Editor’s Note: Marc Edwards is a physician and healthcare consultant. The activity of his PSO complements ours. He has done 2 national studies of clinical peer review practices and published multiple related articles. Beginning this issue, we’ll regularly feature his column: From QA to QI. We hope that it will bring you fresh insights for improving quality and patient safety in your facility.
Sometimes you have to test your assumptions to find the real opportunity for improving quality and safety. Let me share my own story.
Once upon a time, I was called to help a community hospital with a quality turn-around. Two years prior, it had been hammered by the Joint Commission with 51 type 1 citations (remember those?). The quality-minded medical staff had called for the CEO to resign, but the Board maintained support in gratitude for having recently saved the facility from bankruptcy. When the CEO committed to invest energy in quality of care and revenue growth, rather than expense reduction, the parties were able to reconcile. Even so, much work remained to be done.
Early on, I helped them map out a path to re-invigorate quality improvement activity. In one whiteboard chat with physician leaders, I illustrated how the various committees could be optimally realigned to support the effort. When I got to the point of describing my recommendations for the medical staff organization, I said, “And we’ll put a firewall here to isolate medical staff peer review activity from our QI work. We don’t want that old-fashioned finger-pointing QA [Quality Assurance] stuff to contaminate our efforts to drive out fear on the QI side.”
I wish you had been in the room with us. It was like the famous Uncle Remus story where Br’er Rabbit when caught by the fox says, “Do what you will with me Br’er Fox, but whatever you do … PLEASE DON’T THROW ME IN THAT BRIAR PATCH.” Whence forth, the fox throws the rabbit in the briar batch only to find that he just let the rabbit escape. Almost as reflexively, the docs responded, “So, Marc … What would it look like if peer review was done like QI instead of QA?” For me, it was a pure “Aha!” moment. Maybe we didn’t have to it the way that physicians had been doing it for 30 years – the way that I assumed we would always do it.
With that, we took out a blank sheet of paper and started to design an alternative. When piloted in the department of medicine, it was so overwhelmingly successful in engaging physicians in clinical improvement and eliminating defensiveness to educational feedback, that the physician leadership pushed it on all the other departments.
That was the beginning of my obsession with the challenge. In my subsequent work with this and other clients, it turned out that there was still much to learn about how to go from QA to QI.
Marc T. Edwards, MD, MBA
President & CEO
QA to QI
An AHRQ Listed Patient Safety Organization