External peer review is an important catalyst for improving patient safety and quality of care. This is especially true when healthcare organizations incorporate it into ongoing quality improvement efforts. The process is most effective for organizations aiming for high reliability.
Steve Mrozowski, a Principal in Clinical Transformation and leader of external peer review and patient safety, and Andrew Resnick, MD, Chartis Chief Medical and Quality Officer, discuss why external peer review shouldn’t be a negative experience for clinicians. They share how chief medical officers (CMOs) can promote a proactive and objective review of care quality, focus on widespread organizational learning, and engage clinicians in high reliability care.
Steve has more than 25 years of healthcare experience in prehospital services, quality, safety, and high reliability organizing and education. He helps organizations optimize their capabilities to deliver harm-free, patient-centered, and high-quality care. He is most passionate about patient safety structures, just culture, cause analysis, lean processes, and high reliability.
Andrew is a nationally recognized expert in quality, patient safety, and high reliability. He helps organizations set and reach top performance goals through both specific projects and transformational change. With more than 20 years of experience in healthcare, he has served as CMO and chief quality officer at leading healthcare systems throughout the US. He is also active clinically as an associate surgeon at Brigham and Women’s Hospital and as a part-time lecturer at Harvard Medical School.
Chartis: Why don’t organizations already practice routine external peer review of clinical cases? What are some of the biggest challenges?
Steve: Not unlike internal case review, preparing to send provider cases through an external peer review process poses an administrative burden. Even the process of knowing and deciding which cases to send can be challenging. While some organizations have clear triggers, many don’t. For complex cases, hospital leaders must obtain records from referring facilities to allow an external review to understand the full clinical picture.
There’s also a historical perception that the entire peer review process is punitive, which creates a lot of stress and anxiety. All too often, cases that are sent for external review are those that included adverse outcomes or have an undercurrent of internal politics or sensitivity. Healthcare leaders and legal counsel may not want to pull the curtain back to let others look in—even when doing so is ultimately for the purpose of educating clinicians and staff and improving patient quality and safety.
Andrew: It all comes down to organizational culture. Without a culture of transparency and collaboration, it becomes very difficult to get everyone on the same page in terms of qualifying criteria to send cases for external peer review. Oftentimes, organizations end up sending only the most serious ones—which means they miss out on countless opportunities for process improvement.
Alternatively, with the right culture, organizations that routinely send cases can make the entire process constructive. Incorporating a routine external peer review process into continuous improvement efforts helps organizations promote high reliability care and reduce risk.
Chartis: One perceived barrier to routine external peer review is the expense itself. Is it a true barrier?
Steve: External peer review can be relatively affordable. Leaders should be more concerned about the cost to their organization if they don’t routinely send cases for review and miss out on the opportunity to improve their systems based on the lessons learned. That cost can be exceptionally high.
Poor outcomes pose all kinds of financial challenges and reputational harm that could be prevented. But the return on investment can be significant when external peer review is embraced as an opportunity to be transparent, garner lots of learnings, and spread those learnings across a medical staff.
Chartis: What are the criteria or triggers for when an organization should send a case out for external peer review?
Steve: Most organizations send cases in which there are catastrophic adverse events because they need an unbiased view of what happened. But organizations should really also send any case for which there are quality of care concerns as a minimum practice. Learning from cases—even those without significant harm to patients—can help drive performance improvement activities and ideally prevent a more catastrophic outcome.
Even more ideal is the practice of sending a sampling of cases (even those without identified quality concerns) out on a regular cadence. Doing so can simultaneously de-stigmatize external peer review and maintain the true purpose of ongoing education.
Common triggers include cases for which the organization lacks the specialists necessary to perform the review internally or for administrative purposes (such as the routine assessment of medical necessity or for re-privileging or ongoing performance practice evaluation).
Some organizations use the external peer review process to assist with change management when a newly hired clinician using new techniques, for example, joins a well-established medical staff. The external peer review also helps validate that there are no patient safety and quality issues with new or different ways of providing care.
Andrew: On the other end of the spectrum, organizations should also send cases that involve prominent, seasoned clinicians. For example, it can be tricky from a political standpoint to internally review the chief of surgery or a department chair who attracts a large volume of cases to the organization.
Steve: Beyond these special cases, organizations are increasingly leveraging external peer review to get a fresh set of eyes on their broader quality of care. For instance, we work with many organizations that send 30 to 40 cases quarterly for external peer review. This proactive approach is ideal for two reasons: it mitigates risk, and it allows external reviews to identify trends and patterns (such as nonadherence to prescribing practices, outdated policies and order sets, or lack of clear and consistent clinical pathways). Organizations can learn and adjust before poor trends in practice could reach a patient and cause harm.
When identifying cases to send, it’s important to select a cross-section of providers and patients. The results of this type of external peer review can be a great lens into healthcare disparities and health equity as well.
Chartis: This is where external peer review takes on a broader role. When done correctly, how does this process promote high reliability care?
Steve: High reliability care is about reducing variation to promote consistent performance. It’s also about transparency and a culture of continuous learning. When organizations embrace these principles, they approach the external peer review process proactively with curiosity and a desire for continual improvement. High reliability organizations are by nature preoccupied with potential vulnerabilities and committed to building resilience into their processes. Leveraging the learnings from a large sampling of cases can help organizational leaders get ahead of risks or gaps in performance. They can implement improvements before significant adverse events occur.
Andrew: Being proactive demands external review. If you’re only looking at your organization internally, you might miss important national, clinical, and operational trends. Without this bigger picture view, hospitals “don’t know what they don’t know.”
Chartis: When external peer review becomes more routine, how does it benefit clinicians beyond improving care quality?
Andrew: One of the biggest benefits for clinicians is that it changes the tone and impact of reviews. When reviews are not routine, it’s often a very stressful experience. It usually means something went wrong—a complication, error, or other problem—even a fatality. The adverse event alone can be very hard for the clinician to process, and then you add the trauma of being under review and potentially facing legal action, fair hearings, or an impact on privileging, and that can be very triggering. Making external peer review part of the normal quality assurance process alleviates some of this stress and anxiety because it is built in and expected.
With that said, pairing peer review with peer support is also incredibly important. Bad things can happen even when you provide high reliability care. Providing support should be the first thing that happens after an adverse event. The clinician should have support while the safety team investigates the case. This support must be part of the overall culture and patient safety program.
Steve: Going back to that culture of continuous learning, when organizations have a just culture and are truly able to embody a learning culture and have psychological safety, the impact can be incredibly positive. But it must be consistent. It only takes one review conducted for the wrong reasons to perpetuate the stigma that external peer review is always bad. The culture of an organization can mitigate the risk of this happening.
Chartis: When it comes to external peer review, how can CMOs shift their organizational culture to one of transparency, support, and learning?
Steve: There is no cookie cutter approach. But leaders must be open-minded, for example, not coming with a predisposition of what they expect peer reviews to say but with the appreciation that they will gain insight into areas for improvement and education. This appreciation of purpose should be very visible to the medical staff.
They should also recognize that physician external peer review shouldn’t be the only external review they have in place. For instance, if they have an internal review process for broader safety events, nursing care delivery, or radiology over-reads, what is the external arm of each of these? There should be one, and the learnings from these should be embraced and shared broadly.
Andrew: Leaders should also attend safety huddles and be positive and supportive. Leader behavior has such a significant impact. Bad things happen, but the main point is to learn from flaws and eliminate vulnerabilities.
And when it comes to transparency, the organization’s board of directors needs to know about cases—the success stories as well as the adverse events.
Steve: Yes, it does hospital staff and boards a disservice when they find out about an adverse event on the news and not directly from clinicians and leadership. Boards want to know what to improve, prioritize, and fund. Keeping them in the loop helps with this overall culture.
Andrew: Finally, connecting all the dots across quality review is important. Organizations need to have a transparent, integrated performance management framework across outcomes, morbidity and mortality conferences, and adverse events. Linking everything together to continuously monitor and improve the organization is important. The CMO can make this happen—creating a positive culture of performance improvement across the organization.
