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.
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 QAtoQI.com/datadefinitions.htm).
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.
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