Peer Review


Peer review education is crucial to enable Medical Staffs to fulfill their legal and professional duties and responsibilities to deliver quality patient care through an effective, fair and expeditious peer review system.

The Joint Commission Medical Staff Standards (MS.03.0101) states:

“The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process”.

 The bottom line of peer review best practices requires that a hospital and a medical staff comply with all mandated state and federal laws and regulations and conduct peer review in accordance with the medical staff bylaws.  However, there are many considerations beyond the bottom line.

Inadequate peer review processes can have a seriously negative impact on hospitals and hospital groups, such as:

• Negative publicity
• Damage to physicians’ careers and practices
• High profile lawsuits
• Multi-million dollar fines
• Management shake-ups
• Loss of investor confidence
• Joint Commission sanctions and loss of accreditation
• Scrutiny by state and federal agencies and other public organizations
• Consequences of failure to protect the confidentiality of the proceedings and records of organized medical staff peer review committees

An aware, educated and committed staff, and well executed peer review process, can prevent such negative events. Early detection and resolution of physician performance issues can lower costs and protect hospitals and physicians from the potential damage.

Our 3-person presentation team will bring to life key issues related to Peer Review, causes and consequences of deficiencies in the Peer Review process, and corrective measures.

Using our “Theater of the Living Hypotheticals” format, professional actors/facilitators bring issues to life with performances of powerful, realistic scenarios depicting the challenges faced by medical staff, followed by interactive discussion.



1-2 hours (at client discretion)

PRESENTERS (3-person presentation team includes one of the Nossaman LLP attorneys below)

Carlo Coppo is a healthcare attorney and trial lawyer with 53 years of practice and expertise in the areas of healthcare litigation, the defense of lawsuits initiated by disciplined physicians against hospitals, hospital boards, medical executive committees, and members of peer review committees, representation of physicians and healthcare professionals before California licensing boards, and extensive experience as a Hearing Officer and advisor to governing boards in medical staff peer review judicial review proceedings.

David Balfour is a healthcare attorney whose primary area of practice is in defending physicians and other healthcare licensees in investigations and prosecutions by licensing boards. He also represents medical staffs and physicians engaged in the peer review process.

Kit Goldman and Memo Mendez of WTN are nationally acclaimed trainers, facilitators and experts on human and legal issues in the workplace, as well as professional actors. Their unique “edutainment” methodology harnesses the power of entertainment to educate on dozens of workplace topics, achieving unsurpassed levels of engagement and retention. They have appeared frequently as workplace experts in the media. Currently, Goldman and Mendez are collaborating with leading CA health care attorneys on programs for physicians and medical staff services on Cultural Competence, Physician Well Being, Addiction, Disruptive Behavior, Intervention and Peer Review.


• Clear understanding of legal duties
• Educate re: best practices
• Create awareness of the importance of a well executed process
• Identify obstacles and the strategies to overcome them
• Inspire commitment to early detection and proactive resolution of problem behavior
• Illustrate and deconstruct the impact of Peer Review on patients, staff and the institution
• Foster a culture of accountability among staff

SAMPLE CONTENT (may include but NOT limited to)

• Importance of Peer Review
• Definitions, examples, case studies
• Education vs. Discipline
• Legal and professional duties
• Business & Professions code
• Joint Commission Medical and Leadership Standards
• Medicare Conditions of Participation
• Medical Staff Self-Governance vs. Hospital Board Corporate Responsibility
• Who can conduct Peer Review?
• Who has legitimate access to Peer Review records?
• Who can vote?
• Who must be included in Executive Sessions?
• Physician termination and re-appointment