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Turn peer reviews into learning occasions
Share what you learn with entire staff
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Joint Commission standards require the organized medical staff oversee the quality of care, treatment, and services rendered by physicians and other licensed independent practitioners. This includes monitoring the quality of services provided by hospital-based practitioners such as radiologists and pathologists.
In addition to ensuring that these practitioners comply with service expectations, such as report timeliness, their clinical judgments must be evaluated. This evaluation may take the form of some type of peer review; for instance, one radiologist reviews a sample of images and interpretations made by another radiologist. Discrepancies that may be found are shared with the practitioner under review. Unfortunately, the learning that can occur during this peer review process is often limited to the reviewer and the person being reviewed.
For reappointment purposes, it is important to know if a practitioner has inadequate skills; however, inaccurate or misleading radiology or pathology findings are often a consequence of the process or the environment. It is important to share what is learned during peer review of mistakes and untoward events so all practitioners can avoid similar situations.
To share lessons learned, practitioners in the department should hold regular round table discussions to explore the issues that lead to misdiagnoses, report discrepancies, and untoward events. A variety of situations can be discussed at these meetings:
One way to identify cases for discussion is to maintain a departmental log in which practitioners can record details about a reporting discrepancy or other situation that would benefit from group examination. In addition to this informal case gathering method, unwanted occurrences identified through the incident reporting system can be brought to the meeting for discussion.
For incident reports to be used as a reliable case finding source, the department must have a clear definition of reportable events. In Figure 1 is a list of the types of diagnostic and interventional events in radiology that should be documented in an incident report. Similar types of events involving anatomic and clinical pathology should be documented in incident reports.
Do not rely solely on incident reports to identify cases for round table discussion. Often situations are not readily apparent during a patient's hospitalization. For example, a false-negative diagnosis may result in complications that are known only after several weeks or months. These types of cases, once recognized, should be evaluated at the practitioners' round table discussions.
Structuring round table dialogue
The structure of the meetings must ensure that they engender an environment of learning rather than blame. It should be stressed that the discussions are not a witch-hunt for poor performers but rather an opportunity to raise standards for everyone by increasing awareness of the causes of mistakes and untoward events. To reinforce the nonpunitive nature of the meetings, it can be helpful to rotate the leader responsibilities. For each meeting, a different practitioner in the department is assigned responsibility for collecting and collating cases for presentation and for leading the discussions.
Prior to the meeting, the assigned leader selects and prepares cases for presentation. To minimize hindsight bias, only the information available to the practitioner at the time of the initial report should be presented during the initial discussions. For example, during presentation of a case involving X-ray findings, only the films and clinical information that was available to the reporting radiologist at the time should be considered.
The purpose of the presentation at the meeting is to talk about whether other radiologists would have reached the same conclusion as the reporting radiologist. Subsequently, follow-up information can be made available and relevant teaching points raised by the meeting leader or sub-specialists. A similar process can be instituted for case discussions involving interpretation of pathology findings.
Round table discussions allow hospital-based practitioners to review systems contributing to difficult diagnoses and untoward events. The meetings provide opportunities for continuing medical education and also contribute to a culture in which potential problems can be identified and rectified. A brief summary of the lessons learned during the meeting should be maintained; however, be careful about integrating conclusions with the peer review process as this may inhibit open, candid discussions. The round table meetings should be seen as educational for all attendees and not an opportunity to disparage another practitioner's performance.
Errors that may be identified often represent only a small fraction of each practitioner's workload. It is difficult to assess statistical significance due to the subjective process used to select cases for discussion. Yet if concerns are raised about repeated lapses in an individual's performance, a focused evaluation of the work of the individual may be indicated.
In the unlikely event that a significant error is newly discovered during the case discussions, it must be communicated to the patient's physician to ensure that harm to the patient is avoided where possible. If the error adversely affected the patient's management or treatment outcomes it may be necessary to contact the patient directly. The organization's disclosure policy should be followed in these instances.
Identification of process or system problems should be encouraged during the case discussions. For instance, if requests for X-ray exams are not accompanied by adequate information, the radiologist can make an inaccurate interruption or fail to address the patient's specific problem. Mislabeled or improperly stored pathology specimens create similar problems for pathologists. Don't limit the case discussions to critiques of individual performance — use the forum as an opportunity to identify process or system problems that need to be rectified through the organization's performance improvement program.