarding the peer review process, the responsibilities , legal, and ethical requirements

" Licensed and or accredited to perform peer reviews

No peer reviewer may have direct involvement with the case being reviewed.

Peer reviewers must:



" Recuse self from a case if is determined that that the reviewer lacks the specialized knowledge and experience or feels uncomfortable reviewing the case.

" Recuse self from reviewing a case when a conflict of interest for any reason exists or may exist





Deliverables:



Performance Monitoring



The following table details what will be monitored.



Task ID Indicator Standard Acceptable Quality Level Method of Surveillance Incentive

1 Written Summary Include Findings, Suggestions, and or recommendations for further review 100% Direct Observation Exercise of Option Period and past performance

2 Qualifications Board Certified Active Physician in same or similar specialty of case being reviewed 100% Direct Observation Exercise of Option Period and past performance

3 Delivery Delivered in 30 days or less 90% Direct Observation Exercise of Option Period and past performance

4 Delivery Expedited Reviews will be completed in 10 days or less 90% Direct Observation Exercise of Option Period and past performance

5 Delivery Written notification provided if report will not be provided within time frame 90% Direct Observation Exercise of Option Period and past performance

6 Delivery Files Redacted,

Double packaged, Marked as confidential, and returned by a commercial vendor that uses a trackable system. 100% Direct Observation Exercise of Option Period and past performance

Security Requirements

The C&A requirements do not apply, and that a Security Accreditation Package is not required



A Business Associate Agreement is required for this contract.



This contract utilizes redacted files. All files are transmitted using a delivery tracking service that provides delivery confirmation.





Government-Furnished Equipment (GFE)/Government-Furnished Information (GFI).



The Government will provide redacted copies of the cases submitted for peer review.



Other Pertinent Information or Special Considerations.





a. Identification of Possible Follow-on Work.



There is no possibility of follow on work. Each case submitted for peer review is a job.

Subsequent cases for review will/may be submitted as needed.



b. Identification of Potential Conflicts of Interest (COI).



A potential conflict of interest exists if a doctor chosen to review a case is an employee of the VA or has been a employee of the VA in the last 3 years.



c. Identification of Non-Disclosure Requirements.



Non-disclosure requirements printed on Peer Review Worksheet





d. Packaging, Packing and Shipping Instructions.



All documentation is required to will be sent using a commercial service (UPS, FedEx, USPS, Etc…) that can confirm and track delivery of files and reports. The files will be double wrapped and marked confidential



e. Inspection and Acceptance Criteria.



All peer review reports will be reviewed for completeness and timeliness by the Peer Review Program Manager. The program manager will ensure the report meets criteria.



Risk Control

Documents are redacted, double packaged, sealed, and marked as Confidential



Place of Performance.



All work will be completed at the reviewer's office.



Delivery Schedule.





SOW Task# Deliverable Title Format Number Calendar Days After CO Start

1 Peer Review Report Contractor Design 1 copy by mail 30 days from receipt of request







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