Physician Peer Review: Ensuring Immunity, Confidentiality and Compliance

Preserving Immunity or Leveraging Exceptions, Shielding Documentation, Complying With Statutory and JHACO Requirements

Recording of a 90-minute CLE webinar with Q&A

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Conducted on Wednesday, June 17, 2015

Recorded event now available

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Course Materials

This CLE course will provide guidance for healthcare counsel on the peer review process, immunity and exceptions to immunity. The panel will examine recent decisions that make the peer review process and immunity not as absolute as once thought as well as discuss reporting conduct to the National Practitioner Data Bank.


To ensure patient safety and a high quality of care, hospitals use a peer review system to evaluate medical staff and their conduct. Hospitals should have in place a peer review process that meets statutory and JCAHO requirements. While every state has some form of medical peer review privilege, privileges in peer review proceedings are not ironclad.

The New Mexico Supreme Court recently held that a peer reviewer could sue a hospital for its actions in response to the reviewer’s conduct during the peer review process [Yedidag v. Roswell Clinic Corp., No. 34,286 (N.M. 2015)]. This decision should serve as a cautionary tale that the peer review process and immunity are not absolute.

With hospital employment of physicians increasing, healthcare counsel must prepare hospitals and healthcare facilities to manage legal issues related to the peer review process and immunity.

Listen as our authoritative panel of healthcare attorneys discusses the peer review process and compliance with JCAHO and statutory requirements. The panel will examine peer review immunity and exceptions to immunity as well as examine recent decisions that raise questions about the certainty of the peer review process and immunity. The panel will also discuss reporting conduct to the National Practitioner Data Bank.



  1. Peer review immunity
    1. Federal and state law
    2. Exceptions to immunity
    3. Preserving immunity
  2. Peer review process
    1. Statutory requirements for the process
    2. Procedural requirements
    3. JCAHO requirements
  3. Bylaws and other organizational documents
    1. Drafting medical staff bylaws
    2. Amending medical staff bylaws
  4. Antitrust and peer review
  5. NPDB reporting


The panel will review these and other key issues:

  • What are the lessons from recent decisions addressing peer review immunity?
  • What protections are available to peer reviewers and those subject to the peer review process?
  • What steps should counsel for healthcare facilities take to ensure the peer review process and its privileges comply with JCAHO and statutory requirements?


Keith C. Dennen
Keith C. Dennen

Dickinson Wright

Mr. Dennen concentrates his practice in the areas of health care law, intellectual property law, estate and probate,...  |  Read More

Billee Lightvoet Ward
Billee Lightvoet Ward

Of Counsel
Dickinson Wright

Ms. Ward represents healthcare providers, medical device manufacturers, and other healthcare-related entities in...  |  Read More

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