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.
A native of Seattle, he graduated from the University of Washington. He earned his MD degree from the University of Colorado, trained in Family Medicine at Thomas Jefferson University Hospital, and completed an MBA at the University of Connecticut. He is a member of Phi Beta Kappa and maintains board certification in Family Medicine.
In my last column, I discussed the critical role of leaders in shaping organizational culture. Here we take the next step and look at the requirements for achieving high reliability. Given high rates of adverse events, process failures and patient harm, the idea of achieving high reliability in healthcare may seem absurd. Even so, many well-respected healthcare leaders have sounded the clarion call to make this the primary goal.
In my last column, I discussed that many American hospitals are characterized by a culture of blame: one that is antithetical to the pursuit of patient safety and high reliability via organizational learning.
My research has shown that roughly 20 percent of hospitals make significant changes in their clinical peer review program’s structure, process or governance every year. Unfortunately, this high rate of change has not resulted in substantial improvement. Much of the recent change has concentrated on the replication of a multi-specialty review process, with neglect of factors central to the evidenced-based QI Model. You can refresh your understanding of the QI Model through a brief online program self-evaluation questionnaire at http://QAtoQI.com/set.htm.
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.
The QA Model has dominated medicine for 30 years. Enough time has passed for the current generation of physicians to believe that the model is sacrosanct: “It’s the way we’ve always done it and the way it should be done.” The medical profession has, however, used other methods. Peer review has been documented as early as the 11th century and may have originated in ancient Greece. Modern practice emerged from Codman’s End Results System and Ponton’s concept of Medical Audit.
If you’ve been following this column, you know that the majority of hospitals suffer from a culture of blame that poisons efforts to improve quality and safety. The dysfunctional Quality Assurance (QA) Model for Clinical Peer Review is a major part of the problem. It perpetuates the negative cycle of blame and fear by focusing on competence and punishment rather than on performance improvement.
In the May issue of CHPSO Patient Safety News, this column focused on the importance of learning from defects and pointed out the problem with identifying adverse events, near misses and hazardous conditions. This is not a small problem. Typically, only about 10 percent of adverse events are reported. This means that either much effort must be expended to identify such cases by other means or that many learning opportunities will be missed.
Now that we have gained a common vision of possibilities for a QI Model of peer review, it will be useful to return to our framework for improving patient safety to take a deeper dive into learning from defects.
In my last column, I reviewed the basics of extracting valid measures of clinical performance during case review. It turns out that such measures can be of great benefit in minimizing bias in peer review. The key is to remember that measures of clinical performance require an aggregate view over multiple cases. They are not reliable enough to justify harsh corrective action based on a single case.This fits well with the QI model for peer review.When each case review is not a threatening, high-stakes exercise and the rating scale captures all shades of gray, life is easier.
In my last column, I outlined the three primary modes of organizational learning and highlighted the opportunity to measure clinical performance during peer review. Clinical performance measures can be used to promote self-correcting behavior through timely performance feedback. They can also serve to identify performance trends among groups of clinicians. Extracting such measures greatly increases the efficiency and value of peer review. Let’s see how.
In my last column, I highlighted the fundamental differences between the old, dysfunctional QA style of peer review and the more effective QI Model. Let’s now put that in the context of how healthcare leaders create the learning necessary to improve patient safety.
In my last column, I told the story of how I first came to test my assumption that clinical peer review would be forever antithetical to quality improvement.Today, I’d like to outline for you the characteristics that differentiate a QI model for peer review from the dysfunctional, legacy QA model.The QI model frames peer review as a quality improvement activity, not only to improve the process itself, but to better support the effort to improve clinical performance and patient safety.It’s a battle for the hearts and minds of the medical profession that will affect nursing as well: the way w
Owing to the generosity of Thomson Reuters and Premier Inc., electronic reprints of the latest findings on clinical peer review effectiveness will be available at no cost until the end of May. The article appears in the April issue of the American Journal of Medical Quality. The publisher usually charges a fee of $20 for each download to non-subscribers.
Clinical peer review has yet to fulfill its obligation to enhance quality and patient safety. Most hospitals still rely on an outmoded and dysfunctional quality-assurance model for peer review (see CHPSO Patient Safety News July 2010). An emerging QI Model is far superior. You can quickly assess your own program with the evidence-based, online Peer Review Program Self-Evaluation Tool.
The final results of the 2009 American College of Physician Executives’ Peer Review Outcomes Study, just released online by the American Journal of Medical Quality, show that when doctors do clinical peer review using new methods, hospitalized patients benefit from safer care.1