Einstein/Montefiore Department of Medicine

Peer Review

Peer Review


Thomas Aldrich, MD
Quality Improvement Committee Chairman (Moses Division)
Professor, Department of Medicine

Ellen Harrison, MD
Quality Improvement Committee Chairman (Weiler Division)
Associate Professor, Department of Medicine


The peer review process was established to provide a consistent, impartial, professional system to effectively measure, assess, and improve organizational performance.

Montefiore Medical Center’s Peer Review Board consists of medical professionals from every specialty, which reviews cases and holds all Montefiore Medical Center attending physicians accountable for incidents involving their patients that they are aware of or are reasonably expected to be aware of.

The peer review function is ongoing. Conclusions from the process are tracked over time and information is used in the reappointment process and competency assessment. In addition, peer review issues may trigger targets for Montefiore Medical Center’s performance improvement process.

Case Review Process 

Medicine peer review for the Department of Medicine is provided by two Quality Improvement (QI) committees, one at the Weiler campus and one at the Moses campus.

The committees' primary work is to review problem cases. Cases are referred to the committee through a variety of means. They include:

  • All deaths
  • All rapid readmissions
  • Serious unexpected complications
  • Procedure-related morbidity
  • Referrals from other departments’ peer review committees
  • Patient complaints

All cases undergo pre-screening by experienced clinicians and then by the committee’s chairperson. The staff of the Quality Management office prepares a summary of each case and the chairperson assigns the case to a QI committee member who serves as a reviewer. After carefully examining every aspect of the case, this clinician presents his or her findings to the full QI committee for consideration and review. A determination is then made of whether a deviation from the standard of care occurred.

After review, physicians, housestaff and/or physician assistants involved in a particular case receive notification of the findings of the QI committee and that these findings will become final in one month unless new information is provided by those involved.

All findings of the QIC at each campus are reported to the Peer Review Board which oversees the work of all QI committees. The Peer Review Board either endorses the committees’ designation or requests a reconsideration. Once the Peer Review Board is satisfied with the designation, written notification of the final assessment is given to the attending physician and the chairman, and submitted to the file of the attending physician. A record is also kept in the QI Office. Favorable screens and reviews (the vast majority) are also recorded so that physicians’ files do not by definition contain only adverse findings.

Peer Review Rating Scale 


  1. H1 (human error)
    Variation from standard of care: Major
    Impact on patient prognosis or outcome: Major, Minor, None
  2. H2 (human error)
    Variation from standard of care: Not Major
    Impact on patient prognosis or outcome: Major, Minor, None
  3. H3 (human error)
    Variation from standard of care: None
    Impact on patient prognosis or outcome: N/A
  4. S (system error)
    Variation from standard of care: N/A
    Impact on patient prognosis or outcome: Major, Minor, None
  5. T (Track and Trend)
    Variation from standard of care: N/A
    Impact on patient prognosis or outcome: N/A

Key Principles 

  1. Peer review ratings for individuals are determined by assessing variation from the standard of care (H1, H2, H3). Impact on prognosis or outcome is noted but does not change the rating of the severity of the error.
  2. Significant system issues are identified.
  3. The "Track and Trend" rating indicates that a specific issue is under investigation to determine whether an underlying pattern or possible cause can be identified. When a track and trend issue is identified, a data collection system begins, to be followed up with analysis. 
  4. Many cases require multiple ratings. The system is able to accommodate this.
  5. Opinion of peers remains the vital component of a peer review scale. The degree of deviation from the standard of care remains subjective, determined by peers who assess the care according to standard practice.


  1. “H” (Human Error) Rating
    1. Variation from the Standard of Care
      1. “Major” deviations are designated when the care rendered is judged to be an unacceptable variation from standard practice or guidelines.
      2. “Not Major” denotes that a deviation from the accepted standard of care has occurred, but the deviation does not reach the level of being “Major”. This includes documentation deficiencies.
      3. “None” denotes that no human error involving deviation from the standard of care was found.
    2. Impact on Patient Prognosis or Outcome
      1. “Major” denotes a significant adverse effect on chance of cure or resolution of problem, or significant adverse outcome such as mortality or major morbidity.
      2. “Not Major”/“None” denotes minimal or no effect on chance of cure, resolution of problem, morbidity, or mortality.
  2. “S” (System Error) Rating
    1. A system error is found to have occurred that impacted on patient prognosis or outcome, or has significant potential to impact on prognosis or outcome if it recurs.
    2. System issues would be available as categorical responses to be chosen on the case evaluation form.
    3. S scores may be given alone or in conjunction with other ratings.
    4. If the identified system issue falls within the control of the department a corrective action plan would be developed to address it.
  3. “T” (Track and Trend) Rating
    1. T ratings are backed by a demonstrated ability of the Department to track and trend the case.
    2. T ratings are specific and designated at the time of assignment, e.g., linked to an individual or to a particular complication or surgical procedure.
    3. Examples:
      Track and trend of a particular physician’s complication rate when performing surgery or a procedure.
      Track and trend of complications of a particular type of surgery.
      Track and trend of rate of misread/corrected tests for the department.
    4. All T rated issues are reviewed at least once a year by the departmental QI Committee and a decision is made about continuing to follow the issue or to stop. The results of this review are submitted to the Peer Review Board as part of the last regular submission of the calendar year. Submission prior to this date is requested if significant issues are found earlier in the year.
  4. Individuals’ actions could be given two ratings: H1, H2, or H3 + T.
  5. All rating determinations are reviewed by the Peer Review Board.


The Quality Management Department is responsible for maintaining a record of all peer-reviewed cases and their assigned severity codes and attributions. The process for assigning attributions to LIPs and other associates utilizes a confidential personal identification number.

The department chair, QI chair, and care center leadership review and endorse a summary report of all peer-reviewed cases. The Quality Management Department provides staff support in preparing such reports. The report is then submitted to the Peer Review Board quarterly. Departments with a small volume of cases report on an ad hoc basis.


The Peer Review Board Chairman reports to the Montefiore Quality Council, the Medical Executive Committee and the Medical Committee of the Board of Trustees monthly.

Reports of feedback, including conclusions, recommendations and plans are continuously provided to:

  • Senior Vice President/Chief Medical Officer
  • Vice President/Senior Medical Director
  • Vice President/Medical Director
  • Clinical Department Chairman
  • Montefiore Quality Council
  • Medical Committee of the Board of Trustees

Future Direction 

One important step is to create a peer review process tailored to the specific needs of Einstein-Montefiore’s outpatient faculty practices. Currently, administrators are evaluating valid, available, feasible quality indicators and planning to engage the Department’s faculty practices in a process of peer review and quality improvement using these indicators.

Contact Us

Department of Medicine
Albert Einstein College of Medicine
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