Keeping with the philosophies of continuous quality improvement, medical staff peer review should focus primarily on process improvement even when the variation in processes or outcomes may appear at first to be related to the activities of an individual. It is generally agreed that making changes in the organizational processes that support an individual's activities can have a positive effect on everyone's performance. For example, if one physician's patients are found to have more wound infections than patients of other physicians, rather than censure that physician, the medical staff should initiate an evaluation of all the processes which influence patients' development of a wound infection. The resulting process improvements that can be gained by taking a systems approach, rather than individual focus, will ultimately improve the quality of care provided by all healthcare team members.

Individual Case Review

How can a systems analysis strategy be incorporated into your existing medical staff peer review process where the focus has historically been the individual physician? Ideally, the review of unusual patient care events is performed by a multidisciplinary team of health care providers. This team, composed of physicians, nurses and other direct patient care clinicians, would evaluate events by asking questions such as: Are we doing something we shouldn't? Are we failing to do something we should? Is the process operating satisfactorily or has something gone wrong that needs correction?

This multidisciplinary process improvement team must be willing to openly discuss each of the system variables that affect patient care and resist the temptation to place blame on individuals or departments. Achieving this ideal environment requires a medical staff and hospital leadership commitment to cooperation which goes far beyond just calling a meeting of various disciplines.

Traditionally, cases selected for peer review activities were evaluated by a group of physicians. Their case review focused on answering the question "Did the attending physician provide quality patient care?" Adopting a system analysis approach for peer review requires the addition of several more questions to the case review process. Rather than asking merely if the attending physician's performance was acceptable, the reviewer's attention should be directed to all components of care surrounding the event. For example:

• What was the influence, if any, of organizational/management factors? (e.g., house staff turn-over, increased patient census, lack of specialized care teams such as an IV team, noncompliance with universal precautions, lack of communication between practitioners and/or support personnel, etc.)
• What was the influence, if any, of caregiver-related factors? (e.g., knowledge/ judgement/technical skills, failure to perform necessary activity, delay in performing activity, inadequate documentation, etc.)
• What was the influence, if any, of equipment-related factors? (e.g., broken, unavailable or inadequate equipment)
• What was the influence, if any, of patient/disease-related factors? (e.g., socioeconomic class, patient age, immunocompromised patient, patient with underlying chronic condition, patient noncompliance, etc.)
• When cross-departmental issues are identified, the peer review committee may review the issues to the hospital's Quality Council for further action.

Analyzing Trend Data

The quality improvement environment is shifting attention away from individual case review to analysis of aggregate data showing variation of practice among physicians and physician groups. Unlike our past tendencies to look for the "bad" doctor, medical staff analysis of summary information should focus on systems and processes which cause unacceptable patient care process or outcome patterns.

Many hospitals regularly analyze, for example, their crossmatch to transfusion (C:T) ratio as a component of their ongoing monitoring of the use of blood and blood components. When variations are identified, the first step in the analysis of unacceptable trends should be to assess system issues which affect the results. For example, if trend data shows that the Surgery Department has a consistently higher C:T ratio than other hospital departments the reviewing committee should pursue an answer to the question of "why," not "who". The "why" is best explained by those involved in the process - in this case physician members of the Surgery Department and laboratory/ blood bank staff. For this illustration the system analysis might be handled by the Transfusion Committee. Or if the appropriate members are not represented on this committee, the issue might be referred to a special task group comprised of surgeons who regularly order blood transfusions and laboratory/blood bank representatives. Using the quality improvement technique of brainstorming, the investigating group identifies all possible causes of the Surgery Department's C:T ratio variation. These may include:

• severe shortages of blood in the past have caused increased ordering of type and crossmatches
• lack of communication between attending staff and residents results in inadvertent multiple orders for type and crossmatch
• ambiguous blood bank procedures for ordering type and crossmatches
• addition of new trauma services

Next, data would be collected to validate whether or not the group's "presumed" causes are actually producing the higher C:T ratio. Lastly, the group would be charged with designing action plans specific to the root cause of the variation.

This system analysis approach and the resulting improvements derived from this strategy would ultimately benefit all physician members of the Surgery Department, rather than merely alienate the one or two physicians which might have appeared as type and crossmatch "outliers."

Can System Analysis Bring About All Necessary Improvements?

Although quality improvement theory tells us that most problems are caused by the system and not by the individuals working within the system, occasionally process improvements alone are not the answer. The standards of the Joint Commission on Accreditation of Healthcare Organizations address this situation by saying that when an individual's activities are deficient and support systems are unable, or will not be able, to improve the individual's activities, changes are considered in the individual's role, responsibility, and/or status, that are designed to improve processes and patient outcomes. Therefore the medical staff peer review system must always be prepared to address significant problems exhibited by individual doctors which are not correctable by process or system improvements. Fortunately, these situations are rare. Ideally, the medical staff's peer review mechanism concentrates on fixing the "bad" systems in affect the quality of care provided by all physicians.

© 1998 Brown-Spath & Associates

To Learn More: Patrice L. Spath is available for inhouse presentations on this topic and other healthcare quality subjects. She can be reached (503) 357-9185; email: Patrice@brownspath.com Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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