A Systematic Approach to Clinical Peer Review in a Critical Access Hospital

Is There a Relationship Between Facility Peer Review Findings and Quality in the Veterans Health Administration?

BACKGROUND

The aim of clinical peer review (PR) is to improve facility health care quality. However, prior authors have shown that PR may be biased, have rater reliability concerns, or be used for punitive reasons. It is important to determine whether facility PR processes are related to objective facility quality of care.

METHODS

We collected proportion of PR findings that "most experienced and competent clinicians may have managed the case differently" or "most experienced and competent clinicians would have managed the case differently" as an objective measure of facility PR processes and outcomes. We correlated these with facility quality metrics for 2019.

RESULTS

PR findings were not associated with facility quality metrics but were strongly associated with previous year findings.

CONCLUSIONS

This study describes a potentially new source of bias in PR and demonstrates that objective facility outcomes are not related to individual PR findings.

Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center

OBJECTIVES

Although many health care institutions believe that clinical peer review is vital for identifying and improving quality of care, peer review is perceived by many clinicians as variable and inherently punitive. Successful peer review requires institutional leadership and adoption of a just culture approach to investigating and determining accountability for medical errors that result in harm.

METHODS

We describe how an academic medical center implemented and adapted its clinical peer review processes to be consistent with just culture theory and provide a roadmap that other institutions may follow. Specific examples of peer review are highlighted to show how the process improved patient safety in the departments of emergency medicine, internal medicine, and pediatrics.

RESULTS

The most significant process improvement was shifting from a tradition of assigning letter grades of "A," "B," or "C" to determine whether preventable adverse events were caused by "human error," "at-risk behavior," or "reckless behavior." This categorization of human behaviors enabled patient safety officers within 3 departments to develop specific interventions to protect patients and enlist physician support for improving clinical systems.

CONCLUSIONS

Each department's success was due to recognition of different patient and provider cultures that offer unique challenges. The transformation of peer review was a crucial first step to shift perceptions of peer review from a punitive to a constructive process intended to improve patient safety. Our experience with reengineering clinical peer review shows the importance of focusing on just culture as a key method to prevent patient harm.

Peer review and its ethical implications

Peer review is an essential tool for institutions and providers to meet the modern goals of safety and quality in health care. It is a mechanism that leads to a just culture within a health care institution whereby errors and complications are considered products of the system rather than isolated actions by an individual. The benefits and potential drawbacks of peer review are outlined in this review with a special emphasis on the interface between peer review and principles of medical ethics. It is argued that peer review, in the ideal setting, is founded upon the principles of beneficence and justice, and to varying levels on non-maleficence and autonomy.

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

Consultation for child physical abuse: Beyond the history and physical examination

OBJECTIVE

To describe the components of an approach to the consultation for suspected child physical abuse beyond the history, physical findings, and laboratory and radiographic data.

METHOD

Description of both a baseline organizational structure and recommended behaviors.

RESULTS

We describe four domains of the approach to the consultation for suspected child physical abuse by child abuse clinicians: (1)components to have in place before a consultation, (2) components of a quality consultation, (3) sharing a final opinion, and (4) inevitable pitfalls.

CONCLUSION

In proposing this approach, we aim both to make transparent and spark discussion about the way we work and to answer questions about the role of child abuse clinicians raised by recent interest in this subject by the mass media.