Quality, Safety and Peer Review, Part II

The Problem

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.

With so much room for program improvement comes a need for better information. The studies that defined and validated the QI Model involved self-reported survey responses and objective measures of quality and safety from the Centers for Medicare & Medicaid Services and three major health care data vendors. Unfortunately, it takes three years of mortality and morbidity data to produce stable comparative measures. Thus, such measures will not serve well going forward. In order to advance the QI Model, we’ll need timely data on what a variety of programs are actually doing along with concurrent results. Sadly, the research also shows that most hospitals do not track process and outcomes measures from peer review.

The Solution

Thus, I have launched the non-commercial Normative Peer Review Database Project. It is designed to support studies in health care operations improvement, publication of findings, and feedback for improvement of quality and safety. Participants complete an annual program information report and contribute specified peer review program data semi-annually. In return, they receive a normative performance report semi-annually.

Since measurement is integral to process improvement, contribution to this Normative Database creates a win-win. When you measure peer-review process and outcomes, you will strengthen your ability to improve your own program. Your contribution will return useful benchmarking information and support ongoing research on best practices.

The measure set is simple (see CHPSO members may report data to QA to QI as Patient Safety Work Product. You may join or withdraw at any time, and, through CHPSO, there is no charge for this. Merely submit program measures semi-annually and complete a program information report annually. As long as you submit the minimum required measures and complete the annual program information report, you will receive semi-annual normative data reports.

Only de-identified aggregate data will be disclosed in reports and scientific publications. Submitted data will be used only for the purpose of the Normative Database Project and publication of scientific articles. It will not be returned. It will eventually be destroyed or de-identified according to federal regulations. Please contact me for further information.


1. Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2010; published online before print December 15, 2010.

2. Edwards MT. Clinical peer review program self-evaluation for US hospitals. Am J Med Qual. 2010; 25(6):474-480.

3. Edwards MT, Benjamin EM. The process of peer review in US hospitals and its perceived impact on quality of care. J Clin Outcomes Manage. 2009(Oct);16(10):461-467.