The Quick Take

  • Combined Clinical Peer Review and Quality Improvement into a single interdisciplinary committee
  • Included diverse members of the care team
  • Integrated intense analysis and clinical peer review
  • Integrated the Credentials Committee and the Peer Review/Quality Committee
  • Initiated conversations with other Critical Access Hospitals (CAH) and small hospitals regarding external peer review

The Innovation

Starting in late 2008, we began collegial conversations both within our 25-bed CAH, other CAH’s, small hospitals and other medical organizations over issues regarding how to best conduct peer review in a small hospital setting. Early in this process we were challenged by a physician reviewer from the Maine Hospital Board of Licensure to ask: “What have we learned from peer review?” In addition we were challenged: “If you find a problem, what have you done to fix it?” It quickly became clear that peer review was not going to be effective unless it is intimately connected with the quality improvement process.

At that point in time in our hospital sentinel event and intense analysis were done by nursing with minimal input from physicians. The focus was on the system’s issues as opposed to individual accountability. Peer review was done using conventional generic screens for sub-standard care and the low yield of improvement opportunities made us question the value of the exercise.

External peer review had been accomplished through a program of the Maine Medical Association for many years. There was a need for revaluation of that program to increase flexibility in its use. We started by looking at strategies for greater cooperation among the 16 CAHs in our state as well as other small hospitals.

At my own institution, peer review had previously been performed in section meetings of our non-departmentalized staff. A study group of the medical staff, decided to recommend a single committee responsible for interdepartmental peer review with input from nursing and administration. We also elected to have the chair of the Peer Review Committee and the Chair of the Credentials Committee sit on each other’s committee.

We now have a functioning interdisciplinary Peer Review/Quality Committee. The committee consists of physician or PA representation from each of the sections: Adult Medicine, Pediatrics, OR, Anesthesia, Maternal Health and the ED. This is the only committee of which the medical staff members must be elected by the medical staff as a whole. Ex-officio members include the Medical Director, Director of Nursing, Director of support services (who manages the complaints process and coordinates the quality processes), the Director of the Medical Staff Office, and the CEO.

Guidelines at the top of each agenda remind us that the goals are: “Continuous Improvement towards Excellence in Medical Care” and “To Improve Team Function.” Cases are identified through referral from providers, concerns raised by other hospital staff, complaints or non-compliance with indicators. Each case is reviewed by a committee member and a judgment is made about the level of care provided. If a case is found to represent less than appropriate care the provider is offered an opportunity to respond to the initial review. These latter cases have almost universally undergone a review by nursing of the systems issues. These cases are then discussed by the Peer Review Committee, looking at the individual provider’s role as well as the system of care around the particular case.

Our annual inpatient volumes are 2300. Prior to this process about 5% of all cases were reviewed. At this time about 1.5% of cases are reviewed. Meetings are monthly, scheduled for an hour. As we have started this we need to have additional meetings on almost a monthly basis.

In addition this committee is responsible for supporting the section committees in selecting indicators as well as holding them accountable for the indicator performance and follow up on QI issues which flow from the work of this committee (see below).

The Impact

The major impact of the process involved in setting up this committee and its work has been cultural change. We have discussed four accountabilities. The first is the provider’s accountability to their patients. The second is accountability to each other as professionals. The third is the accountability of the medical staff as an organization to the board and the community for quality of medical care. The fourth is the accountability of the administration to the medical staff and the board for providing the necessary support to the process of quality. The medical staff as a whole has a much clearer picture and sense of ownership of these accountabilities.

Interestingly we are now reviewing about a third of the number of cases we previously reviewed, but in much more detail and finding issues which require improvement processes. Not surprisingly communication and documentation are common problems. These are linked to a team building process in which we are engaged at the hospital level.

We have generated a table to monitor the progress of committees on the projects we have asked them to address. There are about 20 systems issues that we have identified in less than a year.

We are also developing greater clarity on the need to standardize processes especially where they cross multiple departments. Since this work comes from the medical staff itself as opposed to external ‘forces’ there is more ownership.

Lessons Learned

The first observation is that the interdisciplinary discussions, including non-physicians, has brought an amazing depth and breadth to the case discussions. It seems to make it easier to call a spade a spade in a small institution. The presence of the perspective of non-provider members brings a needed dimension to the discussions: for instance, our quality person saying, “That’s all well and good, but the patient says this played out very differently.”

Most of the issues turn out to be non-technical. They are about communication, team function and responsiveness, or reflect general medical issues.

Since the committee has responsibility for overseeing all the hospital quality initiatives, it has become much easier to recognize the broader quality issues involved in any given case under consideration. In addition the committee pushes QI issues back to the section committees that are identified through its work.

We are wrestling with spread of the learning from these cases and will be putting out a briefing from the committee of lessons learned on a quarterly basis.

We are starting a process with regard to indicators which we have used with core privileging, of seeking input from each of our specialty committees. The purpose, which seems to be working with the core privileging, is to engage and create ownership from the whole staff in these responsibilities.

We are also requiring indicators from the outpatient practices which are hospital based. We are blessed with a base of collegiality which allows us do this in the context of QI processes which include independent practices.

External peer review continues to be an interesting process. At the present time, this is a collaborative effort between the Maine Medical Association, the Maine Office of Rural Health, the Maine Hospital Association and an advisory committee consisting of providers representing the medical staff of a number of Maine Hospitals. There has even been interest and participation form larger hospitals. There is a great deal of discussion around the need to improve the quality of peer review within the involved organizations and sharing of ideas between them. At our institution individuals undergoing peer review have the option of requesting external peer review.

So after a lot of work getting to the roll out, we seem to be moving in the right direction. The link between peer review and QI is the carrot that gets buy-in and supports cultural change. We are constantly learning about the process and adjusting, but we seem to have a solid foundation and the medical staff has embraced the challenge.


Roger A. Renfrew, MD, FACP

Medical Director

Redington Medical Physician Practices

Redington Fairview General Hospital

Skowhegan, ME