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This article reviews some of the current challenges for maternal death review in the United States, describes key findings from an assessment of U.S. capacity for conducting maternal death reviews, and introduces a new Maternal Mortality Initiative that aims to develop standardized guidelines for state- or city-based maternal deaths review processes.

Background: The Royal Australian and New Zealand College of Radiologists (RANZCR) initiated a unique instrument to audit the quality of patient notes and radiotherapy prescriptions. We present our experience collected over ten years from the use of the RANZCR audit instrument., Methods: In this study, the results of data collected prospectively from January 1999 to June 2009 through the audit instrument were assessed. Radiotherapy chart rounds were held weekly in the uro-oncology tumour stream and real time feedback was provided. Electronic medical records were retrospectively assessed in September 2009 to see if any omissions were subsequently corrected., Results: In total 2597 patients were audited. One hundred and thirty seven (5%) patients had one hundred and ninety nine omissions in documentation or radiotherapy prescription. In 79% of chart rounds no omissions were found at all, in 12% of chart rounds one omission was found and in 9% of chart rounds two or more omissions were found. Out of 199 omissions, 95% were of record keeping and 2% were omissions in the treatment prescription. Of omissions, 152 (76%) were unfiled investigation results of which 77 (51%) were subsequently corrected., Conclusions: Real-time audit with feedback is an effective tool in assessing the standards of radiotherapy documentation in our department, and also probably contributed to the high level of attentiveness. A large proportion of omissions were investigation results, which highlights the need for an improved system of retrieval of investigation results in the radiation oncology department.

Background: Although peer evaluation can be used to evaluate in-hospital handoffs, few studies have described using this strategy., Objective: Our objective was to assess feasibility of an online peer handoff evaluation and characterize performance over time among medical interns., Design: The design was a prospective cohort study., Patients: Subjects were medical interns from residency program rotating at 2 teaching hospitals., Measurements: Measurements were performance on an end-of-rotation evaluation of giving and receiving handoffs., Results: From July 2009 to March 2010, 31 interns completed 60% (172/288) of peer evaluations. Ratings were high across domains (mean, 8.3-8.6). In multivariate regression controlling for evaluator and evaluatee, statistically significant improvements over time were observed for 4 items compared to the first 3 months of the year: 1) communication skills (season 2, +0.34 [95% confidence interval (CI), 0.08-0.60], P = 0.009); 2) listening behavior (season 2, +0.29 [95% CI, 0.04-0.55], P = 0.025); 3) accepting professional responsibility (season 3, +0.37 [95% CI, 0.08-0.65], P = 0.012); and 4) accessing the system (season 2, +0.21 [95% CI, 0.03-0.39], P = 0.023). Ratings were also significantly lower when interns were postcall in written sign-out quality (8.21 vs 8.39, P = 0.008) and accepting feedback (8.25 vs 8.42, P = 0.006). Ratings from a community hospital rotation, with a lower census than the teaching hospital, were significantly higher for overall performance and 7 of 12 domains (P < 0.05 for all). Significant evaluator effects were observed., Conclusions: Although there is evidence of leniency, peer evaluation of handoffs demonstrate increases over time and associations with workload such as postcall status. This suggests the importance of examining how workload impacts handoffs in the future., (Copyright © 2012 Society of Hospital Medicine.)

Background: Service user participation in direct service provision and evaluation has been developing in the western world in the past 20 years. However, this recovery-based care model is relatively new in Asia., Aim: To understand the views and perceptions of the service users and of psychiatric nurses about the recruitment of peer specialists in a regional psychiatric unit in Hong Kong., Method: A qualitative study using probe questions to understand the above issues in the form of focus group discussion. A total of 13 psychiatric nurses and 16 mental health service users were recruited from a regional psychiatric unit for the study., Results: Content analysis based loosely on grounded theory has identified several important themes. While service users are generally enthusiastic about the potential contribution of peer specialists in a service setting, they are much concerned about rejection and discrimination by the psychiatric staff. Psychiatric nurses are also sceptical about the involvement of peer specialists in the delivery of service, although for an entirely different set of reasons. In view of the divergent views of the service users and the psychiatric nurses, a second round of focus group discussion was conducted seven months later to understand whether the themes distilled were consistent with their views expressed in the first round of focus group discussion., Conclusion: It is encouraging is that, for those psychiatric nurses who worked with volunteer service users in the pilot scheme of 'expert user participation', there was a change in view towards positive acceptance about peer specialist involvement in service delivery. The study provides some insight into the potential obstacles to and opportunities in the implementation of peer specialist services in routine psychiatric services in Hong Kong.

The aims of this study were to investigate how the Peer Assessment Rating (PAR index) predicts the perceived need for orthodontic treatment of mandibular protrusion in Japanese subjects, and to elucidate whether the perceived need for treatment was affected by the raters' orthodontic expertise. The subjects were 110 dental students and 32 orthodontists. We showed them casts of 10 untreated mandibular protrusion cases and gave them a questionnaire in which they had to describe their perceptions of the orthodontic treatment needs using a 10-point visual analog scale (VAS). The PAR index was used for cast evaluation. The PAR index scores showed significant correlations with the VAS scores. In casts with a low PAR score, there were no differences in the VAS scores between orthodontists and students. In casts with a PAR score greater than 23, the orthodontists perceived a significantly greater treatment need than did the students;for scores of 22, 28, and 29, students who had received orthodontic treatment themselves were more likely to perceive the treatment need. The PAR index is a good clinical predictor for assessing the perceived treatment needs for mandibular protrusion. Perception of the need for orthodontic treatment for mandibular protrusion depended on the degree of orthodontic expertise in Japanese subjects.

Aims: Current quality measures of percutaneous coronary intervention (PCI) procedures are based on the incidence of major adverse cardiac events (MACE). This crude marker ignores the many clinical nuances that make for sound decision making in PCI. We have established a prospective peer review audit tool to determine the quality of PCI within our cardiac network, which consists of five PCI hospitals serving a population of 1.4 million people in Sussex, UK., Methods and Results: Analysis of 10% of all PCI cases selected at random each month by a non-clinical audit manager is made by a rotating panel of two PCI operators and one cardiac surgeon. Each PCI case is assessed for anatomical suitability, lesion severity, strategic appropriateness and final outcome. Panel findings were reported back to the operator and the audit manager. A total of 326 cases were assessed by the review committee. Results were disseminated to individual operators. Coronary anatomy and lesion severity were considered appropriate for PCI in 94.2% and 96.0% of cases, respectively. Appropriateness of strategy was confirmed in 86.2% and the outcome considered satisfactory in 90.8%. A total of 242 subsequent cases were analysed to assess practice trends. This analysis demonstrated a statistically significant improvement in clinical decision making with respect to appropriateness of strategy (from 86.2% to 92.6%; p=0.004)., Conclusions: Prospective peer review of percutaneous coronary intervention cases by a rotating regional committee is valuable in ensuring procedural quality.

Background: Peer review offers a promising way of promoting improvement in health systems, but the optimal model is not yet clear. We aimed to describe a specific peer review model-reciprocal peer-to-peer review (RP2PR)-to identify the features that appeared to support optimal functioning., Methods: We conducted an ethnographic study involving observations, interviews and documentary analysis of the Improving Lung Cancer Outcomes Project, which involved 30 paired multidisciplinary lung cancer teams participating in facilitated reciprocal site visits. Analysis was based on the constant comparative method., Results: Fundamental features of the model include multidisciplinary participation, a focus on discussion and observation of teams in action, rather than paperwork; facilitated reflection and discussion on data and observations; support to develop focused improvement plans. Five key features were identified as important in optimising this model: peers and pairing methods; minimising logistic burden; structure of visits; independent facilitation; and credibility of the process. Facilitated RP2PR was generally a positive experience for participants, but implementing improvement plans was challenging and required substantial support. RP2PR appears to be optimised when it is well organised; a safe environment for learning is created; credibility is maximised; implementation and impact are supported., Discussion: RP2PR is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR functioned and may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions.

Introduction: Professional societies, like many other organizations, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 14 articles that methodologists and researchers from around the world have prepared to advise guideline developers in respiratory and other diseases on how to achieve this. We updated a review of the literature on guideline adaptation, evaluation, and updating, focusing on four key questions., Methods: In this review we addressed the following questions. (1) Which high-quality guidelines on chronic obstructive pulmonary disease (COPD) are available? (2) How should guidelines be adapted to the user's context and culture? (3) How should the use of guidelines be evaluated in clinical practice? and (4) How should guidelines be efficiently kept up-to-date? We did not conduct systematic reviews ourselves. We relied on a literature review published in 2006 and on a manual produced by the ADAPTE Collaboration to inform our judgments, as well as our collective experience and workshop discussions., Results and Discussion: Guideline adaptation can be seen as an alternative to de novo development and as part of an implementation process, taking into consideration the user's own context. A systematic approach should be followed to ensure high quality of the resulting guidance. On the topic of COPD, many guidelines are available. Guidelines of the Global Initiative for Chronic Obstructive Lung Disease and of the American Thoracic Society and European Respiratory Society are particularly well-suited for adaptation. The adaptation process includes (1) definition of specific questions that need to be answered by the guideline; (2) assessment of guideline quality; (3) assessment of the clinical content, validity, acceptability, applicability, and transferability of the recommendations; and (4) decisions about adoption or adaptation of the recommendations. The use of the guidelines in practice can be measured with performance indicators. Adverse effects of strict adherence to guideline recommendations should be prevented, in particular when the improvement of patient outcomes is unclear. COPD guidelines should be updated at least every 2 years. Collaboration between COPD guideline developers is recommended to prevent duplication of effort.

Purpose: In light of concerns regarding the quality of radiation treatment delivery, we surveyed the practice of quality assurance peer review chart rounds at American academic institutions., Methods and Materials: An anonymous web-based survey was sent to the chief resident of each institution across the United States., Results: The response rate was 80% (57/71). The median amount of time spent per patient was 2.7 minutes (range, 0.6-14.4). The mean attendance by senior physicians and residents was 73% and 93%, respectively. A physicist was consistently present at peer review rounds in 66% of departments. There was a close association between attendance by senior physicians and departmental organization: in departments with protected time policies, good attendance was 81% vs. 31% without protected time (p = 0.001), and in departments that documented attendance, attending presence was 69% vs. 29% in departments without documentation (p < 0.05). More than 80% of institutions peer review all external beam therapy courses; however, rates were much lower for other modalities (radiosurgery 58%, brachytherapy 40%-47%). Patient history, chart documentation, and dose prescription were always peer reviewed in >75% of institutions, whereas dosimetric details (beams, wedges), isodose coverage, intensity-modulated radiation therapy constraints, and dose-volume histograms were always peer reviewed in 63%, 59%, 42%, and 50% of cases, respectively. Chart rounds led to both minor (defined as a small multileaf collimator change/repeated port film) and major (change to dose prescription or replan with dosimetry) treatment changes. Whereas at the majority of institutions changes were rare (<10% of cases), 39% and 11% of institutions reported that minor and major changes, respectively, were made to more than 10% of cases., Conclusion: The implementation of peer review chart rounds seems inconsistent across American academic institutions. Brachytherapy and radiosurgical procedures are rarely reviewed. Attendance by senior physicians is variable, but it improves when scheduling clashes are avoided. The potential effect of a more thorough quality assurance peer review on patient outcomes is not known., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: The aim of this report is to describe the authors' experience with expanding the routine peer-review process to include misdiagnoses from all sources and the use of focused peer review (FPR) in faculty accountability and management., Methods: A department-wide routine peer review was conducted. Each radiologist was assigned 12 cases per month. In addition, clinically reported errors, missed diagnoses discovered outside the routine peer-review process, were identified. Cases were scored from 1 to 5. The department quality office evaluated cases with scores of 3 and 4 from both sources for further processing with FPR, a multistep continuation of the peer-review process using a tracking document. Once initiated, FPR was processed by seeking comments from the division director and the interpreting radiologist. In some cases, FPR was discontinued before completion. Completed FPR documents were submitted to the department chair for administrative action, ranging from no action to termination. All FPR cases are presented at monthly departmental morbidity and mortality conferences., Results: Routine peer review was done on 1,646 cases from a total of about 300,000 studies by 31 radiologists. Thirty-five cases from the two sources with scores of 3 and 4 were analyzed, 21 from the routine peer review and 14 clinically reported errors. The quality officer initiated 25 FPRs, rejecting 10 because errors were not considered significant. Further scrutiny lead to dropping 7 of the 12 routine and 2 of the 13 cases with clinically reported error. Sixteen FPRs were completed, 5 (31%) from routine peer review and 11 (69%) from clinically reported errors. For these 16 completed FPRs, management decisions were made by the department chair., Conclusions: Processing of routine peer-review data together with cases of clinically reported error strengthens the peer-review process. Focused peer review can effectively contribute to the surveillance and management of faculty performance for improved patient care., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: There is a global need to assess physicians' professional performance in actual clinical practice. Valid and reliable instruments are necessary to support these efforts. This study focuses on the reliability and validity, the influences of some sociodemographic biasing factors, associations between self and other evaluations, and the number of evaluations needed for reliable assessment of a physician based on the three instruments used for the multisource assessment of physicians' professional performance in the Netherlands., Methods: This observational validation study of three instruments underlying multisource feedback (MSF) was set in 26 non-academic hospitals in the Netherlands. In total, 146 hospital-based physicians took part in the study. Each physician's professional performance was assessed by peers (physician colleagues), co-workers (including nurses, secretary assistants and other healthcare professionals) and patients. Physicians also completed a self-evaluation. Ratings of 864 peers, 894 co-workers and 1960 patients on MSF were available. We used principal components analysis and methods of classical test theory to evaluate the factor structure, reliability and validity of instruments. We used Pearson's correlation coefficient and linear mixed models to address other objectives., Results: The peer, co-worker and patient instruments respectively had six factors, three factors and one factor with high internal consistencies (Cronbach's alpha 0.95 - 0.96). It appeared that only 2 percent of variance in the mean ratings could be attributed to biasing factors. Self-ratings were not correlated with peer, co-worker or patient ratings. However, ratings of peers, co-workers and patients were correlated. Five peer evaluations, five co-worker evaluations and 11 patient evaluations are required to achieve reliable results (reliability coefficient ≥ 0.70)., Conclusions: The study demonstrated that the three MSF instruments produced reliable and valid data for evaluating physicians' professional performance in the Netherlands. Scores from peers, co-workers and patients were not correlated with self-evaluations. Future research should examine improvement of performance when using MSF.

Background and Objectives: In-hospital mortality of myocardial infarction, heart failure and pneumonia within a private hospital chain were compared with the German average since 2000., Methods: Increased in-hospital mortalities based on diagnosis coding with ICD-10 benchmarked with German average values induced peer reviews in concern hospitals. From 2000 until 2010, peer reviews as performed by at least 2 peers compared retrospectively case management and treatment with best care, classified the treatment and discussed it with responsible physicians. The classification consisted of category 1 for improvement potential, category 2 for miscoding and category 3 for sufficient treatment. Based on the improvement potential an operational plan of treatment improvement for the single hospital was produced which was to be realized by this hospital and supported by concern activities for knowledge improvement., Results: In 2000, the indicators in-hospital mortality of myocardial infarction, heart failure and pneumonia of the hospital chain exceeded German average whereas in 2008 these values were lower (i. e. better) than German average. The peer reviews detected large improvement potentials in treatment processes and helped to improve them., Conclusion: Peer reviews as triggered by quality indicators supported improvement of treatment and likely outcomes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Context: Measurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such as pay-for-performance. As more measures are developed, the intensity with which measures are monitored changes. Performance measures are often retired after a period of sustained performance and not monitored as actively as other measures where performance is more variable. The effect of actively versus passively monitoring performance on measured quality of care is not known., Objective: We compared the nature and rate of change in hospital outpatient clinical performance as a function of a measure's status (active vs. passive), and examined the mean time to stability of performance after changing status. We hypothesize that performance will be higher when measures are actively monitored than when they are passively monitored., Design: Longitudinal, hierarchical retrospective analyses of outpatient clinical performance measure data from Veterans Health Administration's External Peer Review Program from 2000 to 2008., Setting: One hundred thirty-three Veterans Health Administration Medical Centers throughout the United States and its associated territories., Main Outcome Measures: Clinical performance on 17 measures covering 5 clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction, diabetes mellitus, and hypertension., Results: Contrary to expectations, we found that measure status (whether active or passive) did not significantly impact performance over time; time to stability of performance varied considerably by measure, and did not seem to covary with performance at the stability point (ie, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times)., Conclusions: We found no significant "extinction" of performance after measures were retired, suggesting that other features of the health care system, such as organizational policies and procedures or other structural features, may be creating a "strong situation" and sustaining performance. Future research should aim to better understand the effects of monitoring performance using process-of-care measures and creating sustained high performance.

Background: Despite extensive ongoing quality improvement (QI) efforts, substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in Kaiser Permanente, an integrated health care delivery system. In 2008, Kaiser Permanente developed an efficient and effective method for investigating hospital-level mortality to identify patterns of potential harm., Methods: The standardized multidisciplinary mortality review process incorporates the Institute for Healthcare Improvement Global Trigger Tools and 2x2 Mortality Matrix, elements of the United Kingdom's National Health Service (NHS) 3x2 matrix, and two groups of questions to "deep dive" into issues of preventable harm and the use of appropriate care settings. Between April 2008 and November 2009, multidisciplinary teams conducted mortality reviews of the 50 most recent inpatient deaths at 11 hospitals in Kaiser Permanente's Southern California region. An electronic chart abstraction tool facilitated rapid analysis of data. De-identified patient narratives portrayed trends and issues from a patient-centered perspective., Results: Ten categories of harm in inpatient deaths were identified, including failure to rescue, to plan, and to communicate; harm that occurred before hospitalization; medication-related events; surgical or procedural-related harm; hospital-acquired infection and pressure ulcers; falls; and "other." Senior leaders at the study hospitals identified 36 quality improvement goals in response., Conclusions: The mortality review process, which included quantitative data from structured chart abstraction and qualitative description of harm events, efficiently gathered important information on patterns of mortality that was not otherwise available, enabling hospitals to identify trends and focus improvement efforts.

Purpose: Health care organizations that employ advanced practice nurses are challenged to evaluate practice at this advanced level. Current evaluation methods tend to inter-mingle basic nursing competencies with competencies found in medical practice and organizational objectives that are typically derived from human resources departments. This article describes the development of a criterion-based job performance assessment for advanced nursing practice using a framework rooted in a nursing theory., Method: A needs analysis; review of the literature, adaptation of nursing's Synergy Model, and input from various stakeholders guided the development of a generic job description. This job description progressed into a criterion-based performance assessment. Construct validity was tested using a questionnaire administered to a convenience sample of 9 practicing advanced practice nurses, 2 nurse executives, 1 PhD nurse educator, and 1 physician., Conclusion: Autonomy, job satisfaction, and quality improvement for advanced practice nurses are fostered by a review process that defines roles and competencies specific to advanced nursing practice. Peer review, a concept contributing to this process is explored as a means to monitor and improve practice.

The development and execution of a nurse peer review program to evaluate nursing practice associated with significant adverse events has resulted in systemic changes. Descriptive analyses were conducted for 23 peer-reviewed cases involving 41 RNs and 2 advanced practice nurses from 14 specialties over a 4-year period. Thematic analysis revealed four common event categories: assessment and monitoring, team communication, skin integrity, and vascular access. This approach demonstrates the impact of professional nurse accountability for improving the quality of care and may serve as an exemplar for professional practice., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Peer reviews in nursing are historically used to gauge performance within an individual's scope of practice or as a tool to evaluate a sentinel or adverse event. Quality of care measures, clinical pertinence, and evaluating standards of care have begun as parallel strategies to replace the former uses in assuring the right care at the right time in the right setting.

Introduction: The Colleges of Physicians and Surgeons of Alberta and Nova Scotia (CPSNS) use a standardized multisource feedback program, the Physician Achievement Review (PAR/NSPAR), to provide physicians with performance assessment data via questionnaires from medical colleagues, coworkers, and patients on 5 practice domains: consultation communication, patient interaction, professional self-management, clinical competence, and psychosocial management of patients. Physicians receive a confidential report; the intent is practice improvement. However, research indicates that feedback from medical colleagues appears to be less understood than that from coworkers or patients, due to a lack of specificity and concerns regarding feedback credibility. The purpose of this study was to determine how physicians make decisions about performance ratings for family physician (FP) colleagues in the 5 practice domains., Methods: This was an exploratory qualitative study using focus groups-one with 11 family physicians and one with 12 specialists-who had served as NSPAR "medical colleague'' reviewers. We analyzed focus group transcripts using content analysis., Results: Family and specialist physicians provided examples of behaviors indicative of both high- and low-scoring performance for items within the 5 practice domains. From these, an assessment rubric was created to inform both external reviewers and the physicians being reviewed of performance expectations. Reviewers reported using varied sources of information to make assessments, including shared patients, medical records, referral letters, feedback from others, and self-reference., Discussion: The CPSNS has used the assessment rubric to create an online resource to inform medical colleague assessment and enhance the usefulness of their NSPAR scores. Further research will be required to determine its impact., (Copyright © 2011 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

Despite its importance, the objective impact of clinical peer review on the quality and safety of care has not been studied. Data from 296 acute care hospitals show that peer review program and related organizational factors can explain up to 18% of the variation in standardized measures of quality and patient safety. The majority of programs rely on an outmoded and dysfunctional process model. Adoption of best practices informed by the continuing study of peer review program effectiveness has the potential to significantly improve patient outcomes.

Following a multi-institutional research project, the authors formulated 12 tips for the successful implementation of peer assessment in a health-based setting. These tips relate to planning, delivery and feedback. They also offer a wide range of practical guidance and anecdotal evidence relating to peer assessment generally.

Background: A general practice in inner city Melbourne (Victoria), committed to ensuring quality standards of clinical care, developed a process for peer review of their doctors' performance. The aim was to ensure that there was a robust and fair process for evaluation of doctor performance from both a safety point of view, and from the perspective of contribution to team based practice., Objective: This article describes the process and outcomes of this appraisal process., Discussion: From the springboard of weekly clinical meetings which address critical incidents and near misses, the practice doctors developed an annual process of formal performance review incorporating hard and soft indicators of clinical performance and compliance with professional and practice standards. This type of activity falls within the scope of quality improvement in general practice.

Objective: The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). The authors report results from application of the RCT-PQRS to 94 randomized controlled trials of psychodynamic psycho-therapy published between 1974 and May 2010., Method: Five psychotherapy researchers from a range of therapeutic orientations rated a single published paper from each study., Results: The RCT-PQRS had good interrater reliability and internal consistency. The mean total quality score was 25.1 (SD=8.8). More recent studies had higher total quality scores. Sixty-three of 103 comparisons between psychodynamic psychotherapy and a nondynamic comparator were of "adequate" quality. Of 39 comparisons of a psychodynamic treatment and an "active" comparator, six showed dynamic treatment to be superior, five showed dynamic treatment to be inferior, and 28 showed no difference (few of which were powered for equivalence). Of 24 adequate comparisons of psychodynamic psychotherapy with an "inactive" comparator, 18 found dynamic treatment to be superior., Conclusions: Existing randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of psychodynamic psychotherapy to an inactive comparator. This would be sufficient to make psychodynamic psychotherapy an "empirically validated" treatment (per American Psychological Association Division 12 standards) only if further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for specific disorders. We do not yet know what will emerge when other psychotherapies are subjected to this form of quality-based review.

Prior research has shown wide variation in clinical peer review program structure, process, governance, and perceived effectiveness. This study sought to validate the utility of a Peer Review Program Self-Evaluation Tool as a potential guide to physician and hospital leaders seeking greater program value. Data from 330 hospitals show that the total score from the self-evaluation tool is strongly associated with perceived quality impact. Organizational culture also plays a significant role. When controlling for these factors, there was no evidence of benefit from a multispecialty review process. Physicians do not generally use reliable methods to measure clinical performance. A high rate of change since 2007 has not produced much improvement. The Peer Review Program Self-Evaluation Tool reliably differentiates hospitals along a continuum of perceived program performance. The full potential of peer review as a process to improve the quality and safety of care has yet to be realized.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified. Using this consistently, quality improvement strategies can be put in place and tracked for outcomes. This has allowed for better quantification of the problem as well as any change that may result from applying this formal review process and subsequent intervention.

Background: This study set out to evaluate evidence submitted by GPs for appraisal, and to explore how a model of appraisal can be developed which meets the needs of revalidation while remaining developmental and formative. This paper focuses on comparing evidence submitted by principal and sessional GPs, following previous work demonstrating problems facing the latter group., Methods: A checklist devised by one author was used by appraisers in one PCT to record evidence submitted for appraisal. This enabled a comparison between 76 principal and 47 sessional GPs of evidence submitted in one appraisal year from April 2008 to March 2009. The evidence was classified as personal or practice based, and the presence of reflection was noted. This quantitative evidence was supplemented by qualitative data from five focus groups with 22 GPs and one appraisal manager, and by interviews with seven GP appraisal leads in PCTs., Results: While some differences were noted between principal and sessional GPs, there were no differences found between the proportion of principal and sessional GPs who submitted personal evidence concerning data collection/audit, significant events, multi-source feedback and complaints. Focus groups indicated reasons and strategies which reflected these findings., Conclusions: Sessional GPs have already begun to use innovative approaches to ensure they meet the evidence requirements of appraisal and revalidation. However, they are more likely to succeed if they are well supported by educational and practice networks.

Objective: This program was designed to evaluate the effect of morbidity and mortality peer review conferences (MMPRCs) for ventilator-associated pneumonia (VAP) on nurse accountability and compliance with evidence-based VAP prevention practices., Background: Ventilator-associated pneumonia is associated with longer average length of stay (ALOS), greater cost, and increased morbidity and mortality. Traditionally, passive or punitive methods have been used to reduce undesirable outcomes. The MMPRC is not a conventional nursing intervention., Methods: Each MMPRC included case history, relevant hospital course, diagnostic comorbidities, and compliance with VAP prevention strategies. The preventability of each VAP was determined by RN peers. Ventilator days, VAP bundle compliance, VAP incidence, ICU ALOS, cost, and satisfaction data were collected., Results: Nurse accountability improved significantly (chi(2)= 24.041, P < .001), and VAP incidence was reduced. Data demonstrated satisfaction with the MMPRC. Number of ventilator days and ALOS did not change significantly, although VAP bundle compliance improved from 90.1% to 95.2%., Conclusions: The nonpunitive MMPRC process was cost-effective and should be considered for other nurse-sensitive indicators to increase nurse accountability and improve outcomes.

Objectives: There is growing interest in multi-source, multi-level feedback for measuring the performance of health care professionals. However, data are often unbalanced (e.g. there are different numbers of raters for each doctor), uncrossed (e.g. raters rate the doctor on only one occasion) and fully nested (e.g. raters for a doctor are unique to that doctor). Estimating the true score variance among doctors under these circumstances is proving a challenge., Methods: Extensions to reliability and generalisability (G) formulae are introduced to handle unbalanced, uncrossed and fully nested data to produce coefficients that take into account variances among raters, ratees and questionnaire items at different levels of analysis. Decision (D) formulae are developed to handle predictions of minimum numbers of raters for unbalanced studies. An artificial dataset and two real-world datasets consisting of colleague and patient evaluations of doctors are analysed to demonstrate the feasibility and relevance of the formulae. Another independent dataset is used for validating D predictions of G coefficients for varying numbers of raters against actual G coefficients. A combined G coefficient formula is introduced for estimating multi-sourced reliability., Results: The results from the formulae indicate that it is possible to estimate reliability and generalisability in unbalanced, fully nested and uncrossed studies, and to identify extraneous variance that can be removed to estimate true score variance among doctors. The validation results show that it is possible to predict the minimum numbers of raters even if the study is unbalanced., Discussion: Calculating G and D coefficients for psychometric data based on feedback on doctor performance is possible even when the data are unbalanced, uncrossed and fully nested, provided that: (i) variances are separated at the rater and ratee levels, and (ii) the average number of raters per ratee is used in calculations for deriving these coefficients.

In many countries, peer assessment programs based on the examination of patient charts are becoming a standard to assess physician's clinical performance. Although data on validity of the process are acceptable, reliability issues need some improvement. This article addresses the rarely studied aspect of optimal number of patient charts for an acceptable reliable assessment. Fifteen patient charts for each of a group of 20 practicing physicians were independently reviewed by 4 professional peer assessors. Generalizability (G) and decision (D) studies were applied to the data. It appears that as few as 10 patient charts are sufficient for any assessor to obtain a G coefficient of 0.80. Results of the current study suggest the possibility of getting generalizable assessments by peer reviewer with minimal information. These results are not in accordance with the concept of case specificity in which it is claimed that performance on a case is a poor predictor of performance on a different case.

Objective: The aim of this study was to determine if peer review conducted under real-world conditions is systematically biased., Study Design: A repeated-measures design was effectively created when two board-certified obstetrician-gynecologists reviewed the same 26 medical records of patients treated by the same physician, and provided written evaluations of each case and a summary of their criticisms. The reviews were conducted independently for two different, unaffiliated hospitals. Neither reviewer was aware of the other's review, and neither was affiliated with either hospital or knew the physician under review. This study reports the degree of agreement between the two reviewers over the care rendered to these 26 patients., Results: Three of the 26 cases reviewed had complications. Both reviewers criticized these cases, but criticized 2 of them for different reasons. At least one of the reviewers criticized 14 (61%) of the 23 uncomplicated cases, about which no quality concerns had been raised prior to the review. With one exception, they criticized completely different cases and criticized this 1 case for different reasons. Thus, only 4 of the 17 cases criticized by at least one of the reviewers were criticized by both of them, and only 1 of the 4 cases were criticized for the same reason. The Kappa statistic was -0.024, indicating no agreement between the reviewers (P = 0.98)., Conclusions: As presently conducted, peer review can be systematically biased even when conducted independently by external reviewers. Dual-process theory of reasoning can account for the bias and predicts how the bias may potentially be eliminated or reduced.

Traditional continuing medical education (CME), necessary for keeping physicians current and competent, is insufficient in translating physician practice into better patient outcomes. CME, then, must be transformed from a system of episodic interventions to a more personalized, contextual, flexible, and targeted process within a continuing professional development framework. The core of this transformation must be a formal process of physician self-assessment. Unfortunately, health care providers tend toward inaccurate self-assessment, regardless of training, specialty, or manner of self-assessment. Therefore, the development of an external validation system conducted by credible, informal peer review in a safe environment is essential. Clinicians must be able to access practice and patient data without concerns about accuracy, timeliness, confidentiality, attribution, or unintended consequences. New analytical tools are also needed to illuminate the data compilations and present them in compelling, individualized, and comparative formats. However, such developmental work will not be possible without strong community leadership coordinating a collaboration of resources and a sharing of data. Ensuring physician competence has long been an issue for medical societies, state licensing boards, and others invested in improving patient care. Now it's time to get serious. Current efforts at massive health care reform provide the perfect opportunity to fully integrate physician self-assessment and performance improvement into the larger health care system through a continuing professional development model. Practitioners in CME have been far too complacent with the current practices. A shift to a focused and dedicated sense of urgency must occur to ensure physicians' continuous learning and change.

In September 2006, the Royal Australian and New Zealand College of Radiologists (RANZCR) endorsed the modified Peer Review Audit Tool (PRAT). We aimed to assess the feasibility of using this tool in a busy radiation oncology department using an electronic medical record (EMR) system, identify areas of compliance and assess the impact of the audit process on patient management. Fortnightly random clinical audit was undertaken by using the revised RANZCR PRAT in the departments of radiation oncology at Liverpool and Macarthur Cancer Therapy Centres (LCTC and MCTC). Following audit of the EMR, treatment plans were audited by peer review. Data were collected prospectively from June 2007 to June 2008. Audits were carried out on 208 patients. Behaviour criteria were well documented in the EMR, but scanning of histology and medical imaging reports did not occur in up to a third of cases. With electronic prescriptions, treatment prescription errors were rare. In total, 8 (3.8%) out of 208 patients had a change to management recommended. Variability in interpretation of PRAT 'protocol/study' criteria was identified. We found that real-time audit is feasible and effective in detecting both issues with documentation in the EMR, and a small number of patients in whom a change to management is recommended. Recommendations have been made in order to continue to improve the audit process including documentation of any changes recommended and whether the recommended change occurred.

Incorporating evidence-based practice into the hospital setting has been a challenge but is needed to deliver quality healthcare. Interdisciplinary morbidity and mortality conferences are used to discuss perinatal and neonatal care issues with high-risk and low-frequency cases, such as fetal demise, maternal death, or identified areas for improvement. By involving an interdisciplinary team to review the patient's case, a more holistic perspective of the patient's care will be achieved. The purpose of this article is to demonstrate how nurses can be an essential part of the interdisciplinary morbidity and mortality conferences and how to infuse evidence-based practice into the conference. A perinatal morbidity and mortality conference will be described to illustrate how one maternal-neonatal department brought medicine and nursing together to review care.

University College London Hospitals NHS Foundation Trust is committed to developing a learning culture for its staff and, to achieve this, the organisation recently developed the after action review (AAR) model as a way for people involved in specific incidents to explore what happened and what they have learned. This article explains the concept of AAR and uses case studies to illustrate how it can improve patient care.

Introduction: Faculty assessment of students' professionalism is often based upon sporadic exposure to students. Peers are in a unique position to provide valid judgments of these behaviors., Aims: (1) To learn if peer assessments of professional conduct correlate with traditional performance measures; (2) to determine if peer assessments of professionalism influence the designation of honors, and (3) to explore student and faculty opinions regarding peer assessment., Setting: Internal Medicine Clerkship at Southern Illinois University., Program Description: Since 2001 anonymous student peer assessments of professionalism have been used in assigning clerkship grades., Program Evaluation: Peer assessments of professionalism had weak, though significant, correlations with faculty ratings (r = 0.29), performance on the NBME subject test (r = 0.28), and performance on a cumulative performance assessment (r = 0.30), and did not change the total number of honors awarded. A majority of students (71%) felt comfortable evaluating their peers, and 77% would keep the peer evaluation procedure in place. A majority of faculty (83%) indicated that peer assessments added valuable information., Discussion: Peer assessments of professional conduct have little correlation with other performance measures, are more likely to have a positive influence on final clerkship grades, and have little impact on awarding honors.

GP appraisal in Scotland is a strong and vibrant process. Not least this is due to NES's commitment to the ongoing development of its appraisers. Research suggests that the key to effective appraisal is the skill of the appraiser. Training in Scotland has developed using feedback from a wide range of sources. The move from information-based courses towards skills-based courses enhances appraiser development and allows the effective evaluation of appraiser competencies. With appraisal becoming a key element in the revalidation process the quality assurance of appraisal and appraisers becomes increasingly important.

I-CaRe, an inpatient case review tool that walks individual physician reviewers through the details of a patient case, facilitates the collection and assessment of quality and safety data both for internal quality improvement initiatives and external reporting.

Unlabelled: The Health Service Executive (HSE) appointed 20 examining dentists in April 2006 under contract for one year as part of a probity assurance initiative by peer review in the Dental Treatment Services Scheme (DTSS) in the Republic of Ireland., Aim: The aim of the study was to analyse the distribution of codes assigned to the reports drawn up by the examining dentists., Methods: At the end of the year's contract, each examining dentist forwarded an end of contract report of their activity, including the distribution of codes issued, to the HSE. These were correlated into a national summary of examining dentist activity, from which the data used in the study was extracted. A total of 11 different codes were used, varying from an indication of agreement between the examining dentist and the contracting dentist (code A) to a significant disagreement (code D)., Results: The vast majority (94.5%) of reports on the clinical examination of patients, drawn up by examining dentists, were in broad agreement with the treatment or estimate of the responsible contracting dentists. A total of 622 contracting dentists received such reports. The small minority of reports (4.8%) where there was a significant disagreement related to a small number of dentists (47 dentists)., Conclusions: The study provides evidence that most contracting dentists were not a probity risk. The author suggests that any future probity assurance initiative should focus on areas of high risk rather than random selection of patients/contracting dentists. An enhanced advisory role for the examining dentist is recommended.

GP appraisal may, in future, have to include objective and verifiable elements. This condition could be achieved by developing peer review of core areas of clinical practice. The setting for the study was two regions of NHS Education for Scotland (NES) without existing peer review systems (Figure 1). The South East region was further divided into South and East areas. A triangulation methodology was adopted to reflect the perspectives of peer reviewers, GPs submitting materials and the GPs appraising them (Figure 2). Outcomes measures included peer reviewers' feedback, learning needs identified by peer review, feedback from contributors and appraisers' perception of making judgements within GP appraisal. 1 Peer reviewers were recruited, trained and allocated to provide feedback on significant event analysis (SEA), criterion audit or video consultation submitted by professional colleagues. 2 GP appraisers voluntarily submitted materials for peer review then commented on feedback provided by peer reviewers. 3 A focus group of appraisers examined issues relating to professional judgement and national standards within appraisal. 4 All 15 peer reviewers recruited considered the project successful. Peer reviewers thought the model piloted could be delivered nationally if adequately resourced and supported by GPs. 5 Twenty six items (14 SEAs, nine audits and three videos) were submitted for peer review, which demonstrated moderate or high levels of learning need among GP participants. 6 In the focus group, most appraisers expressed difficulty making 'professional judgements' within appraisal but demonstrated a clear willingness to accept peer-reviewed material as evidence for discussion and development. Appraisers identified a range of educational material with the potential to conform to a national standard. There is potential for peer review to contribute to the development of objective and verifiable elements in GP appraisal, encouraging GPs to achieve agreed educational standards independent of the appraisal process. This small study suggests that a national system of peer review to support GP appraisal may be desirable among relevant stakeholders and should be explored further. Additional resources would clearly be required. A comparative review of different systems in other countries suggests further research is necessary to provide greater evidence of feasibility, acceptability and educational benefit of such a system in the UK.

Patient safety is of great concern to healthcare leaders and is a top priority in all healthcare organizations. It is essential to promote an organizational commitment that values a culture of safety through reporting of medical error and analysis of untoward events. Nursing peer review facilitates the establishment of a culture of safety, as it seeks to analyze medical errors and eliminate the reoccurrence of untoward events.

This manuscript describes a scholarly approach to peer case review that identifies and analyzes quality-of-care issues in response to a question about nursing care of a specific patient. The comprehensive method provides a structured format that critically examines untoward patient events, generates an awareness of gaps in care from a systems perspective, ensures action planning focused on legitimate root causes, stimulates performance improvement initiatives, and provides a forum to share learning throughout the organization.