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.
After WWI, the American College of Surgeons (ACS) succeeded in
promoting national standards for hospitals. The Joint Commission
followed the ACS in this role from 1952. Medicare
legislation, enacted in 1964, was a boon to the Joint Commission
because the conditions for hospital participation required a
credible medical care review program and the regulations
stipulated that JC accreditation would guarantee payment
eligibility. What was once a sporadic process became hardwired in
most hospitals following the Audit Model.
Medical Audit, which remains the predominant mode of peer review
in Europe, is a focused study of the process and/or outcomes of
care for a specified patient cohort using pre-defined criteria.
Audits are typically organized around a diagnosis, procedure or
clinical situation. One older example of an audit project to
evaluate the quality of medical records anticipates many aspects
of the QI Model. (1)
In the 70s, however, the widespread creation of new programs was
hampered by limitations in the available process models, tools,
training, and implementation support. The lack of perceived
effectiveness of Medical Audit led to revisions of Joint
Commission standards in 1979. Those modified standards dispensed
with the audit requirement and called for an organized system of
Quality Assurance (QA). About the same time, hospitals and
physicians were facing escalating malpractice insurance costs. In
response to these combined pressures, they began to adopt
“generic screens” for potential substandard care (hospital
readmission, death, return to OR, etc.).These screens were
originally developed to evaluate the feasibility of a no-fault
medical malpractice insurance plan and were never validated as a
tool to improve quality of care. Despite warnings from the
developers, their use became widespread.(2) In the process,
a QA Model for peer review evolved with a narrow, legalistic
focus on the question of whether or not the standard of care had
been met. It has persisted despite the longstanding criticisms of
its methods and effectiveness.
Butler JJ, Quinlan JW. Internal audit in the department
of medicine of a community hospital: Two years’
experience. JAMA. 1958;167(5):567-572.
Sanazaro PJ, Mills DH. A critique of the use of generic
screening in quality assessment. JAMA. 1991;265(15):1977-1981.
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