Clinical Peer Review Research

Evidence-Based Tools for Healthcare Improvement

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Commitment to Advancing Knowledge and Practice

From 2007 through 2018, I donated substantial time and resources to conduct research and report on best practices in clinical peer review in the pursuit of quality and patient safety. This area has largely been neglected by academia.

Promoting Adoption of Best Practices

• Clinical Peer Review Program Self-Assessment Inventory
• Ideal Clinical Peer Review Process Collaborative
• Normative Peer Review Database Project
• Clinical Peer Review Innovation Showcase: Case Studies in Program Improvement

Scientific Publications

• Giardino AP, Edwards MT. (2021) The Interface Between Quality Improvement, Law, and Medical Ethics. in Giardino, AP, Varkey, P, eds. Medical Quality Management: Theory and Practice, 3rd edition. Springer, Cham. (published Online First September 1, 2020) doi:10.1007/978-3-030-48080-6_11
• Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in U.S. Hospitals. Am J Med Qual. 2018;33(5):502-508 (published Online First: April 16, 2018) doi:10.1177/1062860618768057. Author's Version; Request Preprint
  • Abstract
    In pursuit of high reliability, numerous organizations have promoted Just Culture, but its impact has never been assessed. This report combines data from a longitudinal survey-based study of clinical peer review practices in a cohort of 457 acute care hospitals with 43 measures from the Hospital Compare database and interprets them in relation to the long term trends of AHRQ data on the Hospital Survey of Patient Safety Culture. 211 of 270 respondents (79%) indicated their hospital has adopted Just Culture. Over half believe it has had a positive impact. Just Culture implementation and its degree of impact are associated with somewhat better peer review process, but not with objective measures of hospital performance. Non-Punitive Response to Error has consistently been the lowest scoring category (45% positive) in the AHRQ database. Widespread adoption of Just Culture has not reduced reluctance to report or the culture of blame which it targets.
• Edwards MT. In Pursuit of Quality and Safety: an Eight-Year Study of Clinical Peer Review Best Practices in U.S. Hospitals. Int J Qual Health Care. 2018;30(8):602-607 (published Online First: April 9, 2018) doi:10.1093/intqhc/mzy069. Request Preprint
  • Abstract
    Objectives: Gather normative data on the goals of clinical peer review; refine a best practice model and related self-assessment inventory; identify the interval progress towards best practice adoption.
    Design: Online survey (2015-16) of a cohort of 457 programs first studied by volunteer sampling in either 2007 or 2009 on 40 items assessing the degree of conformance to a validated Quality Improvement (QI) model and addressing program goals, structure, process, governance, and impact on quality and safety.
    Setting: Acute care hospitals of all sizes in the U.S.
    Study Participants: Physician and hospital leaders or hospital staff with intimate program knowledge
    Intervention: None
    Main Outcome Measures: Program impact on quality and safety; QI model score.
    Results: 270 responses (59% response rate) showed that clinical peer review most commonly aims to improve quality and safety. From 2007-2015, the median [IQR] annual rate of major program change was 20% [11-24%]. Mean [CI] QI model scores increased 5.6 [2.9-8.3] points from 46.2 at study entry. Only 35% scored at least 60 of 80 possible points—“C” level progress in adopting the QI model. The analysis supports expansion of the QI model and an associated self-evaluation inventory to include 20 items on a 100 point scale for which a 10 point increase predicts a one level improvement in quality impact with an odds ratio [CI] of 2.5 [2.2-3.0].
    Conclusions: Hospital and physician leaders could potentially accelerate progress in quality and safety by revisiting their clinical peer review practices in light of the evidence-based QI model.
    Keywords: clinical peer review; best practices; quality improvement; hospitals
• Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2017;32(2):148-55 (published Online First: February 25, 2016) doi:10.1177/1062860616632295. Request Reprint
  • Abstract
    Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This manuscript presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the under-developed modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.
• Edwards MT. A Longitudinal Study of Clinical Peer Review's Impact on Quality and Safety in US Hospitals. J Healthcare Manage 2013;58(5):369-384. Reprint Orders; Online-only Supplement
  • Abstract
    Clinical peer review is the dominant method of event analysis in US 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.
• Edwards MT. Engaging Physicians in Patient Safety through Self-Reporting of Adverse Events. Physician Exec. 2012;38(4):46-52. Request Reprint
• Edwards MT. Minimizing Bias in Clinical Peer Review. Physician Exec. 2011;37(6):50-54. Request Reprint
• Edwards MT. The Objective Impact of Clinical Peer Review on Quality of Care. Am J Med Qual. 2011;26(2):110-119. The final definitive version is available online at: http://ajm.sagepub.com/content/26/2/110.short; see the press release; Request Postprint
  • Abstract
    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. The final definitive version is available online at: http://ajm.sagepub.com/content/25/6/474.abstract; Request Postprint
  • Abstract
    Prior research has shown wide variation in clinical peer review program structure, process, governance and perceived effectiveness. This study sought to validate the utility of 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.
• Edwards MT. Measuring Clinical Performance. Physician Exec. 2009;35(6):40-43. Request Reprint
• Edwards MT. Peer Review: A New Tool for Quality Improvement. Physician Exec. 2009;35(5):54-59. Request Reprint
• Edwards MT, Benjamin EM. The Process of Peer Review in US Hospitals. J Clin Outcomes Manage. 2009(Oct);16(10):461-467.
• Edwards Mt, Zimet CN, Problems and concerns among medical students- 1975. J Med Educ 1976;51:619-625.

Annotated Bibliographies

• Clinical Peer Review Program-Specific Reports
• Clinical Peer Review Methodological Studies
• Anesthesiology Clinical Peer Review

Links

• Marc T. Edwards on ResearchGate
• Clinical Peer Review Process Improvement Resources
• Clinical Peer Review Innovation Showcase
• The QI Model
• The History of the QA Model
• Clinical Peer Review Program Self-Assessment Inventory
• Normative Peer Review Database Project
• Ideal Peer Review Process Collaborative
• The Peer Review Enhancement Program^SM

• Evidence-Based Answers

  • Optimal Case Review Volume
  • Pre-Review Screening
  • Centralization of Peer Review
  • Non-Physician Medical Staff Peer Review
  • Morbidity & Mortality Conferences
  • Ongoing Professional Practice Evaluation

• Whitepapers

  • Measuring Clinical Performance
  • The Peer Review Improvement Opportunity
  • Reflections on Medical Staff Bylaws
  • Minimizing Bias in Clinical Peer Review
  • Engaging Physicians in Patient Safety
  • A Framework for Patient Safety

• Patient Safety Newsletters

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© 2012-25 Marc T. Edwards

QA to QI Consulting Last modified: August 29, 2025