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Quality Assurance and Peer Review
byx LA W R EN C Ex M.x S H U E R
Medical errors have received a great deal of attention nationally and even locally. The New York Times announced on the front page last month that President Clinton is launching a major initiative to reduce errors in the nation's hospitals. More locally, our own medical staff president, Marty Bronk, discussed in his Medical Staff Update column last month the dilemma of maintaining efficacy and safety in the face of pressures to cut costs.
In this hospital, medical errors are treated in the context of our peer review process. I believe this process is ahead of the curve in terms of ensuring maximum patient safety and satisfying the concerns of regulatory agencies. In recent years we have developed a care review process that emphasizes quality improvement through deliberation rather than through fingerpointing - through data collection, and education, rather than policing.
I think it's helpful to see how this useful process evolved.
Until two years ago, we asked all 11 clinical services to report the degree of deviation from the norms of practice, using a scale of 1 to 4. This was tantamount to a grade and tended to put the practitioner on the defensive, while focsing the discussion rather narrowly. The prevailing process was if someone thought a doctor made a mistake, he or she got "written up." Discussions tended to be punitive, focusing not on how to constructively make corrections, but on whether the doctor's judgment was a "D" or an "E."
Now, the process begins in individual services and the triggers are diverse. For example, in neurosurgery we require review of any case with a death, an unexpected outcome, an infection, a new neurologic deficit or an unplanned return to the operating room. Attending physicians may initiate cases if they have questions or concerns. Patient complaints also are reviewed.
Individual services review the cases at their local peer review conferences. The questions currently assessed in each case are:
1)
Does the case represent a deviation from the standard of care for this
patient population?
2)
Does this case represent a difficulty with judgment/decision making?
3)
Does a clinical process need to be improved?
4)
Could this incident have been readily prevented?
5)
Is there an educational opportunity?
6)
Was the management/documentation of the case a problem after the complication?
7)
Is this case a potential risk management issue/liability? If any one of
the first three questions are answered affirmatively, then the case is
referred to the institutionwide Care Review Committee (CRC). Cases in
which a risk management issue is raised, (question 7) are sent directly
to the risk management department, which conducts its own review that
may or may not parallel the care review process.
If all questions are answered negatively, then it's handled as an educational event at the service's monthly or regular morbidity and mortality conference. Physicians involved in an incident are required to interpret the event for the conference attendees - preferably in person, but otherwise, in writing. The CRC, a medical board committee that I chair, meets each month to review cases and see where changes can be made to prevent future errors. Physicians describe their actions and decision-making process and are questioned by the committee, which afterward decides whether to affirm the decision of the service level review or change that decision.
The CRC includes representatives from more than 25 clinical disciplines, plus pathology. Only physicians are voting members, but nursing, risk management and other disciplines send nonvoting members to participate in discussions.
Between September and November last year, the departments reviewed 194 cases of which 12 were referred to the CRC. The reviewed cases came from diverse disciplines - cardiothoracic surgery, emergency medicine, multi-organ transplant, medical specialties, neurosurgery, ophthalmology, radiation oncology, radiology, and vascular surgery.
Only if a medical staff member demonstrates a pattern of poor judgment or substandard patient care would a CRC review translate into a disciplinary action. The results of a CRC review of an individual physician are placed in the confidential quality file of the medical staff member, to be used primarily by the service chief to refer to at the time of reappointment to the medical staff. The chair of the CRC sends the result of the committee's deliberations on each case to the medical staff member being reviewed and the departmental quality assurance physician. There is no appeal, but medical staff members who disagree with a finding may place a rebuttal in their file. The CRC also reviews criticisms of care uncovered by external review groups, such as the state Board of Medical Quality Assurance.
Again, the proceedings of the CRC are meant to be fact finding and educational, not punitive. The focus is on the quality of decision-making, not outcomes.
For example, a recent review involving a complication that occurred during removal of a patient's central line resulted in expanded training for housestaff. We learned that housestaff were being adequately trained on how to place lines, but the review indicated the need to improve the training of housestaff regarding the proper techniques for removal of central lines.
The CRC hopes periodically to publish a list of lessons learned from care review.
All peer review proceedings are protected by statute from discovery in any legal proceeding. Any correspondence pertaining to a peer review should be labeled "Privileged and Confidential. Peer Review," thus maintaining the protection of statue No. 1157 of the California Evidence Code. All medical staff members are to maintain confidentiality when it comes to discussions of peer review matters.
Each of your services has a quality assurance physician who serves on the CR committee. That's a good person to know, and in most cases will be your link to the committee and the process it serves.
Use the care review process. It is one important tool we can use to improve patient care. We should constantly strive to fine-tune this process, but we should also be proud that we are ahead of the curve on this important national issue.
