Meeting the Challenge of High Reliability

Meeting the daunting challenge of achieving high reliability in healthcare may require use of the same strategies that that worked in aviation and other industries, despite naysayer protests that healthcare is different. The patient safety organization I lead, West Hartford, Conn.-based QA to QI, believes clinical peer review is critical to creating a high reliability organization.

We recently conducted a national study on clinical peer review practices and their role in achieving high reliability. The results of the four-year longitudinal examination of clinical peer review practices at 300 hospitals appeared in the September/October 2013 issue of the Journal of Healthcare Management. The study found that the likelihood of self-reporting of adverse events, hazardous conditions and near misses is an independent predictor of the impact of clinical peer review on quality, safety and physician engagement. This is the first large-scale demonstration of the viability and effectiveness of self-reporting in healthcare.

On the other hand, despite the fact that 20 percent of hospitals reported "major" changes to their peer review process, structure or governance each year, there was only minimal tendency to adopt a set of best practices known as the QI (Quality Improvement) model, which maximizes the identification of opportunities for organizational learning and improvement via peer review. From that perspective, four of every five hospitals could substantially improve peer review program structure, process and/or governance, and thereby advance a culture of safety. Since peer review is the dominant method of event analysis in hospitals, the cost to fix the problem is low and the pay-back potential is high, this should be a priority target.
Peer review that adheres to QI methods is more likely to truly improve patient safety and organizational performance, but the majority of organizations surveyed don't adequately incorporate these principles into peer review.

Transforming clinical peer review for physicians, nurses and other healthcare providers into a vehicle suited to the pursuit of high reliability can be achieved through the following 12 steps:

  1. Distinguish between performance and competence in order to cast peer review as a management process for clinical performance measurement and improvement, distinct from yet interdependent with provider credentialing.

  2.  Promote identification of adverse events, near misses and hazardous conditions by guaranteeing immunity from sanctions for good-faith self-reporting.

  3.  Standardize review committee processes.

  4.  Train reviewers, committee chairs and support staff in program process and QI methods.

  5.  Measure clinical performance during case review.

  6.  In each review, seek out whatever can be learned to improve both individual performance and the process of care.

  7.  Provide timely and balanced performance feedback, including the recognition of excellence.

  8.  Rationalize the connection with the hospital's performance improvement function to assure that identified problems get fixed.

  9.  Harness the power of information systems to periodically aggregate data and analyze trends.

  10.  Track the outcomes and impact of peer review.

  11.  Govern the process effectively and continue to improve incrementally.

  12.  Keep the trustees informed of the impact of peer review on the quality and safety of care.

Marc T. Edwards, MD, MBA, is president and CEO of QA to QI. To access a free online peer review program self-evaluation tool that can be used to communicate improvement opportunity and assess progress with program improvement efforts, click here.

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