Quality, Safety and Clinical Peer Review

12/18/2010 - When doctors do clinical peer review using new methods, hospitalized patients benefit from safer care. A recent study released online by the American Journal of Medical Quality, the first of its kind, also shows that few are using these methods. According to the study’s author, Marc T. Edwards, MD, MBA, a healthcare consultant from West Hartford, CT, it’s a problem of inertia. Although the required changes are both desirable and relatively easy, physicians are struggling against a 30-year legacy of dysfunctional practice.

In the new model, physicians evaluate each other’s performance using the same Quality Improvement (QI) principles that have served well elsewhere in medicine and in other fields. Dr. Edwards notes, “Medical care is complex. It requires coordination of many professional disciplines and lots of information. We’ve learned that this system of care is itself the source of many errors. The QI Model recognizes this. When clinical peer review focuses on learning instead of casting blame, problems get fixed.”

Dr. Edwards has put resources into the public domain to assist physician leaders with program changes including a self-evaluation tool available at https://qatoqi.com/php/set.php. A second article published in the November issue of the American Journal of Medical Quality demonstrates the value of this tool and offers practical recommendations for improvement. The old method of clinical peer review is a narrow extension of the activity that hospitals are required to perform to assure they have a competent medical staff. It focuses only on the physician and ignores the system. It is perceived as threatening. "Everybody expects their doctor to be competent, but nobody wants a complication or injury to result from their medical care. Doctors don’t become incompetent overnight unless they have a major health event like a stroke that is obvious to everyone. Good physicians can have bad outcomes, often from circumstances beyond their immediate control. It’s not helpful to cast blame."

The study compared standardized measures of quality and safety from nearly 300 acute care hospitals to information on peer review process provided by members of the American College of Physician Executives. HealthGrades, Premier CareScience and Thomson Reuters contributed their proprietary data on quality and safety. “I could not have done this study without the full cooperation of these organizations. I am particularly indebted to Dr. Harold Taylor of HealthGrades, Dr. Eugene Kroch of Premier CareScience and Dr. David Foster of Thomson Reuters who provided invaluable technical assistance and insights.

Dr. Edwards believes more attention is needed to identifying best practices for clinical peer review. “We now know that many hospitals need to apply quality improvement principles to their peer review processes. There is a lot of variation in the organization and character of hospitals in this country. We have a good idea of the general formula for improving peer review, but we have much to learn about the specifics of making such changes effective in all these different places. For this reason, I have launched the non-commercial Normative Database Project to accelerate collective learning. It’s a natural extension of my mission in running a Patient Safety Organization and in doing operations research related to clinical peer review.”

The Normative Database Project aims to correlate peer review processes and outcomes across many facilities to better evaluate what works best. Those hospitals that contribute program data will receive performance norms and benchmarks not otherwise available, and will help advance collective knowledge. Details of the project are available at http://QAtoQI.com/proj_normative_database.htm.

QA to QI Consulting

Marc T. Edwards, MD, MBA is President and CEO of QA to QI Consulting. He operates a Listed Patient Safety Organization, markets clinical peer review program management software, and assists clients to make improvements in quality, safety and resource use. For additional information, visit https://qatoqi.com/bio.htm or contact him directly: marc@qatoqi.com; 860.521.8484.

QA to QI LLC dba QA to QI Consulting (West Hartford, CT; www.QAtoQI.com) specializes in the development of evidence-based tools for healthcare improvement through operations research.


Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2010; published online before print December 15, doi: 10.1177/1062860610380732. Print version 2011;26(2):110-119. http://ajm.sagepub.com/content/26/2/110.short

Despite its importance, the objective impact of clinical peer review on the quality and safety of care has not been studied. Data from 296 acute care hospitals show that peer review program and related organizational factors can explain up to 18% of the variation in standardized measures of quality and patient safety. The majority of programs rely on an outmoded and dysfunctional process model. Adoption of best practices informed by continuing study of peer review program effectiveness has potential to significantly improve patient outcomes.

Edwards MT. Clinical peer review program self-evaluation for US hospitals. Am J Med Qual. 2010; 25(6):474-480. http://ajm.sagepub.com/content/25/6/474

Prior research has shown wide variation in clinical peer review program structure, process, governance and perceived effectiveness. This study sought to validate the utility o f a Peer Review Program Self-Evaluation Tool as a potential guide to physician and hospital leaders seeking greater program value. Data from 330 hospitals show that the Total Score from the Self-Evaluation Tool is strongly associated with perceived quality impact. Organizational culture also plays a significant role. When controlling for these factors, there was no evidence of benefit from a multi-specialty review process. Physicians do not generally use reliable methods to measure clinical performance. A high rate of change since 2007 has not produced much improvement. The Peer Review Program Self-Evaluation Tool reliably differentiates hospitals along a continuum of perceived program performance. The full potential of peer review as a process for improving the quality and safety of care has yet to be realized.