Physician Handbook

Peer Review is a practice recognized by the Joint Commission and the State of Maine regulatory agencies.  The Medical Staff has developed a process that defines circumstances requiring a focused review of a practitioner's performance and for the evaluation of a practitioner's performance by peers.  The Medical Staff also has a mechanism to ensure a uniform standard of quality patient care, treatment and services.

Members of the Medical Staff are involved in activities to measure, assess, and improve performance on an organization-wide basis, including a focused practitioner review process.  As part of this process, the Medical Staff identifies circumstances that require peer review to determine whether a practitioner's performance may require further action to improve that practitioner's performance.  The Medical Staff further defines circumstances for review of a practitioner's performance and also has contingencies for when external review may be necessary.  The focused review process involves monitoring, analyzing, and understanding those defined circumstances of practitioner performance which require further evaluation.  The Medical Staff accomplishes this with referrals from care managers who screen patients with defined criteria.  Cases are then forwarded to the Quality Department for further screening.  When appropriate, cases are then assigned to a peer of the practitioner for chart review.  When the findings of the assessment process are relevant to an idividual's performance, the Medical Staff is responsible for determining the use of these findings in the evaluation of a licensed practitioner's competence.   Relevant information is integrated into performance improvement initiatives.

All peer review information is privileged and confidential in accordance with the Medical Staff and hospital bylaws, state and federal laws, and regulations pertaining to confidentiality and nondiscoverability.

RN Quality Specialist:

Rhonda Lanzara-D'alfonso, RN
Quality and Patient Safety Department
879-3962
dalfonsor@mercyme.com

Chief Quality Officer:

Robert Clinton, MD
Quality and Patient Safety Department
741-0475
clintonr@mercyme.com