An Invitation to Give and Get


With so much room for improvement in clinical peer review process, comes a need for better information.

My 2009 national study, sponsored by the ACPE, looked at the utility of the Peer Review Program Self-Evaluation Tool and at relationships between specific peer review program parameters and objectively measured hospital quality and safety.

Thomson Reuters, Premier CareScience, and HealthGrades all graciously contributed their measures, which were used along with the CMS Health Compare dataset.

As important as these measures are, they have limitations. Most critically, they are not timely.

It takes roughly 3 years of mortality and morbidity data to produce stable comparative measures. The initial report from the 2009 ACPE Peer Review Outcomes Study was based on 2005-2007 performance measures. I will be re-iterating the analysis when 2007-2009 data becomes available this spring. The relationships so discovered offer a useful snapshot of where we have been. Nevertheless, such measures will not serve well to iteratively guide ongoing tests of change in peer review processes. Moreover, my research confirms that many programs have not thought it important to track process and outcomes measures from peer review.

The Problem Creates an Opportunity

In order to take the QI Model to the next level, we'll need timely data on what a variety of programs are actually doing along with the results. Since measurement is integral to process improvement, contribution to this Normative Database creates a win-win. When you measure peer review process and outcomes, you will strengthen your ability to improve the process. Your contribution will return useful benchmarking information and support ongoing research on best practices.

  • The measures are simple. They do not require release of sensitive information. Confidentiality is assured.
  • Participation is free. You may join or withdraw at any time.
  • Participants submit program measures semi-annually and complete a program information report annually.
  • You do not need to submit all measures. As long as you submit the minimum required measures and complete the annual program information report, you will receive normative data reports.
  • All data will be treated and secured in the same manner as the Patient Safety Work Product, which may be included (see below). Only aggregate data will be disclosed in reports and scientific publications. Organization identities will not be disclosed.
  • In time, if there is interest in being able to contact leaders at high-performing organizations, we may make such disclosures with written consent.
  • Submitted data will be used only for the purpose of the Normative Database Project and publication of scientific articles. It will not be returned. It will eventually be destroyed or de-identified.

Organization vs. Department-Level Reporting

A number of physician leaders have expressed interest in department-level information (e.g., Surgery, Oncology, Anesthesia). We will accept un-stratified organization-wide data and data stratified by department/service. We will also accept isolated department/service data with the understanding that normative reports might not be available until an adequate threshold of comparative data is reached.

Scope of Measures

  • System/process issues identified
  • Other outcomes of peer review
  • Case volume
  • Turn around times
  • Case identification
  • Pre-review screening activity
  • etc.

See Data Definitions

Share Data Semi-Annually

  • Transmit simple reports electronically, using appropriate security precautions
  • PREP-MSTM users can simply share a backend database snapshot electronically

Receive Reports

  • Normative reports with benchmarks for peer review process and outcomes
  • Answers to questions

Contact Us for More Information