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Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries., (Copyright © 2021. Published by Elsevier Inc.)

Objective: When a formal review of care takes places after the death of a baby, parents are largely unaware it takes place and are often not meaningfully involved in the review process. Parent engagement in the process is likely to be essential for a successful review and to improve patient safety. This study aimed to evaluate an intervention process of parental engagement in perinatal mortality review (PNMR) and to identify barriers and facilitators to its implementation., Design: Mixed-methods study of parents' engagement in PNMR., Setting: Single tertiary maternity unit in the UK., Participants: Bereaved parents and healthcare professionals (HCPs)., Interventions: Parent engagement in the PNMR (intervention) was based on principles derived through national consensus and qualitative research with parents, HCPs and stakeholders in the UK., Outcomes: Recruitment rates, bereaved parents and HCPs' perceptions., Results: Eighty-one per cent of bereaved parents approached (13/16) agreed to participate in the study. Two focus groups with bereaved parents (n=11) and HCP (n=7) were carried out postimplementation to investigate their perceptions of the process.Overarching findings were improved dialogue and continuity of care with parents, and improvements in the PNMR process and patient safety. Bereaved parents agreed that engagement in the PNMR process was invaluable and helped them in their grieving. HCP perceived that parent involvement improved the review process and lessons learnt from the deaths; information to understand the impact of aspects of care on the baby's death were often only found in the parents' recollections., Conclusions: Parental engagement in the PNMR process is achievable and useful for parents and HCP alike, and critically can improve patient safety and future care for mothers and babies. To learn and prevent perinatal deaths effectively, all hospitals should give parents the option to engage with the review of their baby's death., Competing Interests: Competing interests: Authors include the chair and members of the national Perinatal Mortality Review Tool (PMRT) group., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Peer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. Despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. Our purpose is to analyze peer-review process at our institution., Methods and Materials: Based on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. Prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. Items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. Cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session., Results: Over a period of 4 weeks, 148 cases were reviewed. Median of attendants was six physicians, three in-training-physicians and one physicist. Median time per session was 38 (4-72) minutes. 59.5% of cases presented in 1-4 min, 32.4% in 5-9 min and 8.1% in ≥ 10 min. 79.1% of cases were accepted without changes, 11.5% with minor changes, 6% with major changes and 3.4% were rejected with indication of new presentation. Most frequent reason of change was contouring corrections (53.8%) followed by dose or fractionation (26.9%)., Conclusion: Everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. This model is feasible within the normal operation of every radiation oncology Department.

Daily evaluations of certified registered nurse anesthetists' (CRNAs') work habits by anesthesiologists should be adjusted for rater leniency. The current study tested the hypothesis that there is a pairwise association by rater between leniencies of evaluations of CRNAs' daily work habits and of didactic lectures. The historical cohorts were anesthesiologists' evaluations over 53 months of CRNAs' daily work habits and 65 months of didactic lectures by visiting professors and faculty. The binary endpoints were the Likert scale scores for all 6 and 10 items, respectively, equaling the maximums of 5 for all items, or not. Mixed effects logistic regression estimated the odds of each ratee performing above or below average adjusted for rater leniency. Bivariate errors in variables least squares linear regression estimated the association between the leniency of the anesthesiologists' evaluations of work habits and didactic lectures. There were 29/107 (27%) raters who were more severe in their evaluations of CRNAs' work habits than other anesthesiologists (two-sided P < 0.01); 34/107 (32%) raters were more lenient. When evaluating lectures, 3/81 (4%) raters were more severe and 8/81 (10%) more lenient. Among the 67 anesthesiologists rating both, leniency (or severity) for work habits was not associated with that for lectures (P = 0.90, unitless slope between logits 0.02, 95% confidence interval -0.34 to 0.30). Rater leniency is of large magnitude when making daily clinical evaluations, even when using a valid and psychometrically reliable instrument. Rater leniency was context dependent, not solely a reflection of raters' personality or rating style.

Purpose: Assessor training is essential for defensible assessments of physician performance, yet research on the effectiveness of training programs for promoting assessor consistency has produced mixed results. This study explored assessors' perceptions of the influence of training and assessment tools on their conduct of workplace-based assessments of physicians., Method: In 2017, the authors used a constructivist grounded theory approach to interview 13 physician assessors about their perceptions of the effects of training and tool development on their conduct of assessments., Results: Participants reported that training led them to realize that there is a potential for variability in assessors' judgments, prompting them to change their scoring and feedback behaviors to enhance consistency. However, many participants noted they had not substantially changed their numerical scoring. Nonetheless, most thought training would lead to increased standardization and consistency among assessors, highlighting a "standardization paradox" in which participants perceived a programmatic shift toward standardization but minimal changes in their own ratings. An "engagement effect" was also found in which participants involved in both tool development and training cited more substantial learnings than participants involved only in training., Conclusions: Findings suggest that training may help assessors recognize their own subjectivity when judging performance, which may prompt behaviors that support rigorous and consistent scoring but may not lead to perceptible changes in assessors' numeric ratings. Results also suggest that participating in tool development may help assessors align their judgments with the scoring criteria. Overall, results support the continued study of assessor training programs as a means of enhancing assessor consistency.

Purpose: We conducted a prospective observational cohort study of physician compliance with daily early pretreatment planning peer review recommendations and quantified factors associated with compliance., Methods and Materials: All patient cases in our department are presented at 2 peer review conferences: (1) "early" preplanning, occurring daily for patients who have undergone simulation review, and (2) "late" (chart rounds), occurring weekly for patients who have started treatment. Peer review recommendations were prospectively recorded during early review, and compliance with recommendations was determined at chart rounds. Recommendations were assigned magnitude scores (minor, moderate, or major). We analyzed the association of patient, physician, and recommendation characteristics and compliance (scored as a binary variable) with early peer review recommendations, using logistic regression with a mixed effects model., Results: From February 2017 to May 2018, 1271 patient cases underwent early peer review, and 326 (26%) received peer-based recommendations. Of 356 recommendations, 37% were minor, 36% were moderate, and 27% were major. Overall compliance was 59% (95% confidence interval, 54%-64%). On univariate analysis, compliance decreased as the recommendation magnitude increased (minor, 65%; moderate, 60%; major, 47%; P = .019; odds ratio, 0.71 per increase in magnitude). Compliance also differed among different treating physicians (range, 38%-73%, χ 2 test, P = .003) but was not associated with other physician characteristics. Disease group and treatment technique were not associated with compliance. On multivariable analysis, increasing recommendation magnitude remained significantly associated with decreased compliance (multivariate P = .042; odds ratio, 0.74)., Conclusions: Daily early peer review resulted in a substantial proportion of recommended changes. Compliance with early peer review recommendations was fair but varied among physicians. Compliance declined with increasing recommendation magnitude, suggesting that physicians may be reluctant to adopt major changes. These results highlight the potential importance of peer review timing., (Copyright © 2019. Published by Elsevier Inc.)

Background: We report the rationale and design for a peer-evaluation protocol of attending congenital heart surgeon technical skill using direct video observation., Methods: All surgeons contributing data to The Society of Thoracic Surgeons-Congenital Heart Surgery Database (STS-CHSD) are invited to submit videos of themselves operating, to rate peers, or both. Surgeons may submit Norwood procedures, complete atrioventricular canal repairs, and/or arterial switch operations. A HIPPA-compliant website allows secure transmission/evaluation. Videos are anonymously rated using a modified Objective Structured Assessment of Technical Skills score. Ratings are linked to five years of contemporaneous outcome data from the STS-CHSD and surgeon questionnaires. The primary outcome is a composite for major morbidity/mortality., Results: Two hundred seventy-six surgeons from 113 centers are eligible for participation: 83 (30%) surgeons from 53 (45%) centers have agreed to participate, with recruitment ongoing. These surgeons vary considerably in years of experience and outcomes. Participants, both early and late in their careers, describe the process as "very rewarding" and "less time consuming than anticipated." An initial subset of 10 videos demonstrated excellent interrater reliability (interclass correlation = 0.85)., Conclusions: This study proposes to evaluate the technical skills of attending pediatric cardiothoracic surgeons by video observation and peer-review. It is notable that over a quarter of congenital heart surgeons, across a range of experiences, from almost half of United States centers have already agreed to participate. This study also creates a mechanism for peer feedback; we hypothesize that feedback could yield broad and meaningful quality improvement.

Whole slide imaging (WSI) technology has advanced to a point where it has replaced the glass slide as the primary means of pathology evaluation within many areas of medical pathology. The deployment of WSI in the field of toxicologic pathology has been delayed by a lack of clarity around the degree of validation required for its use on Good Laboratory Practice (GLP) studies. The current opinion piece attempts to provide a high-level overview of WSI technology to include basic methodology, advantages and disadvantages over a conventional microscope, validation status of WSI scanners, and perceived concerns over regulatory acceptance for the use of WSI for (GLP) peer review in the field of toxicologic pathology. Observations are based on the extensive use by AstraZeneca of WSI for the peer review of non-GLP studies conducted at Charles River facilities and represent the experiences of the authors. Note: This is an opinion article submitted to the Toxicologic Pathology Forum. It represents the views of the author(s). It does not constitute an official position of the Society of Toxicologic Pathology, British Society of Toxicological Pathology, or European Society of Toxicologic Pathology, and the views expressed might not reflect the best practices recommended by these Societies. This article should not be construed to represent the policies, positions, or opinions of their respective organizations, employers, or regulatory agencies.

Head and Neck Cancer (HNC) radiation oncologists (ROs) enjoy the immense pleasure of curing patients, working within a large multidisciplinary team to effectively deliver curative intent treatment whilst also aiming to minimise late treatment toxicity. Secondary analyses of large-scale HNC clinical trials have shown the critical impact of the quality of radiotherapy plans, where protocol non-compliant plans have yielded inferior survival rates approximating 20%. The peer review process in routine day-to-day HNC practice shows that even in major academic centers a significant proportion of RT plans may require changes to the radiotherapy planning volume. Optimising the therapeutic ratio in HNC has been dramatically facilitated by intensity modulated radiotherapy (IMRT), but that technology has also increased the complexity of HNC radiotherapy treatment and high-volume centers with experienced clinicians may be best placed to deliver this most accurately. International consensus guidelines to standardise or benchmark best practice with respect to the RT-QA process in HNC are needed. The aim of this paper is to highlight the importance of the RT-QA process in the HNC treatment process and to make some recommendations for its inclusion in both clinical trials and routine clinical practice., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: Audit and feedback interventions may be strengthened using social interaction. With this in mind, the Calgary office of the Alberta Physician Learning Program developed a process for audit and group feedback for physician groups. As a part of a larger project to develop a practical approach to the design and implementation of audit and group feedback projects, we explored patterns of physician behavior during facilitated audit and group feedback sessions., Methods: Six audit and group feedback sessions were recorded, transcribed, and analyzed thematically to derive a conceptual model of physicians' behaviors during audit and group feedback sessions., Results: A predictable cycle of behaviors emerged from audit and group feedback sessions. This cycle would repeat with discussion of each new data element: reacting to the data, questioning and understanding the data, justifying and contextualizing, sharing and reflecting on the data and relevant guidelines, and planning for change. "Change cues" that emerged within groups reliably pivoted the discussion towards action planning., Conclusions: In audit and group feedback sessions, physicians display a predictable series of behaviors as they move towards commitment to change. Establishing the meaning and credibility of the data is a necessary precursor to reflection. Group reflection leads to "change cues" triggered by group members, which stimulate action planning.

Objective: Random peer review programs are not optimized to discover cases with diagnostic error and thus have inherent limitations with respect to educational and quality improvement value. Nonrandom peer review offers an alternative approach in which diagnostic error cases are targeted for collection during routine clinical practice. The objective of this study was to compare error cases identified through random and nonrandom peer review approaches at an academic center., Methods: During the 1-year study period, the number of discrepancy cases and score of discrepancy were determined from each approach., Results: The nonrandom peer review process collected 190 cases, of which 60 were scored as 2 (minor discrepancy), 94 as 3 (significant discrepancy), and 36 as 4 (major discrepancy). In the random peer review process, 1,690 cases were reviewed, of which 1,646 were scored as 1 (no discrepancy), 44 were scored as 2 (minor discrepancy), and none were scored as 3 or 4. Several teaching lessons and quality improvement measures were developed as a result of analysis of error cases collected through the nonrandom peer review process., Conclusions: Our experience supports the implementation of nonrandom peer review as a replacement to random peer review, with nonrandom peer review serving as a more effective method for collecting diagnostic error cases with educational and quality improvement value., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: The Manitoba Physician Achievement Review (MPAR) is a 360-degree feedback assessment that physicians undergo every 7 years to retain licensure. Deliberate reflection on feedback has been demonstrated to encourage practice change. The MPAR Reflection Exercise (RE), a peer-assisted debriefing tool, was developed whereby the physician selects a peer with whom to review and reflect on feedback, committing to change. This qualitative study explores how physicians who had undergone the MPAR used the RE, what areas of change are identified and committed to, and what they perceived as the role of reflection in the MPAR process., Methods: The MPAR RE was piloted out to a cohort of MPAR-reviewed physicians. Thematic analysis was conducted on completed exercises (n = 61). Semi-structured interviews were conducted with individuals (n = 6) who completed the MPAR RE until saturation was reached., Results: Physicians reviewed feedback with a range of peers, including colleagues, staff, and spouses. Many physicians were surprised by feedback, both positive and negative, but interviewees found the RE useful in processing feedback. Areas where physicians committed to change were diverse, covering all CanMEDS roles. Most physicians identified themselves as being successful in implementing change, though time, habit, and structures were cited as barriers., Conclusions: Peer-assisted debriefing can assist reflection of multisource feedback. It is easy to implement, is not resource-intensive, and feedback implies that it is effective at promoting change. Participants, with the aid of peers, identified areas for change, developed approaches for change, and largely thought themselves successful at implementing changes. Areas of change included all seven CanMEDS roles.

Objective: This cross-sectional study assessed the impact of a peer-review program on the prevalence of pediatric antipsychotic use among Medicaid-insured youths in a Mid-Atlantic state., Methods: Medicaid claims (2010-2014) were assessed among continuously enrolled youths in the 12 months before and after implementation of peer review. The study identified children ages zero to four preimplementation (N=118,815) and postimplementation (N=121,431), ages five to nine preimplementation (N=98,681) and postimplementation (N=107,872), and ages 10 to 17 preimplementation (N=154,696) and postimplementation (N=161,370). (Age ranges are inclusive of the final number). In each age group, multivariable logistic regression models with generalized estimating equations assessed the change in annual prevalence of antipsychotic use pre- to postimplementation. Use of other leading psychotropic classes and antipsychotic prescribing by medical specialty were also examined., Results: The annual pre- to postimplementation prevalence of antipsychotic use decreased significantly, from .07% to .03% (adjusted odds ratio [AOR]=.41) among children ages zero to four, from 1.57% to .86% (AOR=.54) among those ages five to nine, and from 3.28% to 2.40% (AOR=.72) among those ages 10 to 17. With the exception of alpha-agonist use, which increased postimplementation (AOR=1.30) among those ages zero to four, no clinically significant pre-post change was noted in other leading psychotropic classes among children ages zero to four and 10 to 17. By contrast, postimplementation use of other psychotropic medications decreased among those ages five to nine (AOR=.73)., Conclusions: A state Medicaid peer-review program resulted in decreased antipsychotic use across all age groups, particularly among children younger than ten. No notable substitution of other psychotropic classes for antipsychotics was observed.

Introduction: Multisource feedback (MSF) instruments are used to and must feasibly provide reliable and valid data on physicians' performance from multiple perspectives. The "INviting Co-workers to Evaluate Physicians Tool" (INCEPT) is a multisource feedback instrument used to evaluate physicians' professional performance as perceived by peers, residents, and coworkers. In this study, we report on the validity, reliability, and feasibility of the INCEPT., Methods: The performance of 218 physicians was assessed by 597 peers, 344 residents, and 822 coworkers. Using explorative and confirmatory factor analyses, multilevel regression analyses between narrative and numerical feedback, item-total correlations, interscale correlations, Cronbach's α and generalizability analyses, the psychometric qualities, and feasibility of the INCEPT were investigated., Results: For all respondent groups, three factors were identified, although constructed slightly different: "professional attitude," "patient-centeredness," and "organization and (self)-management." Internal consistency was high for all constructs (Cronbach's α ≥ 0.84 and item-total correlations ≥ 0.52). Confirmatory factor analyses indicated acceptable to good fit. Further validity evidence was given by the associations between narrative and numerical feedback. For reliable total INCEPT scores, three peer, two resident and three coworker evaluations were needed; for subscale scores, evaluations of three peers, three residents and three to four coworkers were sufficient., Discussion: The INCEPT instrument provides physicians performance feedback in a valid and reliable way. The number of evaluations to establish reliable scores is achievable in a regular clinical department. When interpreting feedback, physicians should consider that respondent groups' perceptions differ as indicated by the different item clustering per performance factor.

Study Objective: Anesthesiologists can provide psychometrically reliable daily evaluations of certified registered nurse anesthetist (CRNA) work habits for purposes of the mandatory ongoing professional practice evaluation (OPPE). Our goal was to evaluate the validity of assessing CRNA work habits., Design: Observational study., Setting: Large teaching hospital., Measurements: N=77 anesthesiologists evaluated work habits of N=67 CRNAs. The non-technical attribute of work habits was measured on a 6-item scale (e.g., 1="Only assumed responsibility when forced to, and failed to follow through consistently" versus 5="Consistently identified tasks and completed them efficiently and thoroughly"). One year of scores were used to assess validity. Each daily evaluation could also be accompanied by a written comment. Content analysis of comments was performed using two years of data. Statistical analyses were performed using mixed effects logistic regression, treating each anesthesiologist as a fixed effect to compensate for the leniency of their ratings., Main Results: The N=77 anesthesiologists' response rate was 97.3%, obtained at a mean 2.93days after the request. The internal consistency of the scale was large: Cronbach's alpha 0.952. Controlling the false discovery rate at 5.0%, among the 67 CRNAs, 8 were significantly below average (each P≤0.0048) and 6 were above average (each P≤0.0018). During the 6months after CRNAs knew that their work habits scores would be used for OPPE, there were significant increases in the scores compared with the preceding 6months (odds ratio 1.93, P<0.0001). Greater CRNA's qualitative annual evaluation scores made by the chief CRNA, without knowledge of the work habit scores or comments, were associated with greater odds of the CRNA's leniency-adjusted work habit scores equaling 5.00 (odds ratio 1.53, P=0.0004). Comments of negative sentiment made by the anesthesiologists were associated with greater odds of the leniency-adjusted work habit scores being <5.00 (odds ratio 54.5, P<0.0001). Even though the anesthesiologists were already providing information about work habits using the work habits scale, approximately half the comments of negative sentiment included the theme of work habits (92/153, 60.1%)., Conclusions: Reporting OPPE metrics are mandatory for the maintenance of clinical privileges of anesthesia practitioners in the USA. Basing such peer review on work habits can be quantitative, psychometrically reliable, and valid., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Technological advances in radiation therapy permit steep dose gradients from the target to spare normal tissue, but increase the risk of geographic miss. Suboptimal target delineation adversely affects clinical outcomes. Prospective peer review is a method for quality assurance of oncologists' radiotherapy plans. Published surveys suggest it is widely implemented. However, it may not be feasible to review every case before commencement of radiation therapy in all departments. The rate of plan changes following peer review of cases without a specific subsite or modality is typically around 10%. Stereotactic body radiation therapy, head and neck, gynaecological, gastrointestinal, haematological and lung cases are associated with higher rates of change of around 25%. These cases could thus be prioritised for peer review. Other factors may limit peer review efficacy including organisational culture, time constraints and the physical environment in which sessions are held. Recommendations for peer review endorsed by the American Society for Radiation Oncology were made available in 2013, but a number of relevant studies have been published since. Here we review and update the literature, and provide an updated suggestion for the implementation of peer review to serve as an adjunct to published guidelines. This may help practitioners evaluate their current processes and maximise the utility and effectiveness of peer review sessions., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: Missing life-threatening injuries is a persistent concern in any trauma program. Autopsy is a tool routinely utilized to determine an otherwise occult cause of death in many fields of medicine. It has been adopted as a required component of the trauma peer review (PR) process by both the American College of Surgeons and the Pennsylvania Trauma Foundation. We hypothesized that autopsy would not identify preventable deaths for augmentation of the PR process., Materials and Methods: A retrospective chart review using our institutional trauma registry of all trauma deaths between January 2012 and December 2015 was performed. Per the protocol of our level 1 center, all trauma deaths are referred to the medical examiner (ME) and reviewed as part of the trauma PR process. All autopsy results are evaluated with relation to injury severity score (ISS), trauma injury severity score (TRISS), nature of death, and injuries added by autopsy. ME reports are reviewed by the trauma medical director and referred back to the trauma PR committee if warranted. Trauma injury severity score methodology determines the probability of survival (Ps) given injuries identified. A patient with Ps of ≥0.5 is expected to survive their injuries. Cohorts were created based on when in the hospitalization death occurred: <24 h, or immediate death; 24 to 48 h, or early death; and death >48 h, or late death. A comparison was conducted between the ISS and Ps calculated during trauma workup and on autopsy using chi-square and Fischer's exact tests., Results: A total of 173 patient deaths were referred to the ME with 123 responses received. Average length of stay was 2.61 d. Twenty-six patients had autopsy declined by the ME, 25 received an external examination only, and 72 received a full autopsy. Autopsy identified one case that was reconsidered in PR (P = 0.603) and added diagnoses, but not injuries, to one patient in the early death group (P = 1) and two in the late death group (P = 0.4921). No preventable cause of death was uncovered, and educational use was minimal. Autopsy did identify injuries in seven cases that were initially not consistent with expected mortality, but postmortem Ps was consistent with expected mortality (P = 0.254). Mean ISS was 34.48, and mean Ps was 0.275 among all patients. The most commonly identified injuries added by autopsy were rib injuries, lung injuries, and intracranial hemorrhage., Conclusions: Autopsy does not identify causes of preventable in an otherwise highly functioning trauma program and may be a poor use of institutional resources. In fact, it adds few diagnoses when death occurs after a full trauma assessment has had time to take place. Autopsy may be of use to identify protocol failure in maturing trauma programs, to give answers to grieving families and in select situations where death was unanticipated even after a full evaluation took place., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Assuring quality in cancer care through peer review has become increasingly important in radiation oncology. In 2012, our department implemented an automated electronic system for managing radiation treatment plan peer review. The purpose of this study was to compare the overall impact of this electronic system to our previous manual, paper-based system., Methods and Materials: In an effort to improve management, an automated electronic system for case finding and documentation of review was developed and implemented. The rates of missed initial reviews, late reviews, and missed re-reviews were compared for the pre- versus postelectronic system cohorts using Pearson χ 2 test and relative risk. Major and minor changes or recommendations were documented and shared with the assigned clinical provider., Results: The overall rate of missed reviews was 7.6% (38/500) before system implementation versus 0.4% (28/6985) under the electronic system (P < .001). In terms of relative risk, courses were 19.0 times (95% confidence interval, 11.8-30.7) more likely to be missed for initial review before the automated system. Missed re-reviews occurred in 23.1% (3/13) of courses in the preelectronic system cohort and 6.6% (10/152) of courses in the postelectronic system cohort (P = .034). Late reviews were more frequent during high travel or major holiday periods. Major changes were recommended in 2.2% and 2.8% in the pre- versus postelectronic systems, respectively. Minor changes were recommended in 5.3% of all postelectronic cases., Conclusions: The implementation of an automated electronic system for managing peer review in a large, complex department was effective in significantly reducing the number of missed reviews and missed re-reviews when compared to our previous manual system., (Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Background: We modified the departmental mortality and morbidity (M&M) meetings to evaluate whether patient safety incident review as a part of this meeting was associated with reduced patient safety incidents., Method: A pilot programme of peer review of patient safety incidents (PSI) supported by education relevant to that event and follow-on action plan was introduced as a part of an extended morbidity and mortality meeting in a university hospital orthopaedic department. The pilot programme was conducted over six months (January 2012-June 2012). This programme involved junior and senior doctors including consultants although multidisciplinary groups were invited to attend. We investigated PSI rate/1000 hospital admissions for trauma and elective surgery, which were collected prospectively and independently between Jan 2011 to June 2013. We noted if the incident was caused by a medical or a nursing error and compared PSI rates., Results: Rates of PSI (33/1000) were 7.8 times higher in trauma cases (80.2/1000) than in elective admissions (11.2/1000). There was 18% reduction in trauma and 27% reduction in planned elective admissions. The rate increased after the pilot programme finished but there was still a 7% reduction compared to the pre-pilot period. This study found a significant reduction in the PSI rate for medical error but no change in the rate of nursing error., Conclusion: This continuous reflection, education and action process, where safety events are reviewed as a part of the extended morbidity and mortality meeting, is associated with reduction of patient safety incidents. We recommend that PSI reflection should be introduced in Mortality and Morbidity meetings with mandated attendance of the entire multidisciplinary health care team.

This essay will explore the critical issues and challenges surrounding lifelong learning for professionals, initially exploring within the profession and organizational context of nuclear medicine practice. It will critically examine how the peer-review process called Quality Management Audits in Nuclear Medicine Practice (QUANUM) of the International Atomic Energy Agency (IAEA) can be considered a lifelong learning opportunity to instill a culture of quality to improve patient care and elevate the status of the nuclear medicine profession and practice within the demands of social changes, policy, and globalization. This will be explored initially by providing contextual background to the identity of the IAEA as an organization responsible for nuclear medicine professionals, followed by the benefits that QUANUM can offer. Further key debates surrounding lifelong learning, such as compulsification of lifelong learning and impact on professional change, will then be weaved through the discussion using theoretical grounding through a qualitative review of the literature. Keeping in mind that there is very limited literature focusing on the implications of QUANUM as a lifelong learning process for nuclear medicine professionals, this essay uses select narratives and observations of QUANUM as a lifelong learning process from an auditor's perspective and will further provide a comparative perspective of QUANUM on the basis of other lifelong learning opportunities such as continuing professional development activities and observe parallelisms on its benefits and challenges that it will offer to other professionals in other medical speciality fields and in the teaching profession.

Objective: Determine if peer feedback through a chart review tool (CRT) can impact opioid prescribing for patients with chronic noncancer pain in an outpatient family medicine clinic at an urban, safety-net teaching hospital and to assess providing practices., Design: A quality improvement (QI) project, comparing preopioid and postopioid prescribing practices., Setting: Outpatient family medicine clinic at urban, safety-net teaching hospital., Patients, Participants: A convenience sample of 16 family medicine physicians., Interventions: A CRT was developed to allow physicians to give peer feedback to one another about their opioid prescribing practices as part of a 1-year QI project. We assessed the deidentified data gathered from the CRT., Main Outcome Measure(s): Primary study outcome measures were the amount of opioids prescribed at the end of the QI project compared to the time of initial chart review. We also describe overall prescribing practices., Results: Ninety-nine patient charts from 14 different physicians were reviewed over 1 year. Sixty percent of patients had at least one violation of the clinic's controlled substance prescribing policy in the prior 6 months, and half of the violations were due to missed appointments with specialists to help manage pain. The mean dose of opioids decreased 2.6 mg morphine equivalent dose (MED)/day from time of chart review until the end of project, compared to a 6.9 mg MED/day increase that occurred from 12 months prior to chart review to the time of chart review (p=0.01). Fourteen patients (16 percent) of patients prescribed opioids were taken-off of opioids after the chart review., Conclusions: Use of a CRT in an urban primary care clinic provided helpful insight on prescribing practices and has promise to improve quality of opioid prescribing.

Objective: To assess review completion rates, RADPEER score distribution, and sources of disagreement when using a workstation-integrated radiology peer review program, and to evaluate radiologist perceptions of the program., Design: Retrospective review of prospectively collected data., Setting: Large private outpatient radiology practice., Participants: Radiologists (n = 66) with a mean of 16.0 (standard deviation, 9.2) years of experience., Interventions: Prior studies and reports of cases being actively reported were randomly selected for peer review using the RADPEER scoring system (a 4-point scale, with a score of 1 indicating agreement and scores of 2-4 indicating increasing levels of disagreement)., Main Outcome Measures: Assigned peer review completion rates, review scores, sources of disagreement and radiologist survey responses., Results: Of 31 293 assigned cases, 29 044 (92.8%; 95% CI 92.5-93.1%) were reviewed. Discrepant scores (score = 2, 3 or 4) were given in 0.69% (95% CI 0.60-0.79%) of cases and clinically significant discrepancy (score = 3 or 4) was assigned in 0.42% (95% CI 0.35-0.50%). The most common cause of disagreement was missed diagnosis (75.2%; 95% CI 66.8-82.1%). By anonymous survey, 94% of radiologists felt that peer review was worthwhile, 90% reported that the scores they received were appropriate and 78% felt that the received feedback was valuable., Conclusion: Workstation-based peer review can increase completion rates and levels of radiologist acceptance while producing RADPEER scores similar to those previously reported. This approach may be one way to increase radiologist engagement in peer review quality assurance., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

Purpose: The objective of this study was to evaluate the feasibility of the consensus-oriented group review (COGR) method of radiologist peer review within a large subspecialty imaging department., Methods: This study was institutional review board approved and HIPAA compliant. Radiologist interpretations of CT, MRI, and ultrasound examinations at a large academic radiology department were subject to peer review using the COGR method from October 2011 through September 2013. Discordance rates and sources of discordance were evaluated on the basis of modality and division, with group differences compared using a χ(2) test. Potential associations between peer review outcomes and the time after the initiation of peer review or the number of radiologists participating in peer review were tested by linear regression analysis and the t test, respectively., Results: A total of 11,222 studies reported by 83 radiologists were peer reviewed using COGR during the two-year study period. The average radiologist participated in 112 peer review conferences and had 3.3% of his or her available CT, MRI and ultrasound studies peer reviewed. The rate of discordance was 2.7% (95% confidence interval [CI], 2.4%-3.0%), with significant differences in discordance rates on the basis of division and modality. Discordance rates were highest for MR (3.4%; 95% CI, 2.8%-4.1%), followed by ultrasound (2.7%; 95% CI, 2.0%-3.4%) and CT (2.4%; 95% CI, 2.0%-2.8%). Missed findings were the most common overall cause for discordance (43.8%; 95% CI, 38.2%-49.4%), followed by interpretive errors (23.5%; 95% CI, 18.8%-28.3%), dictation errors (19.0%; 95% CI, 14.6%-23.4%), and recommendation (10.8%; 95% CI, 7.3%-14.3%). Discordant cases, compared with concordant cases, were associated with a significantly greater number of radiologists participating in the peer review process (5.9 vs 4.7 participating radiologists, P < .001) and were significantly more likely to lead to an addendum (62.9% vs 2.7%, P < .0001)., Conclusions: COGR permits departments to collect highly contextualized peer review data to better elucidate sources of error in diagnostic imaging reports, while reviewing a sufficient case volume to comply with external standards for ongoing performance review., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Academic centers increasingly find a need to define a comprehensive peer-review program that can translate high-quality radiation therapy (RT) to community network sites. In this study, we describe the initial results of a quarterly quality audit program that aims to improve RT peer-review and provider educational processes across community sites., Materials and Methods: An electronic tool was used by community-based certified member (CM) sites to enter clinical treatment information about patients undergoing peer review. At least 10% of the patient load for each CM physician was selected for audit on a quarterly basis by expert academic faculty. Quality metrics included the review of the management plan, technical plan, and other indicators. RT was scored as being concordant or nonconcordant with institutional guidelines, national standards, or expert judgment., Results: A total of 719 patients were entered into the peer-review database by the first four CM sites. Of 14% of patients audited, 17% (18 of 104) were deemed nonconcordant. Nonconcordance rates were lowest in prevalent disease sites, such as breast (16%), colorectal (14%), and lung (12%), whereas rates were highest in lymphoma (50%), brain (44%), and gynecology (27%). Deficiencies included incomplete staging work-up, incorrect target and normal tissue delineation, and nonadherence to accepted dose-volume constraints., Conclusion: Given the high rate of nonconcordance, we recommend prospective, pre-RT peer review of all patients, and, in particular, expert review of patients that are from low-volume or complex disease sites. An integrated approach to peer review holds a promise of improving the quality, safety, and value of cancer therapy in the community setting., (Copyright © 2016 by American Society of Clinical Oncology.)

Background: The sociomedical evaluation by the German Pension Insurance serves the purpose of determining entitlement to disability pensions. A quality assurance concept for the sociomedical evaluation was developed, which is based on a peer Review process. Peer review is an established process of external quality assurance in health care. The review is based on a hierarchically constructed manual that was evaluated in this pilot project., Methods: The database consists of 260 medical reports for disability pension of 12 pension insurance agencies. 771 reviews from 19 peers were included in the evaluation of the inter-rater reliability. Kendall's coefficient of concordance W for more than 2 raters is used as primary measure of inter-rater reliability., Results: Reliability appeared to be heterogeneous. Kendalls W varies for the particular criteria from 0.09 to 0.88 and reached for primary criterion reproducibility a value of 0.37., Conclusion: The reliability of the manual seemed acceptable in the context of existing research data and is in line with existing peer review research outcomes. Nevertheless, the concordance is limited and requires optimisation. Starting points for improvement can be seen in a systematic training and regular user meetings of the peers involved., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: An important internal quality control system used in the Cancer Prevention and Research Institute cytopathology laboratory in Florence is the peer review procedure, based on the review of all abnormal cytological smears which routinely emerge. Peer review is an important training opportunity for all cytologists, especially for those with less experience. This article shows the results of the peer review procedure., Methods: Of the 63 754 Papanicolaou (Pap) smears screened in 2011, 1086 were considered to be abnormal [at least atypical squamous cells of undetermined significance (ASC-US+)] on primary screening (selected by a single cytologist) and were subjected to the peer review procedure. The overall performance of the laboratory's cytologists was evaluated using a multiple rater analysis and the comparison of each cytologist with the final diagnosis. Further, the agreement was assessed by means of Cohen's kappa and weighted kappa statistics., Results: In general, a moderate/substantial level of agreement between the ten cytologists and the final diagnoses was evident. Kappa values for each reader compared with the final diagnosis ranged from 0.54 to 0.69. The overall kappa value was 0.62 [95% confidence interval (CI), 0.58-0.66] and overall weighted kappa value was 0.76 (95% CI, 0.74-0.79). The category-specific agreement showed the lowest values for atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H)., Conclusion: In summary, peer review represents an important internal quality control in the evaluation and improvement of inter-observer agreement and of the functioning of the laboratory as a whole. Multi-head microscope sessions may improve particularly the reproducibility of borderline diagnoses and, above all, can be an important training contribution for cytologists., (© 2014 John Wiley & Sons Ltd.)

The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria (AUC) on the Management of Pediatric Supracondylar Humerus Fractures (PSHF). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The PSHF AUC clinical patient scenarios were derived from patient indications that generally accompany a PSHF as well as from current evidence-based clinical practice guidelines and supporting literature. The 220 patient scenarios and 14 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, the Review Panel, a separate group of volunteer physicians, independently reviewed these materials to ensure that they were representative of patient scenarios that clinicians are likely to encounter in daily practice. Finally, the multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3)., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)

Objectives: The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement., Methods: The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards., Results: The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment., Conclusions: We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.

Objective: To assess the validity and reliability of the Sheffield Peer Review Assessment Tool (SPRAT) Japanese version for evaluating doctors' competencies using multisource feedback., Methods: SPRAT, originally developed in the UK, was translated and validated in three phases: (1) an existing Japanese version of SPRAT was back-translated into English; (2) two expert panel meetings were held to develop and assure content validity in a Japanese setting; (3) the newly devised Japanese SPRAT instrument was tested by a multisource feedback survey, validity was tested using principal component factor analysis, and reliability was assessed using generalisability and decision studies based on generalisability theory., Results: 86 doctors who had been practising for between 2 and 33 years participated as assessees and were evaluated with the SPRAT tool. First, the doctors identified 1019 potential assessors who were each sent SPRAT forms (response rate, 81%). The mean number of assessors per doctor was 9.7 (SD=2.5). The decision study showed that 95% CIs of ± 0.5 were achieved with only 5 assessors. 85 of the 86 doctors achieved scores that could be placed with 95% CI above the 4 expected standard. Doctors received lower scores from more senior assessors (p<0.001) and higher scores from those they had known longer (p<0.001). Scores also varied with the job role (p<0.05)., Conclusions: Following translation and content validation, the Japanese instrument behaved similarly to the UK tool. Assessor selection remains a primary concern, as the assessment scores are affected by the seniority of the assessor, the length of the assessor-assessee working relationship, and the assessor's job role. Users of the SPRAT tool need to be aware of these limitations when administering the instrument., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Clinical practice guidelines (CPGs) are not readily implemented in clinical practice. One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs. Peer assessment (PA) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice, awareness of professional performance, and attainment of personal goals., Objective: The purpose of this study was to compare the effectiveness of PA with the usual case discussion (CD) strategy on adherence to CPGs for physical therapist management of upper extremity complaints., Design: A single-masked, cluster-randomized controlled trial with pretest-posttest design was conducted., Intervention: Twenty communities of practice (n=149 physical therapists) were randomly assigned to groups receiving PA or CD, with both interventions consisting of 4 sessions over 6 months. Both PA and CD groups worked on identical clinical cases relevant to the guidelines. Peer assessment focused on individual performance observed and evaluated by peers; CD focused on discussion., Outcomes: Guideline adherence was measured with clinical vignettes, reflective practice was measured with the Self-Reflection and Insight Scale (SRIS), awareness of performance was measured via the correlation between perceived and assessed improvement, and attainment of personal goals was measured with written commitments to change., Results: The PA groups improved more on guideline adherence compared with the CD groups (effect=22.52; 95% confidence interval [95% CI]=2.38, 42.66; P=.03). The SRIS scores did not differ between PA and CD groups. Awareness of performance was greater for the PA groups (r=.36) than for the CD groups (r=.08) (effect=14.73; 95% CI=2.78, 26.68; P=.01). The PA strategy was more effective than the CD strategy in attaining personal goals (effect=0.50; 95% CI=0.04, 0.96; P=.03)., Limitations: Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study., Conclusions: Peer assessment was more effective than CD in improving adherence to CPGs. Personal feedback may have contributed to its effectiveness. Future research should address the role of the group coach., (© 2015 American Physical Therapy Association.)

Objectives: As more demands are placed on primary care providers, new innovative models are required to optimize heart failure (HF) care. The purpose of this study was to evaluate a collaborative therapy review (CTR) program that was implemented to improve guideline-based therapy among HF outpatients., Study Design and Methods: We screened patient lists of 18 PCPs at the Portland Veterans Affairs Medical Center to identify patients with an ICD-9 code for HF. The charts of patients with ejection fractions (EFs) < 40% were then abstracted in more detail. The CTR team reviewed each patient and provided specific guideline-based recommendations. The team then gave specific recommendations to providers through the electronic medical record system. We categorized recommendations relating to drug or device therapies, or need for laboratory testing, and calculated provider acceptance rates by recommendation type., Results: Of the 641 patients reviewed, 156 patients had detailed chart reviews. We found opportunities for improvement in care in 70 (45%) patients who received 100 recommendations. Among the 100 recommendations, 62 (55%) were for guideline-based drugs, 12 (17%) were for consideration of device therapy, and 26 (24%) were to update lab tests or echocardiograms. Eighty percent of the recommendations were acted on within 90 days., Conclusions: The CTR program was able to facilitate guideline-based management for HF patients by identifying treatment gaps and making specific guideline-based recommendations to PCPs. While further evaluations are needed, this approach may serve as an efficient method of leveraging the expertise of specialty-trained clinicians to optimize patient care.

Introduction: Experimental studies on the effectiveness of educational interventions to improve patient care are scarce, especially for low-resources settings. This study investigated the effects of 2 educational interventions on the treatment of hypertensive patients in primary health care in Brazil., Methods: Forty-one physicians were randomly assigned either to an "active educational intervention" (21 physicians) or to a "passive educational intervention" (20 physicians). The former comprised 1 small group discussion of routine practices, 1 outreach visit, and 3 reminders. The latter consisted of delivery of printed guidelines. Measures of quality of treatment provided for hypertensive patients (181 patients of physicians from the active intervention; 136 patients of physicians from the passive intervention) were obtained through patient interview and charts review, before and 3 months after the intervention. Chi-square and independent t-tests were performed for comparison between the conditions., Results: The groups did not differ before the study. After the intervention, the active intervention group outperformed the passive intervention group in several measures, such as improved prescription of antihypertensive drugs (80% of patients of physicians from the active intervention vs 51% patients of physicians from the passive intervention; p < .01), prescription of aspirin (18% vs 6%; p < .01) and hypolipidemic drugs for high-risk patients (39% vs 21%; p < .01), dietary counseling (76% vs 61%; p < .01), guidance on cardiovascular risk (20% vs 3%; p < .01). Patient outcomes did not differ., Discussion: A multifaceted intervention based on review of practices improved treatment of hypertensive patients in a low-resource setting whereas delivery of guidelines did not help. None of the interventions affected patient outcomes., (© 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.)

Introduction: Medical regulatory authorities need efficient and effective methods of ensuring the competence of immigrating international medical graduates (IMGs). Not all IMGs who apply for specialist vocational registration will have directly comparable qualifications to those usually accepted. As general licensure examinations are inappropriate for these doctors, workplace-based assessment (WBA) techniques would appear to provide a solution. However, there is little published data on such outcomes., Methods: All cases of WBA (n = 81) used for vocational registration of IMGs in New Zealand between 2008 and 2013 were collated and analyzed., Results: The successful completion rate of IMGs through the pathway was 87%. The majority (64%) undertook the year of supervised practice and the final assessment in a provincial center. For those unsuccessful in the pathway, inadequate clinical knowledge was the most common deficit found, followed by poor clinical reasoning., Discussion: A WBA approach for assessing readiness of IMGs for vocational registration is feasible. The constructivist theoretical perspective of WBA has particular advantages in assessing the standard of practice for experienced practitioners working in narrow scopes than traditional methods of assessment. The majority of IMGs undertook both the clinical year and the assessment in provincial hospitals, thus providing a workforce for underserved areas., (© 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.)

Appraisals linked to personal development plans (PDPs) are a requirement for NHS organisations to carry out with all staff. NHS policy documents emphasise the importance of appraisal, professional development plans, lifelong learning and clinical supervision for nurses. However, there is limited research regarding appraisal for general practice nurses (GPNs). The aim of this study was to explore the perceptions and experiences of trained GPN appraisers when appraising nurse colleagues, with a particular focus on identifying the barriers and facilitators associated with the implementation of the appraisal process. Appraisals were undertaken using volunteer GPN peer appraisers (n=10) following a NES-approved appraiser course. Forty appraisals were carried out (3-5/appraiser). Following the appraisals, the appraisers were invited to participate in one of two focus groups. The focus groups were recorded and transcribed verbatim. Analysis of the data identified three main themes: role issues, reflection and appraisal interview practicalities. The findings highlighted that effective appraisal can be provided by GPNs and was highly valued by both appraisee and appraiser. The findings identified a number of barriers and facilitators to implementing peer appraisal. Given the unique and varied role GPNs undertake, this study has highlighted the importance of offering high-quality peer appraisal that encourages both reflection and the facilitation of more person-centred PDPs.

Background: Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives., Methods: An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators' experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted., Results: In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm., Conclusion: Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.

Objectives: Performance improvement programs in emergency medicine (EM) have evolved beyond peer reviews of referred cases and now encompass a large set of quality metrics that are measured proactively. However, peer review of cases continues to be an important element of performance improvement, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED). In the past decade, there has been widespread hospital adoption of rapid response teams (RRTs) that respond to patients who decline clinically to reduce adverse outcomes. In an effort to cast a wider net, to take a more systematic approach, and to avoid "blind spots" from individual variability in criteria for referring cases, the institution instituted a new process for selecting cases for ED peer review based on RRT activations within 24 hours of admission from the ED. The hypothesis was that a formal process for review of these activation cases would increase the number of cases for peer review., Methods: This was a prospective, observational study conducted from July 1, 2012, to June 30, 2013, at an urban, academic medical center with an EM residency program. A new automated monthly report was created, capturing all RRT activations within 24 hours of admission from the ED. All events were reviewed by three physicians from the ED performance improvement committee to examine for systems issues, individual provider issues, or both, that might yield opportunities for improvement. Cases with potential opportunities were reviewed by the full ED performance improvement committee. Cases were classified according to the indication for response team activation using the system outlined by the U.S. Agency for Healthcare Research and Quality., Results: During the study period 61,814 patients were treated in the ED, and 13,067 were admitted to inpatient status. Thirty-two RRT activations within 24 hours of admission from the ED occurred among these admitted patients, representing 0.24% of admissions (95% confidence interval [CI] = 0.16% to 0.33%). Of the 32 cases, only one was also referred independently for ED performance improvement review via the traditional ad hoc process. During the same period of time, 85 cases were referred to the ED performance improvement committee via the traditional ad hoc referral process. Thus, the RRT cases added an additional 31 cases, or 36.5%, to the 85 cases reviewed in ED performance improvement. Of the 32 cases, two were determined by the performance improvement committee to have individual provider factors in their ED care, which contributed to the clinical decline triggering the response teams; none had system factors. Most of the response team activations were for neurologic changes (n = 13) and respiratory status changes (n = 12). In two cases there was long-term morbidity or mortality related to the team activation event; in neither of these cases were ED system or individual provider factors judged to have contributed., Conclusions: The review of RRT activations within 24 hours of admission from the ED significantly supplemented the typical ad hoc referral system for peer review of cases, highlighting cases that likely would not have received attention within the ED. This novel and unique case review process revealed opportunities for education and performance improvement. This and other systematic approaches to case detection may be useful adjuncts to traditional case referrals for review., (© 2014 by the Society for Academic Emergency Medicine.)

Purpose: The use of multisource feedback (MSF) or 360-degree evaluation has become a recognized method of assessing physician performance in practice. The purpose of the present systematic review was to investigate the reliability, generalizability, validity, and feasibility of MSF for the assessment of physicians., Method: The authors searched the EMBASE, PsycINFO, MEDLINE, PubMed, and CINAHL databases for peer-reviewed, English-language articles published from 1975 to January, 2013. Studies were included if they met the follow ing inclusion criteria: used one or more MSF instruments to assess physician performance in practice; reported psychometric evidence of the instrument(s) in the form of reliability, generalizability coefficients, and construct or criterion-related validity; and provided information regarding the administration or feasibility of the process in collecting the feedback data., Results: Of the 96 full-text articles assessed for eligibility, 43 articles were included. The use of MSF has been shown to be an effective method for providing feedback to physicians from a multitude of specialties about their clinical and nonclinical (i.e., professionalism, communication, interpersonal relationship, management) performance. In general, assessment of physician performance was based on the completion of the MSF instruments by 8 medical colleagues, 8 coworkers, and 25 patients to achieve adequate reliability and generalizability coefficients of α ≥ 0.90 and Ep ≥ 0.80, respectively., Conclusions: The use of MSF employing medical colleagues, coworkers, and patients as a method to assess physicians in practice has been shown to have high reliability, validity, and feasibility.

Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system., (© 2012 National Association for Healthcare Quality.)

Purpose: Existing diagnostic radiology peer-review systems do not address the specificities of interventional radiology (IR) practice. The purpose of this study was to assess the feasibility of a specifically developed interventional peer review method, IR Peer., Materials and Methods: Retrospective review of a prospectively encoded pilot database aimed at demonstrating the feasibility of IR Peer in a multiphysician practice was performed. This scoring system used morning peer review of selected IR cases from the previous day in the form of a five-item questionnaire and an ordinal answer scale that grades reviewers' agreement with imaging findings, procedural/technical management, early outcomes, and follow-up plan. Patient lists from IR Peer and morbidity and mortality (M&M) conferences were compared to evaluate the amount of overlap and capability of IR Peer to help detect adverse events (AEs)., Results: A total of 417 consecutive reviews of IR attending physician cases by peers were performed in 163 consecutive patients over 18 months, and 94% of cases were reviewed by two or three IR attending physicians. Each question was answered 99%-100% of the time. Answers showed disagreement in 10% of cases (2% by a single reviewer, 8% by several), most related to procedural technique. Overall AE incidence was 1.8%. IR Peer contributed 10.7% of cases to the M&M list., Conclusions: IR Peer is feasible, relevant, and easy to implement in a multiphysician IR practice. When used along with other quality-assurance processes, it might help in the detection of AEs for M&M; the latter will require further confirmatory research., (© SIR, 2013.)

The American Board of Medical Specialties Maintenance of Certification Program (ABMS MOC) is designed to provide a comprehensive approach to physician lifelong learning, self-assessment, and quality improvement (QI) through its 4-part framework and coverage of the 6 competencies previously adopted by the ABMS and the Accreditation Council for Graduate Medical Education (ACGME). In this article, the theoretical rationale and exemplary empiric data regarding the MOC program and its individual parts are reviewed. The value of each part is considered in relation to 4 criteria about the relationship of the competencies addressed within that part to (1) patient outcomes, (2) physician performance, (3) validity of the assessment or educational methods utilized, and (4) learning or improvement potential. Overall, a sound theoretical rationale and a respectable evidence base exists to support the current structure and elements of the MOC program. However, it is incumbent on the ABMS and ABMS member boards to continue to examine their programs moving forward to assure the public and the profession that they are meeting expectations, are clinically relevant, and provide value to patients and participating physicians, and to refine and improve them as ongoing research indicates., (Copyright © 2013 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

Background: Handoffs among post-graduate year 1 (PGY1) trainees occur with high frequency. Peer assessment of handoff competence would add a new perspective on how well the handoff information helped them to provide optimal patient care., Objective: The goals of this study were to test the feasibility of the approach of an instrument for peer assessment of handoffs by meeting criteria of being able to use technology to capture evaluations in real time, exhibiting strong psychometric properties, and having high PGY1 satisfaction scores., Design: An iPad® application was built for a seven-item handoff instrument. Over a two-month period, post-call PGY1s completed assessments of three co-PGY1s from whom they received handoffs the prior evening., Participants: Internal Medicine PGY1s at the University of Pennsylvania., Main Measures: ANOVA was used to explore interperson score differences (validity). Generalizability analyses provided estimates of score precision (reproducibility). PGY1s completed satisfaction surveys about the process., Key Results: Sixty-two PGY1s (100 %) participated in the study. 59 % of the targeted evaluations were completed. The major limitations were network connectivity and inability to find the post-call trainee. PGY1 scores on the single item of "overall competency" ranged from 4 to 9 with a mean of 7.31 (SD 1.09). Generalizability coefficients approached 0.60 for 10 evaluations per PGY1 for a single rotation and 12 evaluations per PGY1 across multiple rotations. The majority of PGY1s believed that they could adequately assess handoff competence and that the peer assessment process was valuable (70 and 77 %, respectively)., Conclusion: Psychometric properties of an instrument for peer assessment of handoffs are encouraging. Obtaining 10 or 12 evaluations per PGY1 allowed for reliable assessment of handoff skills. Peer evaluations of handoffs using mobile technology were feasible, and were well received by PGY1s.

Peer review is used increasingly in the NHS as a form of evaluation between professionals, services and organisations, and as a way of offering participants a snapshot assessment of particular health services or at points in a clinical pathway. The model outlined in this article has been developed as an aide-memoire to clinical commissioning groups, provider organisations and clinical staff for the process of gathering evidence of good assurance and governance arrangements.