1
|
Brook K, Agarwala AV, Tewfik GL. Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture. J Patient Saf 2024; 20:280-287. [PMID: 38470962 DOI: 10.1097/pts.0000000000001224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.
Collapse
Affiliation(s)
| | - Aalok V Agarwala
- Department of Anaesthesia, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - George L Tewfik
- Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey
| |
Collapse
|
2
|
Horwitz D, Dumas RP, Cunningham K, Palacio CH, Margulies DR, Eme C, Bukur M. How do we PI? Results of an EAST quality, patient safety, and outcomes survey. Trauma Surg Acute Care Open 2023; 8:e001059. [PMID: 37560073 PMCID: PMC10407366 DOI: 10.1136/tsaco-2022-001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/16/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Quality improvement is a cornerstone for any verified trauma center. Conducting effective quality and performance improvement, however, remains a challenge. In this study, we sought to better explore the landscape and challenges facing the members of the Eastern Association for the Surgery of Trauma (EAST) through a survey. METHODS A survey was designed by the EAST Quality Patient Safety and Outcomes Committee. It was reviewed by the EAST Research and Scholarship Committee and then distributed to 2511 EAST members. The questions were designed to understand the frequency, content, and perceptions surrounding quality improvement processes. RESULTS There were 151 respondents of the 2511 surveys sent (6.0%). The majority were trauma faculty (55%) or trauma medical directors (TMDs) (37%) at American College of Surgeons level I (62%) or II (17%) trauma centers. We found a wide variety of resources being used across hospitals with the majority of cases being identified by a TMD or attending (81%) for a multidisciplinary peer review (70.2%). There was a statistically significant difference in the perception of the effectiveness of the quality improvement process with TMDs being more likely to describe their process as moderately or very effective compared with their peers (77.5% vs. 57.7%, p=0.026). The 'Just Culture' model appeared to have a positive effect on the process improvement environment, with providers less likely to report a non-conducive environment (10.9% vs. 27.6%, p=0.012) and less feelings of assigning blame (3.1% vs. 13.8%, p=0.026). CONCLUSION Case review remains an essential but challenging process. Our survey reveals a need to continue to advocate for appropriate time and resources to conduct strong quality improvement processes. LEVEL OF EVIDENCE Epidemiological study, level III.
Collapse
Affiliation(s)
- Daniel Horwitz
- Department of Surgery, NYU Langone Health, New York, New York, USA
- Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York City, New York, USA
| | - Ryan Peter Dumas
- Department of Surgery, UT Southwestern Medical, Dallas, Texas, USA
| | - Kyle Cunningham
- Department of Surgery, Atrium Health, Charlotte, North Carolina, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christine Eme
- Eastern Association for the Surgery of Trauma, Chicago, Illinois, USA
| | - Marko Bukur
- Department of Surgery, NYU Langone Health, New York, New York, USA
- Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York City, New York, USA
| |
Collapse
|
3
|
Lepard JR, Yaeger K, Mazzola C, Stacy J, Shuer L, Kimmel K. Mechanisms of Peer Review and Their Potential Impact on Neurosurgeons: A Pilot Survey. World Neurosurg 2022; 167:e469-e474. [PMID: 35973519 DOI: 10.1016/j.wneu.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physician peer review is a universal practice in U.S. hospitals. While there are many commonalities in peer review procedures, many of them established by law, there is also much institutional variation, which should be well understood by practicing neurosurgeons. METHODS A 13-question pilot survey was conducted of a sample of 5 hospital systems with whom members of the Council of State Neurosurgical Societies Medico-Legal Committee are affiliated. Survey questions were constructed to qualitatively assess 3 features of hospital peer review: 1) committee composition and process, 2) committee outcomes, and 3) legal protections and ramifications. RESULTS The most common paradigm for a physician peer review committee was an interdisciplinary group with representatives from most major medical and surgical subspecialties. Referrals for peer review inquiry could be made by any hospital employee and were largely anonymous. Most institutions included a precommittee screening process conducted by the physician peer review committee leadership. The most common outcomes of an inquiry were resolution with no further action or ongoing focused professional practice evaluation. Hospital privileges were only rarely reported to be revoked or terminated. Members of the physician peer review committee were consistently protected from retaliatory litigation related to peer review participation. Most hospitals had a multilayered decision process and availability of appeal to minimize potential for punitive investigations. CONCLUSIONS According to a recent study, only 62% of hospitals consider their peer review process to be highly or significantly standardized. This pilot survey provides commentary of potential areas of commonality and variation among hospital peer review practices.
Collapse
Affiliation(s)
- Jacob R Lepard
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Kurt Yaeger
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Catherine Mazzola
- Division of Pediatric Neurological Surgery, New Jersey Pediatric Neuroscience Institute, Morristown, New Jersey, USA
| | - Jason Stacy
- Division of Neurosurgery, North Mississippi Medical Center, Tupelo, Mississippi, USA
| | - Lawrence Shuer
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kristopher Kimmel
- Department of Neurosurgery, Rochester Regional Health, Rochester, New York, USA
| | | |
Collapse
|
4
|
Lossius MN, Rosenberg EI, Thompson LA, Gerner J, Holland CK. Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center. J Patient Saf 2021; 17:e1873-e1878. [PMID: 32195781 DOI: 10.1097/pts.0000000000000692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Lindsay A Thompson
- Departments of Pediatrics and Health Outcomes and Biomedical Informatics, University of Florida
| | - Janet Gerner
- Sebastian Ferrero Office of Clinical Quality and Patient Safety, UF Health Shands Hospital
| | - Carolyn K Holland
- Department of Emergency Medicine, University of Florida, Gainesville, Florida
| |
Collapse
|
5
|
Bader H, Abdulelah M, Maghnam R, Chin D. Clinical peer Review; A mandatory process with potential inherent bias in desperate need of reform. J Community Hosp Intern Med Perspect 2021; 11:817-820. [PMID: 34804397 PMCID: PMC8604442 DOI: 10.1080/20009666.2021.1965704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/03/2021] [Indexed: 11/23/2022] Open
Abstract
Clinical peer review, a process mandated across all hospitals in the USA, originated as a measure to protect patients by ensuring a standardized level of medical service that is provided by all practicing physicians. The process involves retrospective chart reviewing to assess the quality of patients' care provided by physicians as well as adherence to the most appropriate guidelines. The process of clinical peer review almost entirely serves its ultimate purpose in quality preservation; However, certain laws gave immunity to reviewers resulting in abuse and using the clinical peer review process for secondary gain. Some notable cases of abuse were discussed in the article, we also shed light on two forms of bias that can potentially interfere with the review process and the dreaded outcomes that come along a negative peer review. We also propose methods to overcome these biases to further standardize and improve this crucial process.
Collapse
Affiliation(s)
- Husam Bader
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | | | - Rama Maghnam
- Department of Pediatrics, Monmouth Medical Center, Long Branch, NJ, USA
| | - David Chin
- Department of Internal Medicine, Presbyterian Rust Medical Center, Rio Rancho, NM, USA
| |
Collapse
|
6
|
Credentialing, Certification, and Peer Review Essentials for the Neurosurgeon. World Neurosurg 2021; 151:364-369. [PMID: 34243670 DOI: 10.1016/j.wneu.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/23/2022]
Abstract
Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries.
Collapse
|
7
|
Richmond BK, Welsh D. Education, Ethics, and History: The Peer Review Process in the US. J Am Coll Surg 2021; 233:480-486. [PMID: 34062244 DOI: 10.1016/j.jamcollsurg.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022]
Abstract
Despite the near-universal acceptance of the benefits of a sound peer review process (PRP), the topic of peer review remains a source of controversy among surgeons. The current PRP is plagued by heterogeneity across different hospital and institutional systems. These inconsistencies, combined with a perceived lack of fairness inherent to the PRP in some institutions, led to concerns among practicing surgeons. In this review of the relevant literature on the PRP, we attempted to provide some context and insight into the history of the PRP, its role, its shortcomings, its potential abuses, and some key requirements for its successful execution.
Collapse
Affiliation(s)
- Bryan K Richmond
- Department of Surgery, Charleston Division, West Virginia University, Charleston, WV; Charleston Area Medical Center Institute for Academic Medicine, Charleston, WV.
| | - David Welsh
- Surgical Associates of Southeastern Indiana, Batesville, IN
| |
Collapse
|
8
|
Armstrong V, Tan N, Sekhar A, Richardson ML, Kanne JP, Sai V, Chernyak V, Godwin JD, Tammisetti VS, Eberhardt SC, Henry TS. Peer Learning Through Multi-Institutional Web-based Case Conferences: Perceived Value (and Challenges) From Abdominal, Cardiothoracic, and Musculoskeletal Radiology Case Conference Participants. Acad Radiol 2020; 27:1641-1646. [PMID: 31848074 DOI: 10.1016/j.acra.2019.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/02/2019] [Accepted: 11/12/2019] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES Peer learning is a case-based group-learning model intended to improve performance. In this descriptive paper, we describe multi-institutional, multi-subspecialty, web-based radiology case conferences and summarize the participants' experiences. MATERIALS AND METHODS A semi-structured, 27-question survey was administered to radiologists participating in abdominal, cardiothoracic, and musculoskeletal case conferences. Survey questions included demographics, perceived educational value and challenges experienced. Survey question formats were continuous, binary, five-point Likert scale or text-based. The measures of central tendencies, proportions of responses and patterns were tabulated. RESULTS From 57 responders, 12/57 (21.1%) were abdominal, 16/57 (28.1%) were cardiothoracic, and 29/57 (50.8%) were musculoskeletal conference participants; 50/56 (89.3%) represented academic practice. Median age was 45 years (range 35-74); 43/57 (75.4%) were male. Geographically, 16/52 (30.8%) of participants were from the East Coast, 16/52 (30.8%) Midwest, 18/52 (34.6%) West Coast, and 2/52 (3.8%) International. The median reported educational value was 5/5 (interquartile range 5-5). Benefits of the case conference included education (50/95, 52.6%) and networking (39/95, 41.1%). Participants reported presenting the following cases: "great call" 32/48 (66.7%), learning opportunity 32/48 (66.7%), new knowledge 41/49 (83.7%), "zebras" 46/49 (93.9%), and procedural-based 16/46 (34.8%). All 51/51 (100%) of responders reportedly gained new knowledge, 49/51 (96.1%) became more open to group discussion, 34/51 (66.7%) changed search patterns, and 50/51 (98%) would continue to participate. Reported challenges included time zone differences and support from departments for a protected time to participate. CONCLUSION Peer learning through multi-institutional case conferences provides educational and networking opportunities. Current challenges and desires include having department-supported protected time and ability to receive continuing medical education credit.
Collapse
Affiliation(s)
| | - Nelly Tan
- Loma Linda University Medical Center, Loma Linda, California.
| | - Aarti Sekhar
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Lawson ND, Boyd JW. How broad are state physician health program descriptions of physician impairment? Subst Abuse Treat Prev Policy 2018; 13:30. [PMID: 30139369 PMCID: PMC6107949 DOI: 10.1186/s13011-018-0168-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician health program websites in 23 states provide many descriptions of possible physician impairment. This study sought to determine whether these descriptions are so broad that almost everyone might potentially be suspected of being impaired given these descriptions. METHODS The authors randomly selected 25 descriptions of impairment and then presented them anonymously online to members of the general population in full-time employment through Amazon's Mechanical Turk (N = 199). Half of the respondents randomly received a narrowly worded version, and half received a broadly worded version of the survey questions. RESULTS In the narrowly worded version of the survey, 70.9% of respondents endorsed at least one description of impairment, and 59.2% endorsed more than one. In the broadly phrased version, 96.9% endorsed at least one description, and 95.8% endorsed more than one. These respondents endorsed a median of 10 out of 25 (40%) descriptions. CONCLUSIONS These findings call into question whether these descriptions really identify persons with poor performance or who pose a high risk of substantial, imminent harm to self or others in the workplace. They also demonstrate the extent to which these descriptions could potentially be misapplied and brand almost anyone as impaired.
Collapse
Affiliation(s)
- Nicholas D. Lawson
- Georgetown University Law Center, 600 New Jersey Ave NW, Washington, DC, 20001 USA
| | - J. Wesley Boyd
- Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School, 26 Central St, Somerville, MA 02143 USA
| |
Collapse
|
10
|
Vyas D, Cronin S. Peer Review and Surgical Innovation: Robotic Surgery and Its Hurdles. ACTA ACUST UNITED AC 2015; 2:39-44. [PMID: 27517092 DOI: 10.1166/ajrs.2015.1018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The peer review processes as outlined in the Health Care Quality Improvement Act (HCQIA) is meant ensure quality standard of care through a self-policing mechanism by the medical community. This process grants immunity for people filing a peer review, which is meant to protect whistleblowers. However, it also creates a loophole that can be used maliciously to hinder competition. This is accentuated when surgeons are integrating new technologies, such as robotic surgery, into their practice. With more than 2000 da Vinci robots in use and more than 300 new units being shipped each year, robotic surgery has become a mainstay in the surgical field. The applications for robots continue to expand as surgeons discover their expanding capability. We need a better peer review process. That ensures the peer review is void of competitive bias. Peer reviewers need to be familiar with the procedure and the technology. The current process could stymie innovation in the name of competition.
Collapse
Affiliation(s)
- Dinesh Vyas
- Michigan State University College of Human Medicine, Room A-110, East Lansing, MI 48824, USA
| | - Sean Cronin
- Michigan State University College of Human Medicine, Room A-110, East Lansing, MI 48824, USA
| |
Collapse
|
11
|
Shu Q, Cai M, Tao HB, Cheng ZH, Chen J, Hu YH, Li G. What Does a Hospital Survey on Patient Safety Reveal About Patient Safety Culture of Surgical Units Compared With That of Other Units? Medicine (Baltimore) 2015; 94:e1074. [PMID: 26166083 PMCID: PMC4504589 DOI: 10.1097/md.0000000000001074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to examine the strengths and weaknesses of surgical units as compared with other units, and to provide an opportunity to improve patient safety culture in surgical settings by suggesting targeted actions using Hospital Survey on Patient Safety Culture (HSOPSC) investigation.A Hospital Survey on Patient Safety questionnaire was conducted to physicians and nurses in a tertiary hospital in Shandong China. 12 patient safety culture dimensions and 2 outcome variables were measured.A total of 23.5% of respondents came from surgical units, and 76.5% worked in other units. The "overall perceptions of safety" (48.1% vs 40.4%, P < 0.001) and "frequency of events reported" (63.7% vs 60.7%, P = 0.001) of surgical units were higher than those of other units. However, the communication openness (38.7% vs 42.5%, P < 0.001) of surgical units was lower than in other units. Medical workers in surgical units reported more events than those in other units, and more respondents in the surgical units assess "patient safety grade" to be good/excellent. Three dimensions were considered as strengths, whereas 5 other dimensions were considered to be weaknesses in surgical units. Six dimensions have potential to aid in improving events reporting and patient safety grade. Appropriate working times will also contribute to ensuring patient safety. Medical staff with longer years of experience reported more events.Surgical units outperform the nonsurgical ones in overall perception of safety and the number of events reported but underperform in the openness of communication. Four strategies, namely deepening the understanding about patient safety of supervisors, narrowing the communication gap within and across clinical units, recruiting more workers, and employing the event reporting system and building a nonpunitive culture, are recommended to improve patient safety in surgical units in the context of 1 hospital.
Collapse
Affiliation(s)
- Qin Shu
- From the Department of Health Administration (QS, MC, HT, ZC, JC, YH), School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology; and Tongji Hospital (GL), Tongji Medical college, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | | | | | | | | | | | | |
Collapse
|
12
|
Meeks DW, Meyer AND, Rose B, Walker YN, Singh H. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. BMJ Qual Saf 2014; 23:1023-30. [DOI: 10.1136/bmjqs-2014-003239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
13
|
Vyas D, Hozain AE. Clinical peer review in the United States: History, legal development and subsequent abuse. World J Gastroenterol 2014; 20:6357-6363. [PMID: 24914357 PMCID: PMC4047321 DOI: 10.3748/wjg.v20.i21.6357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 04/03/2014] [Indexed: 02/07/2023] Open
Abstract
The Joint Commission on Accreditation requires hospitals to conduct peer review to retain accreditation. Despite the intended purpose of improving quality medical care, the peer review process has suffered several setbacks throughout its tenure. In the 1980s, abuse of peer review for personal economic interest led to a highly publicized multimillion-dollar verdict by the United States Supreme Court against the perpetrating physicians and hospital. The verdict led to decreased physician participation for fear of possible litigation. Believing that peer review was critical to quality medical care, Congress subsequently enacted the Health Care Quality Improvement Act (HCQIA) granting comprehensive legal immunity for peer reviewers to increase participation. While serving its intended goal, HCQIA has also granted peer reviewers significant immunity likely emboldening abuses resulting in Sham Peer Reviews. While legal reform of HCQIA is necessary to reduce sham peer reviews, further measures including the need for standardization of the peer review process alongside external organizational monitoring are critical to improving peer review and reducing the prevalence of sham peer reviews.
Collapse
|
14
|
Brundage M, Foxcroft S, McGowan T, Gutierrez E, Sharpe M, Warde P. A survey of radiation treatment planning peer-review activities in a provincial radiation oncology programme: current practice and future directions. BMJ Open 2013; 3:bmjopen-2013-003241. [PMID: 23903814 PMCID: PMC3731715 DOI: 10.1136/bmjopen-2013-003241] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe current patterns of practice of radiation oncology peer review within a provincial cancer system, identifying barriers and facilitators to its use with the ultimate aim of process improvement. DESIGN A survey of radiation oncology programmes at provincial cancer centres. SETTING All cancer centres within the province of Ontario, Canada (n=14). These are community-based outpatient facilities overseen by Cancer Care Ontario, the provincial cancer agency. PARTICIPANTS A delegate from each radiation oncology programme filled out a single survey based on input from their multidisciplinary team. OUTCOME MEASURES Rated importance of peer review; current utilisation; format of the peer-review process; organisation and timing; case attributes; outcomes of the peer-review process and perceived barriers and facilitators to expanding peer-review processes. RESULTS 14 (100%) centres responded. All rated the importance of peer review as at least 8/10 (10=extremely important). Detection of medical error and improvement of planning processes were the highest rated perceived benefits of peer review (each median 9/10). Six centres (43%) reviewed at least 50% of curative cases; four of these centres (29%) conducted peer review in more than 80% of cases treated with curative intent. Fewer than 20% of cases treated with palliative intent were reviewed in most centres. Five centres (36%) reported usually conducting peer review prior to the initiation of treatment. Five centres (36%) recorded the outcomes of peer review on the medical record. Thirteen centres (93%) planned to expand peer-review activities; a critical mass of radiation oncologists was the most important limiting factor (median 6/10). CONCLUSIONS Radiation oncology peer-review practices can vary even within a cancer system with provincial oversight. The application of guidelines and standards for peer-review processes, and monitoring of implementation and outcomes, will require effective knowledge translation activities.
Collapse
Affiliation(s)
- Michael Brundage
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston General Hospital, Kingston, Ontario, Canada
- Radiation Treatment Program, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Sophie Foxcroft
- Radiation Treatment Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Tom McGowan
- Department of Radiation Oncology, Credit Valley Hospital, Mississauga, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Eric Gutierrez
- Radiation Treatment Program, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Michael Sharpe
- Radiation Treatment Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Padraig Warde
- Radiation Treatment Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Chan LS, Elabiad M, Zheng L, Wagman B, Low G, Chang R, Testa N, Hall SL. A medical staff peer review system in a public teaching hospital--an internal quality improvement tool. J Healthc Qual 2012; 36:37-44. [PMID: 22646743 DOI: 10.1111/j.1945-1474.2012.00208.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system.
Collapse
|
16
|
Is risk-adjusted mortality an indicator of quality of care in general surgery?: a comparison of risk adjustment to peer review. Ann Surg 2010; 252:452-8; discussion 458-9. [PMID: 20739845 DOI: 10.1097/sla.0b013e3181f10a66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE(S) Profiling of hospitals using risk-adjusted mortality rates as a measure of quality is becoming increasingly frequent. We sought to determine the validity of this approach by comparing the risk-adjusted predicted mortality to the findings of concurrent peer review and retrospective chart review of deaths that occur on a general surgery service. METHODS Consecutive patients admitted to a busy general surgery service from January 2000 to January 2006 were prospectively entered into the Surgical Activity Tracking System. Rigorous, systematic peer review was performed concurrently by service members on all deaths. Adjudication was later validated by an independent senior surgeon. Three methodologies of risk adjustment (University Health Consortium, Physiological and Operative Severity Score for the enUmeration of Mortality, and the Charlson index) were used and compared the "excess mortality" predicted by each to the number of potentially preventable deaths determined by peer review. RESULTS A total of 9623 patients were admitted and 75 died (0.7%). University Health Consortium and Physiological and Operative Severity Score predicted an excess mortality of 62 and 65 deaths, respectively; Charlson predicted that 73% of the cohort would be dead in 1 year. Concurrent and retrospective peer review found that death was potentially preventable in only 22 and 21 patients, respectively. CONCLUSIONS Peer adjudication and extensive clinical review adds much to the analysis of an adverse outcome, similar to the "black box" in an airplane crash. Although methods of risk adjustment may be helpful in identifying patients for peer review, they should be used for internal process improvement and not published as metrics of hospital or provider performance.
Collapse
|
17
|
Krous HF, Langston C. The role of the pediatric pathologist as expert witness in a case of neonatal death. Pediatr Dev Pathol 2008; 11:200-5. [PMID: 17990922 DOI: 10.2350/07-04-0258.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 06/05/2007] [Indexed: 11/20/2022]
Abstract
The pediatric pathology literature has given scant attention to expert testimony by physicians in medical malpractice actions that involve infants and children. We report the case of a neonate who died after a brief clinical course characterized by intermittent respiratory distress. The prosecting pathologist's erroneous postmortem diagnoses prompted the infant's mother to sue the attending physician for malpractice. During the course of the litigation, it became clear that the pathologist's testimony was evasive and misleading. After deliberating briefly, the jury ruled in favor of the defendant. Had the plaintiff's attorney obtained a 2nd opinion from another pathologist, preferably a pediatric pathologist, the legal proceedings in this case may have been avoided, thereby averting needless distress for both the plaintiff and defendant, aside from the costs involved. We discuss U.S. Supreme Court rulings pertaining to medical expert testimony and identify remedies to increase just outcomes in cases of medical malpractice.
Collapse
Affiliation(s)
- Henry F Krous
- Rady Children's Hospital-San Diego, San Diego, CA, USA.
| | | |
Collapse
|
18
|
Abstract
Abstract
Context.—Pathologists work in an environment in which, to the extent possible, diagnostic decisions are based on scientific principles. It can therefore be a rather shocking experience when a pathologist finds one of his or her diagnostic decisions being evaluated by a legal system developed and controlled by lawyers and judges rather than by scientists or pathologists. This experience can be even more troubling when a key participant in the proceedings is a fellow pathologist guiding a jury toward an unfamiliar interpretation of the pathology standard of care.
Objective.—To provide the interested pathologist with the background information necessary to (1) understand the role of expert testimony in malpractice litigation and (2) understand why there can be a gap between expert opinions expressed in court and expert opinions expressed in a medical care context.
Data Sources.—Medical literature review supplemented by review of subspecialty position papers, selected articles from newspapers and magazines, and legal decisions. The medical literature review was limited to articles published in English and was based largely on articles retrieved using the MeSH terms expert testimony/legislation & jurisprudence, and pathology/legislation & jurisprudence.
Conclusions.—Medical error has become an increasingly important topic for pathologists, and although errors or allegations of error are evaluated in many ways, the evaluation with the most impact on the individual pathologist is a malpractice case. During the last decade physicians have increasingly become aware of the critical role played by expert testimony in malpractice litigation. Some physicians have asserted that providing expert testimony is the practice of medicine, and that it is unacceptable for juries to be presented with expert testimony that incorrectly describes medical practice standards. However, this opinion has been vigorously opposed by attorneys who feel that juries are best able to come to a correct conclusion if they base their deliberations on a broad spectrum of opinion. Gaining an increased role in the oversight of expert testimony would allow physicians to establish a closer alignment between opinions expressed in court testimony and opinions expressed in clinical practice. However, despite some physician success in inserting themselves into the oversight process, both physicians and physician organizations attempting to take action against misleading expert testimony continue to be vulnerable to legal attack.
Collapse
|
19
|
Alfaro V. Aspectos generales en la redacción de artículos científicos y consideraciones prácticas en el ámbito de la Oncología. Clin Transl Oncol 2004. [DOI: 10.1007/bf02711727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|