It is the intention of this article to define the term “peer review” or “review by peers” in the
broadest terms and to secure to those who engage in any aspect of review in, at, for, or on
the behalf of the hospital and its medical staff, the broadest possible privilege and immunity
from liability.
8.2 “Peer” is defined as a person who has equal standing with another person, or other
persons, as in education, age, training, rank or status. In quality of care reviews, peers are
defined as professionals in the same specialty of professional practice or a related
specialty.
8.3 Indications for Peer Review
The procedures provided in this Article shall be invoked, after collegial intervention efforts
have not resolved the issue, whenever it appears that the activities or professional conduct
of any member of the Medical Staff :
8.3.1 Jeopardizes or may jeopardize the care, treatment of provision of medical services to
a patient, or the safety of a patient, visitor or employee;
8.3.2 Each case in which there is suspected deviation standard of care or professional
practice, an adverse outcome or failing to meet the established criteria for
management, or a patient or provider compliant shall be reviewed.
8.3.3 Each service line and the Quality Improvement, Patient Safety, and Clinical Risk
Management Department shall determine which clinical outcome indicator(s)
require peer review.
8.3.4 All unexpected/preventable mortalities occurring during hospitalization or
immediately after discharge (when known) shall be reviewed. Initial screening
criteria may be implemented to determine when physician peer reviewed is required.
8.3.5 Presents a question regarding the competence, character, judgment, ethics, stability
of personality, including the ability to work cooperatively with others in the provision
of safe patient care, treatment and services, adequate physical and mental health,
moral character, or qualification of the member; or
8.3.6 Violates these Bylaws, Rules and Regulation of the Medical Staff, the Rules and
Regulations of the Departments of the Medical Staff, or Hospital policies, including