The jury is out on peer review

Despite advanced training and conscientious attention to detail, anesthesiologists aren’t immune from errors on occasion. What they do after an error is the subject of Sunday’s point-counterpoint session “Peer Review: Blame Game or Quality Improvement?”

Monica W. Harbell, M.D.

Physician peer review is a concept originally designed to protect the public from incompetent and unethical physicians. The Joint Commission on Accreditation of Healthcare Organizations initiated peer reviews in 1952.

Luis E. Tollinche, M.D., FASA

“While the intent of peer review is good – to improve the quality of patient care – the current peer review system employed in many hospitals is flawed and prone to misuse,” said Monica W. Harbell, M.D., Assistant Professor, Department of Anesthesiology and Perioperative Medicine at the Mayo Clinic in Arizona.

Dr. Harbell and two colleagues who are equally passionate about patient safety look forward to discussing the pros and cons. They will trace the evolution of the traditional peer review system and discuss new theories that are beginning to take its place.

Hospitals perform peer reviews to remain accredited. Over the years, less-than-ethical hospital administrators and physicians have used peer reviews to settle scores, reduce costs and stifle competition. The victims of these sham peer reviews have lost their hospital privileges, positions, income and reputations.

Emily Methangkool, M.D.

To make matters worse, in 1986, Congress passed the Health Care Quality Improvement Act. It grants hospitals and physicians immunity from litigation when they admonish physicians during peer reviews. This law has made it increasingly difficult for falsely accused providers to defend themselves.

Some believe the runaway peer review system has also had an effect on patient safety. Physicians who work in punitive environments are less likely to report their own errors.

Peer Review: Blame Game or Quality Improvement?

2:45-3:45 p.m.


“This culture perpetuates fear and distrust. People blame each other to avoid being disciplined or demeaned. Consequently, improvement in patient safety and quality care is diminished,” said Luis E. Tollinche, M.D., FASA, Chair of Anesthesia Quality Assurance/Quality Improvement at Memorial Sloan Kettering Cancer Center.

Today, many health care organizations are exploring new quality assurance models. Rather than blaming and shaming an individual, the goal is to evaluate the system or process that led to the error.

“Even the term ‘peer review’ is punitive,” said Emily Methangkool, M.D., Assistant Clinical Professor of Anesthesiology and Co-Chair of Quality Assurance/Quality Improvement at UCLA Medical Center. “It implies the individual is to blame for the event. I would argue for calling it a ‘case review’ instead.”

Dr. Methangkool describes the case review process at UCLA, “Each physician is asked to submit a computerized, anonymous form after every case. When cases are reviewed, individuals remain anonymous, and the discussion is focused on how systems and processes can be improved.”

In this new “just culture” or “learning culture,” staff can admit mistakes, offer alternative viewpoints and challenge existing practice without fear of punishment or ridicule. Even more important, mistakes turn into teachable moments.

“Institutions that learn from events and analyze them from a system/process standpoint have fewer adverse events,” Dr. Tollinche said.

According to recent studies, an estimated 400,000 patient deaths per year result from preventable harm. While physicians, including anesthesiologists, should not be punished for being human, perhaps it’s time to ask if peer review is helping or hindering safety culture.

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