A hot topic in quality improvement lately is the idea of peer-to-peer hospital reviews, in which a team from one hospital visits another and provides a structured, confidential, non-punitive review. Proponents say this approach could yield meaningful opportunities for quality improvement before a binding accreditation review, but it also poses some potential risks.
The idea has gained traction recently in the healthcare community, including a Wall Street Journal blog by Peter Pronovost, MD, PhD, John Hopkins Medicine senior vice president and director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality. He notes that the concept is borrowed from the nuclear power industry.
“In peer-to-peer, a team of reviewers — executives, managers, front line clinicians, researchers, and others — visit another hospital for a structured, confidential, and non-punitive review of its safety and quality efforts. While it would be foolhardy to show your flaws to regulators, in peer-to-peer assessments it is encouraged,” Pronovost wrote. “The goal is to create an environment of learning, not judging, for both sides. The organization being reviewed discusses its weaknesses, while highlighting its successes, which can then be shared more broadly.”
The Johns Hopkins Hospital used a more limited peer-to-peer approach to help ICUs reduce their rates of catheter-related bloodstream infections, bringing in a team from Massachusetts General Hospital for a review and sending a team to review their counterparts in Boston. Pronovost says the experience helped both hospitals improve quality and could be employed for hospital-wide reviews. (Pronovost’s blog is available online at: http://on.wsj.com/2oNDYBb.)
The process could be beneficial, yielding some of the same insight that comes from an accreditation survey without the consequences of noncompliance, says Dan Fieker, DO, an infectious disease specialist in Breckenridge, CO, and a surveyor with the Accreditation Association for Ambulatory Health Care-Healthcare Facilities Accreditation Program (AAAHC-HFAP), the leading accreditor of ambulatory care providers.
Peer-to-peer review is encouraged in the ambulatory care accreditation process. Fieker notes that a recent AAAHC analysis found that a lack of peer review was among the highest incidence (10% or more) of partially compliant or noncompliant surveyor ratings for meeting AAAHC Standards at the facilities surveyed. The AAAHC Quality Roadmap 2016 synthesized data from 1,363 onsite accreditation surveys performed by AAAHC from June 2015 to June 2016. (The full report is available online at http://bit.ly/2pnymkm.)
“The healthcare community is accustomed to regulatory and accreditation bodies coming in to assess how well they are complying with best practices and the required activities in various areas, but that assessment comes with a determination by that body that can have an impact on the organization,” Fieker says. “What we don’t see is enough of clinicians, experts in a variety of fields like administration, nursing, and pharmacy, go into a facility in a non-punitive manner to evaluate processes of care and see how systems can be improved. That’s not happening, but it should.”
Hospitals may hire outside consultants for that kind of objective assessment, but that can be tremendously expensive, Fieker notes. Peer-to-peer assessments could be done at little or no cost, he theorizes, with each party benefitting from the system.
Establishing a peer-to-peer review program would require careful organization, he says. The hospitals would need a clear, documented understanding of the purpose of the reviews and the confidentiality expectations, he says. There currently is no such model, so interested hospitals would have to develop one.
Though peer-to-peer review offers benefits over accreditation reviews — which often are seen as punitive and non-consultative — Fieker says arranging one will be a significant undertaking. The reviewing hospital might need to be in the same geographic region so that both hospitals have some factors in common, but they should not be in the same immediate community, he says.
Such a program should be entirely voluntary and organized by the medical community, not by any government or accrediting body, he says. Getting everyone on board would not be easy because a peer-to-peer hospital review would send up red flags for many hospital leaders. Risk managers and legal counsel, for instance, would worry about documenting potentially damaging information and whether it could be subpoenaed, the possibility of losing peer review privilege with some information, and myriad other legal issues.
“A big concern will be the financial, competitive issues, the idea that you’re going to be giving up your secrets to a competing hospital,” he says. “You couldn’t have two or three hospitals in a city going around and reviewing each other. The hospital coming in to review you would have to be from some distance so that there is no sense that you are competing for the same patients, which will make CEOs too nervous about letting your competitor see your weaknesses and exploit them.”
