The Quick Take

  • Replaced standard of care-focused assessment with cause analysis
  • Replaced inquiries of involved clinicians with consultation
  • Included all members of the care team
  • Focused on preventing patient harm
  • Characterized physician errors using the AHRQ patient safety glossary

The Innovation

In 2007, the Quality Improvement Executive Committee (QIEC) at our hospital undertook a major change in peer review process following realization that our longstanding focus on standard of care was not succeeding to fulfill our mandate to improve the quality and safety of care. Although the old program satisfactorily supported credentialing activity, it put physicians on the defensive, ignored system of care issues, and limited our ability to identify remediable causes. Moreover, the threatening nature of the process inhibited the medical staff from reporting adverse events, near misses and unsafe conditions. It took us 4-5 months to develop the new process.

The revised program sought to create a blame-free environment by soliciting input from the physicians and nurses who were involved as identified from a preliminary review of the case. A physician member of the committee interviewed the physicians and a nurse member interviewed the nurses. We routinely sent letters inviting these individuals to a private interview, respectfully addressing them as “experts” whose assistance was needed for insight into the events being analyzed to prevent future patient harm. We focused on the identification and classification of errors based on a human factors model, by seeking to learn as much as we could about the circumstances contributing to the event. We were respectful in our approach and avoided asking intimidating questions, like “Why didn’t you …?” No one refused to participate.

The results of the interviews were presented to the full committee in an effort to reconstruct the event scenario. In deliberating the case, we sought to develop recommendations to prevent a recurrence and to identify providers who may have made an error. We did not use a review form and did not otherwise evaluate or score physician performance. All interviewed providers received a letter of appreciation for their participation in the process. We provided detailed individualized feedback to providers who had made errors via educational letters. Providers with repetitive errors underwent a focused review of quality involving a look at multiple cases.

Our committee of 12 members included the Chief Operating Officer, the nursing director, and representatives from the major medical staff departments. The quality manager, medical staff services manager, risk manager and hospital attorney also attended. We met monthly for 1-2 hours. In general, only nurses gave input regarding the clinical performance of nurses and only physicians gave input about physicians. Cases were identified for review via our Quantros analytic system, incident reports and as a by-product of chart reviews conducted by our Quality Department for other purposes. These cases were screened by the Quality Manager and the Chair or Vice-Chair of the QIEC. In 2008, the second year of the program, out of about 200 cases referred to the QIEC, roughly 50 were reviewed by the full committee. The 50 cases represent about 0.5% of our annual inpatient volume.

The Impact

The second year of our cause analysis process produced the following results:

  • 3 educational programs were made by clinical departments for their membership, one each in the ED, Radiology and Ob-Gyn.
  • 2 educational mailings to the medical staff: one addressed situational awareness and the other addressed the risk of respiratory depression with narcotics.
  • 5 system of care process improvement projects:
    • Interfaced with the occupational trauma committee to revisit the policy of admitting multiple trauma cases to primary care
    • Interfaced with the Credentials Committee for clarification of Doppler imaging privileges being granted to ED physicians
    • Improved administrative systems for physician notification of abnormal test results
    • Revised guidelines for ICU bed assignment
    • Mandated a vital sign re-check in all ED patients at the time of discharge or transfer
  • Multiple educational interventions for individual physicians and nurses.
  • 2 focused reviews were conducted. Both resulted in recommendations to the credentials committee.

Lessons Learned

While the new program did everything that we hoped to accomplish, we learned the hard way that failure to get input and buy-in from all stakeholders has its consequences. The Credentials Committee was dissatisfied by the absence of grading during the cause analysis of cases and successfully influenced the Medical Executive Committee to mandate a return to the old format in 2009. Had we included some physician-attributable measures clinical performance in each review, this might not have happened. In retrospect, this could have been done without compromising our goal of a non-punitive process.


Marc Flitter, MD


Chairman, QIEC 2007-9

San Juan Regional Medical Center

Farmington, NM