The Quality Assurance or QA Model for clinical peer review has far outlived its utility in meeting Joint Commission requirements. Now, it only serves to perpetuate a culture of blame and poison efforts to develop a culture of safety and high-reliability. Because peer review remains the dominant method by which adverse events are examined, the mode in which it is conducted has far-reaching effects. Progress in patient safety will be stymied until the model is changed.
My research has characterized a Quality Improvement or QI Model that corrects the dysfunction of the QA Model.(1,2,3,4) The QI Model is the result of consistent application of well-established quality improvement principles to the process of peer review. These principles hold that human error is inevitable. Error occurs most commonly as a result of multiple interacting factors in the system of care. Thus, the QI Model views all adverse events, near misses and hazardous conditions as organizational learning opportunities.
The peer review program will be more effective in promoting learning to the extent that:
The review process is standardized.
Clinicians frequently self-report adverse events, near misses and hazardous conditions affecting their patients.
The quality of case review is high.
Clinician to clinician issues and other process problems are identified during case review.
The program is integrated with other hospital quality improvement activity so that identified problems get fixed.
Clinical excellence receives recognition.
Medical staff leadership provides attentive program governance.
Hospital trustees are regularly informed about the program’s operation and outcomes.
Clinicians receive timely performance feedback.
Reviewers enthusiastically participate in the process.
Case review documentation includes ratings of multiple elements of activity-specific performance.
Clinical performance ratings are made using reliable scales.
Case review volume exceeds 1 percent of hospital inpatient volume.
Pertinent diagnostic studies are routinely examined along with the medical record.
Program outcomes are monitored.
These program characteristics correlate with both subjective and objective measures of program impact on quality and safety. They also correlate with medical staff satisfaction with the program, physician engagement in quality and safety, and even with physician-hospital relations. As program design principles, they might seem obvious, yet it is surprising how uncommonly they have been applied. Most programs still operate largely in QA mode.
The path to high-reliability is paved with the motto: TRUST – REPORT – IMPROVE. Because the QI Model eschews the “blame game,” promotes self-reporting, and focuses on the extraction of learning opportunities, transformation of medical staff peer review directly advances a culture of safety. The same principles can be applied to nursing peer review and to other methods of event analysis. Overall, the shift to the QI Model can have profound impact on the organization.
I have created a free online tool that makes it easy to assess how well your program conforms to the QI Model. You can use the resulting QI Model score to communicate the improvement opportunity to others in your organization. Once you’ve initiated program improvement efforts, you can also use it to track your progress. If you’ve come to appreciate the value of transforming your organization’s peer review process, the next step is to figure out how to do it. My upcoming column will offer practical advice.
Dr. Edwards has more than 20 years of healthcare management and consulting experience, including service as the senior physician executive in both teaching and community hospitals. He is the foremost authority on best practices in clinical peer review having conducted 3 national studies and published 7 related articles. He helps hospitals improve quality, safety, and resource use and operates a Federally-listed Patient Safety Organization.