Clinical Quality and Safety Peer Review Committee Policy
About This Policy
- Effective Date:
- Date of Last Review/Update:
- Responsible University Office:
- Faculty Affairs and Professional Development
- Responsible University Administrator:
- Executive Associate Dean for Faculty Affairs and Professional Development
This policy applies to all IUSM faculty members licensed to provide healthcare services
employed by or otherwise holding an appointment with IUSM, including volunteer
For purposes of this Policy, the term "peer review" refers to the evaluation of (i) the
qualifications and/or ability of IUSM faculty to provide clinical education or conduct
clinical research, regardless of location; (ii) patient care provided by IUSM faculty; and
(iii) the merits of a complaint or other information relayed or made available to the Committee regarding a faculty member’s competency or professional conduct, including
activities related to the clinical education or clinical research missions of IUSM (referred to as “Peer Review Issue(s)”).
Authority and Composition
The Committee and its designees, as provided in this policy, have the authority to review, investigate, and evaluate qualifications, patient care, professional conduct, and patient safety issues involving IUSM faculty and, when necessary, to impose corrective action stemming from such investigations consistent with other existing IU and/or IUSM policies.
The Committee will consist of no less than fifty percent (50%) individual professional healthcare providers. The Committee will consist of: 1) the current Executive Associate Dean for Faculty Affairs and Professional Development; 2) the current President of the Council of Clinical Chairs; 3) the current Vice President of the Council of Clinical Chairs; and 4) the current Secretary of the Council of Clinical Chairs (“Committee Members”).
The Committee may appoint ad hoc committees or designate individuals to review, investigate, or address peer review issues on behalf of the Committee. The Committee shall consider whether it is necessary to solicit perspectives from individuals of other genders or races in order to fairly consider and/or address a Peer Review Issue.
In the event of an actual or perceived conflict of interest of a Committee Member relating to a particular Peer Review Issue, the conflicted Committee Member will recuse himself or herself from the review, investigation, and adjudication, as applicable, of that particular Peer Review Issue. The remaining Committee Members will mutually agree upon an individual to serve as a temporary Committee Member for the purposes of reviewing, investigating, and adjudicating, as applicable, the Peer Review Issue in question.
The Committee Members, staff, advisors, and those assisting any sub- or ad hoc committee or designee in the peer review process shall be considered designees and/or personnel of a peer review committee and entitled to confidentiality and immunity from damages under applicable state and federal law.
Reason for Policy
The purpose of the Indiana University School of Medicine (“IUSM”) Peer Review Committee (“Committee”) is to foster a standard process for timely and effective peer review of quality of care related issues involving IUSM faculty licensed to provide healthcare services. The goal of the peer review process is to improve the quality and safety of care rendered by IUSM faculty. The Committee is encouraged to evaluate and communicate in a candid, objective, and conscientious manner.
The following procedure applies to Peer Review Issues referred to or made known to the
- Peer Review Issue Source: Without limitation, Peer Review Issues may be referred from or identified by any of the following:
• Incident reports;
• The IUSM Provider Complaint Triage Team;
• Patient, learner, faculty, or staff complaints;
• Police or other public safety officials;
• Human Resources (HR) inquiry or complaint;
• Indiana University Health Physicians (IUHP);
• IUPUI Office of Equal Opportunity;
• Affiliated Medical Staff Office;
• EthicsPoint, Trust Line or other similar complaint intake point; or
• Other reports from IU-affiliated organizations and parties
2. Preliminary Review: All Peer Review Issues, regardless of source, should be
directed to the Committee for a preliminary review. The Committee or designee,
including the IUSM Provider Complaint Triage Team, has the delegated authority
to determine whether the Peer Review Issue necessitates further review by the
Committee. The Committee or designee may consult with appropriate resources
when making this determination, including consulting with the faculty member
who is the subject of the Peer Review Issue (“Subject”). The Committee or designee will determine whether the matter warrants further review by the Committee or otherwise direct the matter to an appropriate IUSM, University, or external process or resource for further review independent of and/or in follow up to the Committee’s review.
Following the preliminary review, the Committee or designee may determine and report to the Committee that:
a. No Further Action or Limited Action: The Peer Review Issue can be resolved by: (i) limited informal action of the Committee or designee; (ii)
referring the matter to a resource or entity outside of IUSM; or (iii)
determining that no further action or investigation is warranted under the
circumstances. A determination that no further action or investigation is
warranted does not preclude the Committee from maintaining a record of the
Peer Review Issue or related communications with the Subject or reopening
the issue later if new information or a change in circumstances warrants the
b. Administrative Leave: An immediate administrative leave or other immediate corrective action is warranted. Consistent with applicable IUSM polices, the Committee or designee has the authority to place the Subject on an immediate paid or unpaid administrative leave pending the outcome of an investigation.
c. Investigation: The nature of the Peer Review Issue reasonably could result
in action that adversely affects the Subject’s employment or affiliation with IUSM or otherwise may warrant corrective action. The Committee may then commence a formal investigation. Preliminary reviews performed by the Committee or designee are not considered an investigation.
3. Administrative Leave Pending an Investigation: When an administrative leave is imposed, the Committee or designee shall promptly notify the Subject in writing of the administrative leave, with copy to the Committee. As soon as is reasonably
practicable after an administrative leave is imposed, the Committee shall review the basis for the administrative leave and either continue, modify, or terminate the
administrative leave. The Committee shall inform the Subject of the Committee’s
decision regarding continuance of the administrative leave in writing.
4. Formal Investigation by Committee: If a Peer Review Issue is forwarded to the
Committee for investigation as described in 2) above, the Committee may either
investigate the matter itself or appoint an ad hoc committee or individual to
conduct the investigation. The Committee, ad hoc committee or individual shall
convene as soon as reasonably practicable to investigate the matter and take the
appropriate next steps, which may include, but are not limited to, any or all of the
• Conduct a review that evaluates the issues or scope pertinent to the matter unless otherwise directed by the Committee, including a review of any relevant documentation or other materials or information;
• Meet with individuals having knowledge of the issues under review, including any complainant(s);
• Meet with the Subject;
• Refer the Subject for a health assessment;
• Refer the matter to external resources, as deemed necessary;
• Contact any hospitals or other medical facilities or organizations that may have information pertinent to the matter;
• Determine whether the issue(s) are more appropriate for resolution via another office or entity;
• Consult with legal counsel; and/or
• Such other actions as are appropriate under the circumstances.
Subject Participation. As early as is appropriate during the investigation,
Committee shall afford the Subject the opportunity to appear before or
otherwise provide information to the Committee as part of its investigation.
The Committee shall also permit the Subject to review records accumulated
by the Committee at a time and place determined appropriate by the Committee.
5. Conclusion of Formal Investigation: Upon conclusion of the investigation, the
Committee or designee may prepare a written report of its findings and recommendations, which may include any, or a combination of, the following:
• Take no further action;
• Issue a letter of warning, admonition, or reprimand;
• Institute proctoring or similar oversight of the faculty member’s professional practice;
• Ongoing evaluations or interventions as deemed necessary;
• Referral to other IUSM or University offices for follow up, as appropriate;
• Suspension of the faculty member;
• Dismissal of the faculty member; and/or
• Such other actions as the Committee or designee deems appropriate.
a. If the Committee delegated the investigation to an ad hoc committee or
individual, such designee may submit a final written report to the Committee for review. The Committee may then decide whether to accept, modify, or reject the report’s recommendations ("Peer Review Decision").
6. Confidentiality: All matters undertaken pursuant to this Policy are confidential
pursuant to applicable state and/or federal law. As such, all peer review information
addressed hereunder shall only be disclosed in response to, or as part of, lawful
communications to another peer review committee or its designee or as otherwise
required by law in accordance with Indiana law (Indiana Code 34-30-15 et seq.).
The Committee may disclose its communications, records, and determinations to
other peer review committees or entities consistent with Indiana law.
- First draft of policy: December 2019.
- Reviewed and approved by IUSM Faculty Steering Committee: February 20, 2020.
- Reviewed and approved by IUSM School Executive Committee: November 2, 2020.
- Policy migrated and published to new policy portal 04 June 2021.
- Policy updated on 20 April 2023 to reflect changes in some titles.