The History of the QA Model for Clinical Peer Review

Most physicians practicing today are too young to remember the major shifts which occurred in clinical peer review practice in the ‘70s that gave rise to the dysfunctional QA Model. Thus, it’s instructive to review the history.

Prior to World War I, Codman pioneered his end results system of self-reporting.(1) Soon thereafter, Ponton proposed a criteria-based audit model for peer review that followed the development of accounting practices in US industry.(2) These ideas informed the subsequent work of the Anesthesia Study Commissions (3), Butler and Quinlan (4), Lembcke (5), and Williamson.(6) Despite these efforts, hospital medical staffs were slow to adopt clinical peer review processes.

With the advent of Medicare in 1964, hospitals were required to have a medical review program as a condition of participation. The programs were expected to address both cost and quality through utilization review and medical care evaluation studies (process-oriented medical audit). In 1972, in the face of rapidly escalating Medicare costs, congress established a provider-based PSRO program to further promote medical audit.(7) The Joint Commission promulgated an analogous standard requiring medical audit. Since Joint Commission accreditation guaranteed payment eligibility, hospitals and their medical staffs rushed to implement these new programs.

Those efforts were hampered by limitations in the available process models, tools, training, and support.(8) They failed to control costs. As a result, Congress replaced PSROs with the PRO program. In 1979, the Joint Commission dropped the medical audit requirement in favor of standards which called for an organized program of Quality Assurance. About the same time, the first malpractice insurance crisis led hospitals to build risk management programs. They commonly adopted the generic screens for substandard care developed for the California Medical Insurance Feasibility Study, notwithstanding the lack of validation for that purpose.(9)

The resulting legalistic focus on substandard care and malpractice risk set the stage for a clinical peer review process focused on outlier identification and management. The idea of raising the overall standard of practice articulated by Butler and Quinlan was subsequently lost. The full implications of labeling outliers then took hold in relation to credentialing standards, giving rise to the confusion between evaluating performance and determining competence. This made peer review decision-making a high-stakes, threatening game. When hospitals tried to exit the game, the risk of vicarious malpractice liability pulled them back in. Thus arose the QA Model for peer review.

  1. Codman EA. A Study in Hospital Efficiency. Boston, MA: T Todd Company; 1917.
  2. Ponton TR, Gauging efficiency of hospital and its staff. Mod Hosp. 1928;31(Aug):64-68.
  3. Ruth HS. Anesthesia study commissions. JAMA. 1945;127(8):514-517.
  4. Butler JJ, Quinlan JW. Internal audit in the department of medicine of a community hospital: Two years’ experience. JAMA. 1958;167(5):567-572.
  5. Lembcke PA. Evolution of the medical audit. JAMA. 1967;199(8):111-118.
  6. Williamson JW. Evaluating quality of patient care: a strategy relating outcome and process assessment. JAMA. 1971;218(4):564-69.
  7. Dershewitz RA, Gross RJ. Why medical audits are in disfavor. Arch Int Med. 1980;140(2):168-169.
  8. Legge D. Peer review in the USA: an historical perspective. Med J Aust. 1981;1:709-711.
  9. Sanazaro PJ, Mills DH. A critique of the use of generic screening in quality assessment. JAMA. 1991;265(15):1977-1981.