Adams School of Dentistry: Peer Review Program and Processes

I. Purpose

To improve quality of care provided by Dental Care Providers at the UNC-Chapel Hill Adams School of Dentistry (hereinafter collectively referred to as "ASOD") and to promote effective and efficient utilization of services through a peer review process. The process is designed to assess, review, study or evaluate the credentials, competence, and professional conduct or provision of patient care of a health care provider. More specifically, this Peer Review process is formed for the purpose of evaluating the quality of, cost of, or necessity for dental health care services.

II. Policy

It is the policy of ASOD to conduct Peer Review of Dental Providers who provide services at ASOD, through the Review Committee, in an effort to provide continuous assessment and improvement of patient care. This policy becomes effective on May 1, 2022.

III. Definitions

Dental Care Provider - A person who pursuant to the provisions of Chapter 90, Article 2 of the North Carolina General Statutes (NCGS) is licensed, or is otherwise registered or certified to engage in the practice of or otherwise performs duties associated with dentistry or dental hygiene.

Dental Peer Review Committee ("DPRC") - A committee composed of Dental Care Providers authorized under Chapter 90, Article 2A of the NCGS that is formed for the purpose of evaluating the quality of, cost of, or necessity for health care services, including provider credentialing.

Peer - A "peer" is a health care professional who has comparable education, training, experience, licensure, or similar clinical privileges or scope of practice.

Peer Review - Peer review is the process of evaluating an individual Dental Care Provider's performance by the DPRC. It includes the identification of opportunities to improve care. When the results of Peer Review indicate a need for performance improvement at the individual and/or aggregate levels, appropriate quality improvement activities should be undertaken to ensure that improvement occurs.

Peer Review is conducted using multiple sources of information including, but not limited to:

1. the review of individual cases,
2. the review of aggregate data, and
3. the use of rate measures in comparison with established benchmarks or norms.

Confidential Documents - To the fullest extent possible, records and materials produced and/or considered by the DPRC are considered to be confidential.

ASOD - The Adams School of Dentistry at The University of North Carolina at Chapel Hill.

IV. Responsibility

When conducted systematically and credibly, Peer Review can result in short and long-term improvements in health care by identifying areas for improvement in the performance of one or multiple clinicians. This can ultimately lead to organizational improvements and ensure optimal patient outcomes. Peer Review as described herein, is intended to promote confidential and non-punitive processes that consistently contribute to quality improvement practices at the individual clinician level. The primary goal is overall improvement in the care provided to patients receiving care from ASOD through a review of individual clinician decisions and actions. Peer Review fosters a responsive environment where issues are identified, acted upon proactively and in ways that ensure continuous quality improvement and best possible outcomes and performance. The DPRC has the authority and responsibility to monitor and evaluate the quality of patient care through organizational process improvement activities identified in this policy.

V. Committee Structure

The Dean of the ASOD appoints DPRC members, with the following composition and qualification:

1. ASOD's Dean serves as a committee member of the DPRC.
2. ASOD's Executive Dean or their designee chairs the DPRC.
3. The DPRC consists of the nine committee members representing various ASOD divisions and administrative units. All members will meet the requirements for inclusion on the DPRC.
4. All DPRC members will be dentists or dental hygienists licensed under NCGS Chapter 90. DPRC members will be initially nominated for a period of two (2) to three (3) years, the terms being specified by the ASOD Dean, or their designee, upon initial appointment. The ASOD Dean, or their designee, will appoint members to fill vacant positions, and each member appointed thereafter will serve three (3) years. Members can be reappointed for a second term.
5. The DPRC should generally be representative of ASOD Dental Care Providers who are readily identified as Peers.
6. The DPRC Chair will ensure that training is provided to all new members.
7. The DPRC may seek outside consultation, as necessary, to clarify complex aspects of a specialized case, or when required to ensure a fair and credible process.
8. A quorum is one member above one-half of the committee membership present at a meeting.
9. No DPRC member may have direct involvement with the case under review.
10. DPRC members must withdraw from a case review if:
    1. Special expertise or knowledge needed exceeds their expertise or they are uncomfortable evaluating the case; or
    2. A conflict of interest exists or any circumstances exist whereby a member may be unable to provide an objective, impartial, accurate and informed review.
    3. The DPRC member has performed any management on the patient whose case is under review. However, opinions and information may be obtained from participants who were involved in the patient's care, where applicable.
11. The DPRC meets once per quarter, or as needed.

VI. Case Identification and Selection Process

The DPRC will review a reasonable number of cases with specified outcomes based on the DPRC's resources. These include, but are not limited to, the following:

1. Important single events that by performance thresholds, trends, or patterns significantly vary from established patterns of clinical practice, recognized standards, or from that of other Peers;
2. When an individual Dental Care Provider's performance varies significantly from established patterns of practice, recognized standards, or from that of other Peers;
3. When the results of an organizational improvement activity identifies a variation in an individual Dental Care Provider’s performance;
4. When the results of ASOD's monitoring function identifies a variation in an individual Dental Care Provider's performance (i.e., when performance data, if tracked, suggests a Dental Care Provider may not be following established quality measures);
5. When the professional conduct of an individual is believed to be below the standards required of a Dental Care Provider in a similar situation;
6. When an ASOD staff or patient/family complaint is received about the quality of care or behavior of a ASOD Dental Care Provider;
7. Risk management issues; and/or
8. At the discretion of the DPRC.

VII. Peer Review Process

Meeting Structure

DPRC meetings should occur periodically, the frequency depending on the reviews being conducted by the DPRC. DPRC meetings should be in person, by teleconference, or videoconference (the latter options are only acceptable so long as communications are maintained so all individuals can hear everyone else).

Initial Review Process

An ASOD employee and licensee under NCGS Chapter 90 and a member of the DPRC (the "Coordinator") will prepare and randomly assign the medical records to be reviewed to the DPRC members for the Peer Review process. The complete dental record will be made available in a HIPAA compliant format and method, including making the electronic health record available to the DPRC member with instructions or a form on how to conduct the review. The reviewing DPRC member must document all reviewed materials. The completed reviews with patient and clinician identifiers will be delivered to the Coordinator. The Coordinator will collect and aggregate the data to be reported to the DPRC at the regularly scheduled meetings.

Peer Review Committee Responsibilities

1. DPRC members will be responsible to ensure that the reviews are completed within an assigned timeframe, or within four (4) months from the date that the review was initiated, whichever occurs sooner. These times may be amended if the services of an external Peer Review are utilized.
2. All reviews must be conducted by a reviewer of the same profession as the Dental Care Provider and, when necessary, of the same specialty as the Dental Care Provider, although nothing herein limits a licensed dentist from reviewing any dental hygienist or dental assistant's care.
3. Identify certain unusual events which may necessitate Peer Review should they occur. Additionally, during routine Peer Review, additional suspected variation from anticipated outcomes may be identified and these may necessitate additional Peer Review as well.

Peer Review Committee Process

1. The Practitioner under review may be asked for additional information or to meet with the DPRC. If additional information or presence is requested, the DPRC will use the following process:
   1. When the DPRC schedules a Dental Care Provider's performance or conduct for discussion, the Dental Care Provider may be requested to attend the meeting.
   2. The Dental Care Provider must be notified at least ten (10) calendar days prior to the scheduled committee meeting date of the DPRC’s request for the Dental Care Provider's presence at the meeting. If the DPRC requests the Dental Care Provider's attendance, the DPRC must provide the Dental Care Provider with summary information related to the issue of the meeting.
   3. If the Dental Care Provider’s attendance is not warranted, but the DPRC requests additional information from the Dental Care Provider regarding the management of the case or to provide input regarding the event involving the Dental Care Provider's conduct, the DPRC must notify the Dental Care Provider of the DPRC's request for additional information at least ten (10) calendar days prior to the scheduled DPRC meeting date.
   4. The Dental Care Provider must have ten (10) calendar days in which to respond to the committee’s request in writing. In the alternative, if the Dental Care Provider prefers to attend the meeting of the DPRC, the Dental Care Provider must notify the DPRC chair within the same ten (10) calendar day period.
   5. Unless excused for good cause, it is the responsibility of the Dental Care Provider to provide the requested information in writing or to request to attend the meeting, within the time frames outlined above. Failure to comply may be grounds for corrective action.
   6. Counsel on behalf of the Dental Care Provider will not be permitted to attend due to the informal nature of the DPRC meeting.
2. The Dental Care Provider whose care is under review has the right to sit in on the DPRC meeting during the time the Dental Care Provider's case is reviewed and to discuss and provide additional information to the DPRC as necessary, if notice has been provided as described above. However, the Dental Care Provider is not entitled to sit in during the DPRC’s discussions regarding the case. Nothing herein requires notice in advance of the initial review by the DPRC.
3. If applicable, a follow-up action will be recommended to the DPRC for consideration during the DPRC meeting, which may include but not limited to:
   1. A letter to the Dental Care Provider finding no need for improvement or further action;
   2. A letter to the Dental Care Provider requesting additional information;
   3. An educational letter to the Dental Care Provider identifying a need for improvement - no response necessary;
   4. A letter to the Dental Care Provider (and Division Chair of Provider) identifying a need for improvement and a request for the Dental Care Provider to submit a written response outlining the Dental Care Provider's plan for improvement, subject to DPRC approval;
   5. Documented verbal counseling in the Dental Care Provider’s file;
   6. Monitoring of the Dental Care Provider’s performance/conduct by Division Chair over a given period of time;
   7. Recommendations for the Dental Care Provider to undergo additional education and/or related activities; and
   8. Recommendation for disciplinary action, up to and including dismissal, consistent with relevant ASOD and University policies.
4. Dental Care Providers who have been asked for additional information or who have been asked to meet with the DPRC will be notified of the outcome of the Peer Review and provided with a written summary of the relevant Peer Review findings and rationale for action. The Dental Care Provider is not provided with a copy of the actual Peer Review that was completed for that case. The DPRC Coordinator will prepare the letters and the chair of DPRC will send to the individual Dental Care Providers. The Division Chair of the Dental Care Provider will also receive a copy of the letter.
5. Attendance at DPRC meetings is limited to permitted members and participants only. Membership on the DPRC must be limited to Dental Care Providers licensed under NCGS Chapter 90. Meetings are not open to additional participants other than consultants, witnesses, or experts retained by the DPRC using approved forms. Any individual invited by the chair to attend any part of a DPRC meeting must be advised of the confidentiality requirements applicable to such meetings and must complete a Confidentiality Agreement provided hereto at Exhibit A.

Appeal Rights

Within ten (10) calendar days of the receipt of an approved follow-up action, the Dental Care Provider under review has the right to request an appeal from the Peer Review Committee. The request:

• must be in writing,
• must include an identification of the grounds for appeal, and
• must include a clear and concise statement of the facts in support of the appeal.

The allowable grounds for the appeal are:

• Substantial non-compliance with the procedures of the Peer Review Committee, and/or
• Insufficient evidence in the hearing record to support the decision.

The DPRC will convene for the appeal hearing within thirty (30) calendar days of receipt of the written request from the Dental Care Provider under review.

The ASOD Dean will review the appeal request and any other material they deem relevant and will recommend to the DPRC whether the DPRC should affirm, modify, or reverse the original finding and recommendations. After the recommendation from the ASOD Dean, the DPRC will issue a determination. This decision will be considered final.

VIII. Committee Records

1. All records, documents and other information generated during the course of a Peer Review proceeding, including reports, statements, memoranda, correspondence, meetings minutes, and other records of proceedings, materials, opinions, findings, conclusions and recommendations must be clearly marked as "Dental Peer Review Committee - Privileged and Confidential" and are considered privileged documents as described above.
2. All activities, discussions, evaluations, materials, and findings of the DPRC must be confidential and not discussed in any form or format (written, electronic, or oral) outside the committee proceedings. All DPRC members are to be educated as to the absolute requirement for confidentiality. Documents and materials are to be fact-based. Exhibit A is the Confidentiality Agreement that all DPRC members must sign.
3. Records should include a list of DPRC members in attendance for each committee meeting, as well as the full name, title, and committee membership status of each person present at each meeting.
4. Mark each document and all materials, including individual notes, clearly on each page with the following confidentiality statement:
   1. “This is a confidential medical review committee document/material provided within the confidentiality protections of North Carolina law, and intended only for the addressee(s). Unauthorized review, forwarding, printing, copying, distributing, or using such information is strictly prohibited. If you received this material in error, or if you have reason to believe you are not authorized to receive it, please promptly notify the sender by telephone, and return or shred the material.”
5. Mark every communication sent by any member of the DPRC involving any committee matter with the full name, title, and committee membership status of the author, sender, and recipients. Ensure that the communication clearly articulates the DPRC's purpose and that this purpose also relates to the DPRC's Peer Review function.
6. Set up and maintain a separate file for DPRC materials marked "Dental Peer Review Committee - Privileged and Confidential." This file and any other DPRC records or materials in any form or format (paper or electronic) should be stored on-site at ASOD. In addition, electronic files, records or other materials should be stored only on a ASOD-owned device using ASOD network resources (e.g., not on local drives), and otherwise in accordance with ASOD data privacy security policies.
7. Distribute information and materials only to those who are DPRC members. While educational lessons can be learned from the Peer Review process, maintenance of confidentiality is necessary to assure an ongoing frank and open exchange and review.
8. Per the ASOD Access to Patient Information Policy and the UNC-Chapel Hill Privacy of Protected Health Information Policy, all ASOD personnel have a duty to safeguard patient information. Distributing DPRC materials with patient PHI via email, share-site, or other electronic distribution is to be avoided, when possible, with the exception of EPIC and EPIC secured messages. If electronic distribution is unavoidable, the sender should use only ASOD encrypted email or ASOD-approved, secure internal document-sharing technology (such as SharePoint or Private Teams), in either case electronically marking the documents and limiting access rights prior to transmission or uploading to prohibit forwarding by the recipient or access by persons other than DPRC members. This may prevent printing of the document, so you may need to work with the DPRC members to determine the most appropriate distribution method. Also, if electronic distribution is necessary, follow the requirements above, identifying the full name, title, and committee membership status of the author, sender, and recipients.

IX. Retained Services

ASOD may on occasion retain services of an expert to assist in the Peer Review process. The provisions of NCGS Chapter 90, Article 2A apply to the contractor in the same way as it applies to ASOD Dental Care Providers. Circumstances when this may occur include, but are not limited to, when the DPRC chair determines that there is no member of the DPRC who can serve as a "peer" and requests an external peer review process.

X. Confidentiality Statement

DPRC members should complete and sign a confidentiality statement. See Exhibit A.

Contact Information

Name: Dr. Ed Swift

Title: Executive Vice Dean for Education

Telephone: 919-918-1259

Email: edward_swift@unc.edu