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
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
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
Case review volume exceeds 1 percent of hospital inpatient
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
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