Clinical peer review

Clinical Peer Review is the process by which health care professionals evaluate each other’s clinical performance. Clinical peer review is segmented by discipline. No inter-disciplinary models for clinical peer review have been described. Physician Peer Review is most common and is found in virtually all hospitals.^[1] Peer review is also done in some settings by other clinical disciplines including nursing and pharmacy. Initially used by Dans,^[2] Clinical Peer Review is the best term to collectively refer to all such activity.

Clinical peer review should be distinguished from the peer review that medical journals use to evaluate the merits of a scientific manuscript, from the peer review process used to evaluate health care research grant applications, and, also, from the process by which clinical teaching might be evaluated. All these forms of peer review are confounded in the term Medical peer review. Moreover, Medical peer review has been used by the American Medical Association (AMA) to refer not only to the process of improving quality and safety in health care organizations,^[3] but also to process by which adverse actions involving clinical privileges or professional society membership may be pursued.^[4]

Physician Peer Review

Today, physician peer review is most commonly done in hospitals, but may also occur in other practice settings including surgical centers and large group practices. The primary purpose of peer review is to improve the quality and safety of care. Secondarily, it serves to reduce the organization’s vicarious malpractice liability and meet regulatory requirements. In the US, these include accreditation, licensure and Medicare participation.^[5] Peer review also supports the other processes that healthcare organizations have in place to assure that physicians are competent and practice within the boundaries of professionally-accepted norms.

In varying degrees, physicians having been doing peer review for a long time. Peer review has been well documented in the 11th century and likely originated much earlier.^[6] In the 1900s, peer review methods appear to have evolved in relation to the pioneering work of Codman’s End Result System ^[7] and Ponton’s concept of Medical Audit.^[8] Lembcke, himself a major contributor to audit methodology, in reviewing this history, notes the pre-emptive influence of hospital standardization promoted by the American College of Surgeons (ACS) following WWI.^[9] The Joint Commission (on Accreditation of Hospitals) followed the ACS in this role from 1952. Medicare legislation, enacted in 1964, was a boon to the Joint Commission. The conditions for hospital participation required a credible medical care review program. The regulations further stipulated that Joint Commission accreditation would guarantee payment eligibility.^[10] What was once a sporadic process, became hardwired in most hospitals following the Audit model. The widespread creation of new programs was hampered, however, by limitations in the available process models, tools, training and implementation support.

Medical audit is a focused study of the process and/or outcomes of care for a specified patient cohort using pre-defined criteria. Audits are typically organized around a diagnosis, procedure or clinical situation.^[11] The audit process can be effective in improving clinical performance.^[12] It remains the predominant mode of peer review in Europe.

In the 70s, however, the widespread creation of new programs was hampered by limitations in the available process models, tools, training and implementation support. The lack of perceived effectiveness of medical audit led to revisions of Joint Commission standards in 1979. Those modified standards dispensed with the audit requirement and called for an organized system of Quality Assurance (QA). About the same time, hospital and physicians were facing escalating malpractice insurance costs. In response to these combined pressures, they began to adopt "generic screens" for potential substandard care. These screens were originally developed to evaluate the feasibility of a no-fault medical malpractice insurance plan and were never validated as a tool to improve quality of care. Despite warnings from the developers, their use became widespread.^[13] In the process, a QA model for peer review evolved with a narrow focus on the question of whether or not the standard of care had been met. It has persisted despite the many criticisms of its methods and effectiveness.^{[2][14][15][16]} Today, its methods are increasingly recognized to be outdated and incongruent with the Quality Improvement (QI) principles that have been successfully adopted into the field of health care over the past decade.^[15][16]

There is good evidence that contemporary peer review process can be further improved. The American College of Obstetrics and Gynecology has offered a Voluntary Review of Quality of Care Program for more than 2 decades. Perceived issues with the adequacy of peer review were an explicit reason for requesting this service by 15% of participating hospitals, yet recommendations for improved peer review process were made to 60%.^[17] A 2007 study of peer review in US hospitals found wide variation in practice. The more effective programs had more features consistent with quality improvement principles.^[1] There were substantial opportunities for program improvement. The implication is that a new QI model for peer review seems to be evolving.

A 2009 study confirmed these findings in a separate sampling of hospitals.^[18] It also showed that important differences among programs predict a meaningful portion of the variation on 32 objective measures of patient care quality and safety.^[19]

A four-year longitudinal study of 300 programs identified the quality of case review and the likelihood of self-reporting of adverse events, near misses and hazardous conditions as additional multivariate predictors of the impact of clinical peer review on quality and safety, medical staff perceptions of the program, and clinician engagement in quality and safety initiatives.^[20] Despite a persistently high annual rate of major program change, about 80% of programs still have significant opportunity for improvement. It is argued that the out-moded QA model perpetuates a culture of blame that is toxic to efforts to advance quality and high reliability among both physicians and nurses.

External Peer Review

The 2007 study showed that the vast majority of physician peer review is done "in house": 87% of hospitals send less than 1% of their peer review cases to external agencies. The external review process is generally reserved for cases requiring special expertise for evaluation or for situations in which the independent opinion of an outside reviewer would be helpful (see independent review). The process is significantly more costly than in-house review, since the majority of hospital review is done as a voluntary contribution of the medical staff.

Mandated external peer review has not played an enduring role in the US, but was tested back in the 70s. A 1972 amendment to the Social Security Act established Professional Standards Review Organizations (PSRO) with a view to controlling escalating Medicare costs through physician-organized review.^[21] The PSRO model was not considered to be effective and was replaced in 1982 by a further act of Congress which established Utilization and Quality Control Peer Review Organizations (PROs). This model too was fraught with limitations. Studies of its methods called into question its reliability and validity for peer review.^[22] A survey of Iowa state medical society members in the early 90s regarding perceptions of the PRO program illustrated the potential harm of a poorly designed program.^[23] Furthermore, the Institute of Medicine issued a report identifying the system of care as the root cause of many instances of poor quality. As a result, in the mid-90s, the PROs changed their focus and methods; and began to de-emphasize their role as agents of external peer review. The change was completed by 2002, when they were renamed Quality Improvement Organizations.^[24]

Nursing Peer Review

Nursing peer review appears to have gained momentum as a result of growth of hospital participation in the American Nursing Association’s Magnet Program.^[25] Even so, less than 7% of U.S. hospitals have qualified. Magnet hospitals are required to have had a peer review evaluation process in place designed to improve practice and performance for all RNs for at least 2 years.^[26] The literature on nursing peer review is more limited than that which has been developed for physician peer review,^[27] and has focused more on annual performance appraisal than on case review.^[28] No aggregate studies of clinical nursing peer review practices have been published. Nevertheless, more sophisticated studies have been reported.^[29]

Mostly what is mistakenly referred to as "peer review" in clinical practice is really a form of the annual performance evaluation. The annual performance review is a managerial process and does not meet the definition or outcomes needed related to peer review. Other organizational practices may violate the peer review guidelines set forth 1988 by the ANA 1988.^[30] The most frequent violation is the performance of direct care peer review by managers. One of the reasons for the confusion is that the ANA guidelines for peer review had been out of print prior to being reprinted and updated in 2011.^[31]

Definition of Peer Review The primary purpose of peer review is to help assure the quality of nursing care through the safe deliverance of standards of care and newly discovered evidence-based practices. The first definition of nursing peer review was published in 1988 by the American Nurses Association and is still applicable today. This definition includes the following statements: "The American Nurses Association believes nurses bare primary responsibility and accountability for the quality of nursing care their clients receive. Standards of nursing practice provide a means for measuring the quality of nursing care a client receives. Each nurse is responsible for interpreting and implementing the standards of nursing practice. Likewise, each nurse must participate with other nurses in the decision-making process for evaluating nursing care…Peer review implies that the nursing care delivered by a group of nurses or an individual nurse is evaluated by individuals of the same rank or standing according to established standards of practice…. Peer review is an organized effort whereby practicing professionals review the quality and appropriateness of services ordered or performed by their professional peers. Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice" (ANA 1988 p. 3).

The early ANA Peer Review Guidelines (1988) and Code of Ethics for Nurses (2001) focus on maintaining standards of nursing practice and upgrading nursing care in three contemporary focus areas for peer review. The three dimensions of peer review are: (a) quality and safety, (b) role actualization, and (c) practice advancement. Each area of contemporary peer review has an organizational, unit, and individual focus.^[32] The following six peer review practice principles stem from and are grounded in the 1988 ANA Guidelines and may help to assure an evidence-based and consistent approach to peer review: 1. A peer is someone of the same rank. 2. Peer review is practice focused. 3. Feedback is timely, routine and a continuous expectation. 4. Peer review fosters a continuous learning culture of patient safety and best practice. 5. Feedback is not anonymous. 6. Feedback incorporates the developmental stage of the nurse.

Written and standardized operating procedures for peer review also need development and adoption by the direct care staff and incorporation into the professional practice model (shared governance) bylaws.^[33]

Confusion exists about the differences between the Professional Peer Review process, the Annual Performance Review (APR) and the role of peer evaluation. The APR is a managerial human resource function performed with direct reports, and is aimed at defining, aligning and recognizing each employee’s contribution to the organization’s success. In contrast, professional peer review is conducted within the professional practice model and is not a managerial accountability. Peer evaluation is the process of getting feedback on one’s specific role competencies or "at work" behaviors from people that one works within the department and from other departments. "Colleague evaluation" is a more appropriate term than "peer evaluation" as this is not a form of professional peer review.^[34]

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