Closing the Loop in Peer Review

For all the lessons from Gundersen's peer review team, watch the full webinar on-demand. 

Gundersen Health System does peer review a little differently.  

When they began their RL6:PeerReview journey, they had one, main goal in mind: closing the loop.  

"Closing the loop refers to the process of completing and verifying a peer review process and outcomes," explains Lynn Fortun, Program Coordinator for Peer Review at Gundersen.  

"While we historically notified all parties involved about the outcome of a review and the reasoning, we didn’t know what happened beyond that – whether a learning plan was provided or if education was discussed, for example," explains Lynn.   

For the team at Gundersen, this final step was key to ensuring that their peer review process was as effective as possible and that the most emphasis was on the non-punitive nature of peer review and the learning opportunities.  

"We needed to close that loop to ensure that our committee outcomes and recommendations were being implemented and considered," says Lynn.  

What does peer review entail at Gundersen?

The Medical Staff Peer Review Committee at Gundersen brings together a highly-diverse group of volunteer members.  

The committee includes:  

  • 18 full-time provider members  
  • 10 ad-hoc provider members  
  • 3 risk managers  
  • Gundersen's CEO, Chief Quality Officer, Medical VP and Legal Counsel  

The program is facilitated by Lynn as well as Gabby Hansen, who is the RN Screener. Each month, the committee holds two formal meetings and reviews provider care as requested by reviewers after screening.  

Gabby screens about 1,000 cases each year. And though only a portion of those cases make it to committee, there is no shortage of material for the committee to cover during each of their meetings.  

"We ask members to objectively review the care providers by their peers," says Lynn. And it's more complicated than you might think – grey areas and questions means that many inquiry letters are sent out to providers to ask questions and ensure that the review doesn't just consider the facts on paper, but also accounts for the providers frame of mind at the time. 

Moving from paper to digital  

Like many organizations, when Gundersen began formal peer review in 2007 the entire process was completed by hand, using paper. That included everything from the review forms to paper letters.  

When Gundersen instituted their EMR in 2008, they switched peer review to a digital program. In 2011, they developed a home grown database to house and manage peer review case forms and data.  

Between 2014 and 2016 they focused on researching how a database that could support peer focused peer review. They chose RL6:PeerReview to support their peer review work and implemented in 2016, working closely with the RLDatix team to ensure that the product supported their process.  

And then the pursuit of closing the loop began!  

Closing the loop  

Some of the changes that Gundersen made to peer review came from learnings from the Greeley Peer Review Bootcamp which focused on changing outcome terms, focus and final actions. Some of the changes Gundersen made to their peer review terms included:   

Old Terms 

New Terms 

Care appropriate  

No improvement opportunity  

Suboptimal care  

Minor improvement opportunity  

Inappropriate care 

Significant improvement opportunity  


Lynn and Gabby also facilitated some focus changes to help close the loop. Where the old focus was on the overall care of the patient, the new focus is on the provider's care of a patient. The process now focuses on any harm to the patient, and tries not to be distracted by non-provider related issues. Finally, they now limit each review to one provider, with the option to generate more reviews, whereas historically the reviews could include an entire care team.  

RL6:PeerReview also offers opportunities to help streamline the peer review process with:   

  • Easily and readily reviewable data 
  • Customizable alerts 
  • Ability to schedule reports 
  • Option to surface priority data in a dashboard  

But while efficiencies were important, the real goal was to close that loop. Part of that was ensuring that each completed review was associated with a documented action plan. Action plans can include:  

  • No action  
  • Practitioner self-acknowledged action plan is sufficient  
  • Educational letter to practitioner sufficient  
  • Educational letter and department chair discussion  
  • Educational letter and formal improvement plan with monitoring  
  • Refer to executive committee 

After carefully considering the format of the system and working with their internal teams and the team at RLDatix to fit the software to their needs, Gundersen was able to close the loop.   

"There is no point at which we don't know what happened with an outcome," says Gabby.   

To experience the full peer review "roller coaster" as Gabby and Lynn fondly refer to it, you can watch the their full, on-demand webinar.  

For those who attended the webinar live, here are the answers to questions that we didn't have time to get to during the live Q&A.  

How has your participation in the EAP program going? When do you anticipate going live? 

EAP testing is going well, we are so thankful to be a part of working out kinks that we would likely otherwise be working out when the time came to upgrade. There are always system incompatibilities it seems, and even the idea of helping others learn how to implement it when the time comes has been enjoyable. We are getting a lot of good help figuring this all out from RLDatix! We are just in discussion for go-live, hoping by the end of 1st quarter to be in PROD-the testing process is about 6 weeks.

Do you have a time restriction for individual case discussions at the meetings so you stay on time and complete all the reviews in your two-hour meetings? 

We don’t have a “time restriction” for each case as we encourage good discussion and don’t want to inhibit that discussion.  We have two great co-chairs, however, who will encourage the group to wrap-up the discussion if it starts getting sidetracked.  The co-chairs receive the agenda prior to the meeting (and again at the meeting) so they know how many cases we need to get through. An average meeting consists of discussion of 10-15 cases per meeting including responses from providers for old cases as well as new cases.

Did you import data from your previous system into RL6:PeerReview? 

No, we did not import any previous data – but started with all new data.  Our “home-grown” system was not set up to be able to export data easily. 

If you keep peer review completely separate from credentialing, how does credentialing become aware of a provider that may have several educational opportunities and may not be appropriate from recredentialing? 

This is part of why we wanted to be sure that we “closed the loop”.  When we have a significant improvement opportunity identified, we “cc” the outcome determination and pertinent information to that provider’s department chair and medical vice president.  Since our peer review is a non-punitive process, it is up to the department chair and/or VP to deal with human resource/employment issues.  It would be their responsibility to share any “performance improvement” issues with credentialing.

What is the process when there are many peer reviews for the same physician? 

Any one physician could have many reviews across our spectrum of case triggers (mortality, code or MRT or transfer to a higher level of care).  Again, we do notify department chair(s) and vice presidents in situations when a significant improvement opportunity is identified.  So – any physician with “several” significant improvement opportunity outcomes (on several different cases) should be on the radar of the department chair or VP.  As an educational committee with a non-punitive process, it isn’t the responsibility of the committee to “monitor” performance issues.  That being said, however, the committee does notice providers that have several issues (or repeated issues) brought forward for committee discussion (including significant improvement opportunity) and the co-chairs may elevate their concern(s) verbally to the department chairs or vice presidents for their attention.  Our co-chairs are the only people on the committee that can share any peer review related information outside of the peer review process and maintain protective privilege.


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