In my last column, I outlined a path to promote a blame-free culture of safety in which self-reporting of adverse events, near misses, and hazardous conditions can lead to learning from defects and real improvement. I again noted that the dysfunctional, outmoded QA Model for clinical peer review poses a major barrier to such progress and must be replaced with the QI Model. Nonetheless, it’s good to understand the history of the QA Model and the forces that shaped it, particularly in this time of rapid healthcare regulatory change. As George Santayana observed, "Those who cannot remember the past are condemned to repeat it."
The QA Model has dominated medicine for 30 years. Enough time has passed for the current generation of physicians to believe that the model is sacrosanct: “It’s the way we’ve always done it and the way it should be done.” The medical profession has, however, used other methods. Peer review has been documented as early as the 11th century and may have originated in ancient Greece. Modern practice emerged from Codman’s End Results System and Ponton’s concept of Medical Audit.
After WWI, the American College of Surgeons (ACS) succeeded in promoting national standards for hospitals. The Joint Commission (JC) followed the ACS in this role from 1952. Medicare legislation, enacted in 1964, was a boon to the JC, because the conditions for hospital participation required a credible medical care review program and the regulations stipulated that JC accreditation would guarantee payment eligibility. What was once a sporadic process became hardwired in most hospitals following the Audit Model.
Medical Audit, which remains the predominant mode of peer review in Europe, is a focused study of the process and/or outcomes of care for a specified patient cohort using pre-defined criteria. Audits are typically organized around a diagnosis, procedure or clinical situation. One older example of an audit project to evaluate the quality of medical records anticipates many aspects of the QI Model.(1)
In the 70s, however, the widespread creation of new programs was hampered by limitations in the available process models, tools, training, and implementation support. The lack of perceived effectiveness of Medical Audit led to revisions of Joint Commission standards in 1979. Those modified standards dispensed with the audit requirement and called for an organized system of Quality Assurance (QA). About the same time, hospitals and physicians were facing escalating malpractice insurance costs. In response to these combined pressures, they began to adopt “generic screens” for potential substandard care (hospital readmission, death, return to OR, etc.). These screens were originally developed to evaluate the feasibility of a no-fault medical malpractice insurance plan and were never validated as a tool to improve quality of care. Despite warnings from the developers, their use became widespread.(2) In the process, a QA Model for peer review evolved with a narrow, legalistic focus on the question of whether or not the standard of care had been met. It has persisted despite the longstanding criticisms of its methods and effectiveness.
With this background, we can move on to get a solid understanding of the QI Model for clinical peer review.
Marc T. Edwards, MD, MBA
President & CEO
QA to QI
An AHRQ Listed Patient Safety Organization