Hospitals Still Struggling with Barriers to High Reliability

10/1/2013 - At a time when most hospitals are struggling with cultural barriers to safety and high-reliability, the full report of findings from the Longitudinal Clinical Peer Review Effectiveness Study, conducted by Dr. Marc Edwards of QA to QI LLC: A Patient Safety Organization, is featured in the September/October issue of the Journal of Healthcare Management and puts forward a practical solution. The study showed that four of every five hospitals have substantial room for improvement in peer review program structure, process and/or governance. Dr. Edwards expressed his delight that his article was accepted by JHM. "It puts the information in front of the right audience to take the needed action."

The study validated and extended the the best practice QI model for clinical peer review, which stands in stark contrast to the out-moded, dysfunctional QA model that continues to dominate practice and poisons efforts to improve safety. The QI model is associated not only with greater quality and safety, but also with superior physician engagement and better physician-hospital relations. Very little progress has been made in adopting the QI model since it was first identified.

The study was the first to demonstrate that self-reporting of adverse events, near misses and hazardous conditions – a practice proven to enhance safety in the aviation industry, an exemplar for high reliability – is beginning to be embraced in healthcare and is producing the expected results. According to Dr. Edwards, "These results also have important implications for nursing practice, regardless of whether a formal nursing peer review program is in place. Nursing is plagued by the same punitive culture that affects physicians."

Hospital and physician leaders can quickly and easily evaluate their peer review process with an online tool first published in 2009 that has been updated to reflect the results of the current study. The results can be used to help communicate the need for change and to track progress with improvement efforts.

Marc T. Edwards

Marc T. Edwards, MD, MBA is President and CEO of QA to QI LLC. He operates a Patient Safety Organization, conducts research in healthcare operations improvement, markets clinical peer review program management software, and assists clients to make improvements in quality, safety and resource use. For additional information, visit or contact him directly:; 860.521.8484.

QA to QI LLC: A Patient Safety Organization (West Hartford, CT; specializes in the development of evidence-based tools for healthcare improvement through operations research.

Article Citation

Edwards MT. A Longitudinal Study of Clinical Peer Review's Impact on Quality and Safety in U.S. Hospitals. J Healthcare Manage 2013;58(5):369-384. Reprints; Online-only Supplement

Article Abstract

Clinical peer review is the dominant method of event analysis in U.S. hospitals. It is pivotal to medical staff efforts to improve quality and safety, yet the Quality Assurance process model that has prevailed for the past 30 years evokes fear and is fundamentally antithetical to a culture of safety. Two prior national studies characterized a quality improvement model that corrects this dysfunction, but failed to demonstrate progress towards its adoption despite a high rate of program change between 2007 and 2009. This study's online survey of 470 organizations participating in either prior study further assessed relationships between program factors, including the degree of conformance to the quality improvement model (the QI model score), and subjectively measured program impact variables. Among the 300 hospitals that responded (64%), the median QI model score was only 60 on a 100 point scale. Scores increased somewhat for the 2007 cohort (mean pair-wise difference of 5.9 [2 - 10]), but not for the 2009 cohort. The QI model is expanded as a result of the finding that self-reporting of adverse events, near misses and hazardous conditions –  an essential practice in high-reliability organizations - is no longer rare in hospitals. Self-reporting and the quality of case review are additional multivariate predictors of the perceived ongoing impact of clinical peer review on quality and safety, medical staff perceptions of the program, and medical staff engagement in quality and safety initiatives. Hospital leaders and trustees who seek to improve patient outcomes should facilitate the adoption of this best practice model for clinical peer review.