Disrupting Physician Clinical Practice Peer Review

Disrupting Physician Clinical Practice Peer Review

 

Rajesh Swaroop, MD

Perm J 2019;23:18-207 [Full Citation]

https://doi.org/10.7812/TPP/18-207
E-pub: 03/28/2019

ABSTRACT

The goal of physician peer review has been to assess and improve the quality of care by individual physicians. Unfortunately, this enshrined piece of medical practice suffers from deep flaws that hamper the achievement of assessment and improvement. This institution is in serious need of disruption, both for the safety of patients and for the wellness of practicing physicians. This commentary describes the inherent flaws of physician practice review and how physicians and health care organizations can address them.

INTRODUCTION

Peer review of physician clinical practice has existed in essentially the same form for more than 100 years.1 The laudable goal of peer review has been to assess and improve the quality of care by individual physicians. Maintaining a program of peer review of physician clinical practice is also a requirement for continued hospital accreditation by The Joint Commission. Unfortunately, this enshrined piece of medical practice suffers from deep flaws that hamper the achievement of assessment and improvement.2 This institution is in serious need of disruption, both for the safety of patients and the wellness of practicing physicians.

The current state of physician clinical practice review could be called the deliberative framework. In my institution, cases involving an instance of care provided by an individual physician are referred by physicians, nurses, or risk managers, or from patient complaints about quality of care. The case is then prescreened by a nurse quality coordinator and ultimately reviewed in detail by a physician trained in peer review or a peer-review body consisting of a group of physicians trained in peer review. The final written review is attested by the physician chief of service as to a lack of bias. If an opportunity to improve care is identified, the physician being reviewed is notified. If the opportunity is determined to meet a threshold of potential “significant patient harm,” the reviewed physician can be required to complete a structured plan of performance improvement. The reviewed physician’s privilege of continued practice can be placed at risk if s/he does not satisfactorily complete performance improvement plans.

In theory, the mechanism of physician practice review is an unbiased thorough review of care by peer physicians to uphold maintenance of quality standards.

INHERENT FLAWS OF PHYSICIAN PRACTICE REVIEW

The flaws inherent to physician practice review are many, but some deserve special recognition.

Lack of Resources and Existence of Bias

A thorough physician practice review requires time, energy, and structure. There are many health care systems where reviews are not supported with adequate resources.

A problematic issue is the existence of bias. Bias encompasses many concerns, which include financial bias, work group bias, cognitive bias, and sex-based/racial/sexual-orientation discrimination. In health care systems where physicians are competing for market share, there is an inherent financial conflict for competing physicians to review each other.1 Because it is extremely difficult to preserve absolute anonymity in peer review, peer reviewers may legitimately consider how an unfavorable review may affect their ongoing relationship with a reviewed physician who is in their work group. Literature on cognitive bias suggests that hindsight bias and availability bias are common, among other cognitive errors.3,4 Finally, a lack of heterogeneity in peer-review bodies can lead to groupthink, resulting in the “in” group members receiving more lenient scores compared with those who are perceived as being “outsiders.”5 Homogeneous groups, unfortunately, also frequently lack the insight to know about their own biases, which are frequently unconscious and unintentional.

Misinterpretation or Misuses of Peer Review

Another concern is the co-opting of peer review as a proxy for managing people. The primary aim of peer review is assessing and improving quality of care. However, lack of emotional intelligence and group cooperation by an individual physician can trigger reviews, forcing the peer-review process to deal with issues that are fundamentally not about the quality of care provided. Similarly, complaints from patients about cost, service, or access to care may be unfortunately triaged into the peer-review process, again forcing peer review to deal with issues that are not primarily about quality of care provided.

The misinterpretation of physician peer review as being a justice system is another fundamental problem. Leaders, reviewed physicians, physicians performing peer review, and Quality Department staff may perceive their activities as being part of a system of justice. This is an unfortunate view because, unlike law, there are many situations in health care in which the standard of care is unclear or evolving. A justice-based approach also triggers defensiveness on the part of reviewed physicians, which impedes the ability to learn. It also drives the system into being focused on individuals, although much more frequently there are underlying important systemic and workflow issues. Valiant attempts at creating a more logical approach have included development of just culture algorithms, to clearly indicate when to hold individuals vs systems accountable. However, the widespread use of just culture algorithms has not yet been achieved. The unfortunate result of these issues is that many frontline physicians view peer review as a fundamentally unfair justice system—and on the basis of their worldview that is an accurate assessment.

DISRUPTING PEER REVIEW

The first step to disrupting peer review is to bring it back to the original intention of assessing and improving care. Taking conscious steps to address the inherent flaws is necessary. Finally, adding the modern interpretation of care delivery from a team of health care providers rather than from an individual physician fills out the model of the disruptive framework.

A crucial theme in the disruptive approach is to place culture first. An organization that actively supports a healthy culture of learning should view peer review as an important tool to achieve its aims.

Relentless attention on the aim of learning is necessary to reassert the psychological safety of the physician learners. This also brings back peer review to its original intention. For any case that proceeds to the peer review process, it is critical to ask and receive a learning point that can be broadly shared. It is also important for psychological safety to transparently share those learning points. There may be medicolegal concerns, but regulators would look favorably on this practice. Any shared learnings should be deidentified with names of physicians and patients removed.

ADDRESSING FLAWS

In large health care organizations, financial bias is generally not a concern because financial motivations are in alignment. Health care systems that have competitor physician groups could consider having equal representation of groups on peer-review committees.

Work group bias can be concerning. A steadfast attention to learning as the primary driver of peer review can make this easier. It is encouraged to have the physician leaders model vulnerability in speaking about cases from which they learned. It is essential to have this behavior inculcated at multiple levels, including by Medical Directors, Department Chiefs, Division Chiefs, and so on. A true learning organization would see that learning opportunities accrue for all of us, and recognizing them is a privilege, not a punishment.

Cognitive bias may be inescapable, but the first step is awareness. A commonly occurring form of cognitive bias is hindsight bias, that is, scoring cases on the basis of outcomes rather than actions. When cases are presented for group discussion and scoring, hindsight bias can be mitigated by avoiding disclosure of patient outcome when feasible. Focus should be placed on the actions of the physicians and the accepted standards of care.

Availability bias is the habit of using the ease of retrieving an example from one’s memory as a judgment of the frequency of an event.6 This can be mitigated by referencing scientific literature for objective prevalence and incidence data rather than relying on the memory of individual peer reviewers.

Unconscious sex-based/racial/sexual-orientation bias is best overcome by having a diverse group of physician reviewers. This includes creating roughly proportional representation of minority groups, reviewers of both sexes, and those with varied work experiences.

Although difficult, having clear distinction between quality issues and human resources issues is essential for preserving the intention of the physician case review process. This often may require discussion with physician leaders for appropriate triage. There is a blurred line between quality of care provided and overall human interaction, so a reasonable aim is to have a consistent practice of when cases are referred to peer review.

A NEW AGE OF ENGAGEMENT

In the current state of the deliberative framework of peer review, an extraordinary amount of energy and attention goes toward assessing care and scoring the cases. Although important, this is not the fundamental goal of the disruptive framework. Rather, the fundamental goal is to improve care.

Most improvement requires managing systems and processes, rather than singling out individual errors. The Plan-Do-Study-Act cycle is well established as a mechanism for improving processes. In addition, many key performance improvement initiatives for health care systems and processes require strong physician leaders. Therefore, the energy shift from physician peer reviewers should be from deliberating scores to engaging in active performance improvement on the issues identified. Peer reviewers in the modern era should see their role much more broadly than reviewing cases. It is time for those physicians to emerge from the conference room and into the clinics and hospital wards. Their passion and energy should be dedicated to leading teams toward better outcomes.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

How to Cite this Article

Swaroop R. Disrupting physician clinical practice peer review. Perm J 2019;23:18-207. DOI: https://doi.org/10.7812/TPP/18-207.

Author Affiliations

1 Orange County Medical Center, Irvine, CA

Corresponding Author

Rajesh Swaroop, MD (raj.x.swaroop@kp.org)

References
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 2. Goldman RL. The reliability of peer assessments of quality of care. JAMA 1992 Feb 19;267(7):958-60. DOI: https://doi.org/10.1177/016327879401700101.
 3. Henrikson K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care 2003 Dec;12(Suppl 2):ii46-ii50. DOI: https://doi.org/10.1136/qhc.12.suppl_2.ii46.
 4. Kahneman D. Thinking fast and slow. New York, NY: Farrar, Straus and Giroux; 2011.
 5. Everett JA, Faber NS, Crockett M. Preferences and beliefs in ingroup favoritism. Front Behav Neurosci 2015 Feb 13;9:15. DOI: https://doi.org/10.3389/fnbeh.2015.00015.
 6. Tversky A, Kahneman D. Availability: A heuristic for judging frequency and probability. Cogn Psychol 1973 Sep;5(2):207-32. DOI: https://doi.org/10.1016/0010-0285(73)90033-9.

Keywords: clinical peer review, healthy culture of learning, just culture, physician peer review, performance review, psychological safety, wellness

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