6.3 KiB
| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| Clinical peer review | 3/5 | https://en.wikipedia.org/wiki/Clinical_peer_review | reference | science, encyclopedia | 2026-05-05T09:52:52.389008+00:00 | kb-cron |
The first documented description of a peer review process is found in the Ethics of the Physician written by Ishap bin Ali al-Rahawi (854–931) of al-Raha, Syria. His work, as well as later Arabic medical manuals, states that a visiting physician must always make duplicate notes of a patient's condition on every visit. When the patient was cured or had died, the notes of the physician were examined by a local medical council of other physicians, who would review the practicing physician's notes to decide whether his or her performance met the required standards of medical care. If their reviews were negative, the practicing physician could face a lawsuit from a maltreated patient. Such practices are known to have continued into the 11th century. In the 1900s, peer review methods evolved in relation to the pioneering work of Codman's End Result System and Ponton's concept of Medical Audit. Lembcke, himself a major contributor to audit methodology, in reviewing this history, notes the pre-emptive influence of hospital standardization promoted by the American College of Surgeons (ACS) following WWI. The Joint Commission (on Accreditation of Hospitals) followed the ACS in this role from 1952. Medicare legislation, enacted in 1964, boosted the stature and influence of the Joint Commission because the conditions for hospital participation required a credible medical care review program and the regulations stipulated that Joint Commission accreditation would guarantee payment eligibility. What was once a sporadic process, became hardwired in most hospitals following the medical audit model. The widespread creation of new programs was hampered, however, by limitations in the available process models, tools, training and implementation support. Medical audit is a focused study of the process and/or outcomes of care for a specified patient cohort using pre-defined criteria. Audits are typically organized around a diagnosis, procedure or clinical situation. It remains the predominant mode of peer review in Europe and other countries. In the US, however, the lack of perceived effectiveness of medical audit led to revisions of Joint Commission standards in 1980. Those modified standards dispensed with the audit requirement and called for an organized system of Quality Assurance (QA). About the same time, hospital and physicians were facing escalating malpractice insurance costs. In response to these combined pressures, they began to adopt "generic screens" for potential substandard care. These screens were originally developed to evaluate the feasibility of a no-fault medical malpractice insurance plan and were never validated as a tool to improve quality of care. Despite warnings from the developers, their use became widespread. In the process, a QA model for peer review evolved with a narrow focus on the question of whether or not the standard of care had been met. It has persisted despite the many criticisms of its methods and effectiveness. Today, its methods are increasingly recognized to be outdated and incongruent with the Quality Improvement (QI) principles that have been increasingly embraced by healthcare organizations. There is good evidence that contemporary peer review process can be further improved. The American College of Obstetrics and Gynecology has offered a Voluntary Review of Quality of Care Program for more than 2 decades. Perceived issues with the adequacy of peer review were an explicit reason for requesting this service by 15% of participating hospitals, yet recommendations for improved peer review process were made to 60%. A 2007 study of peer review in US hospitals found wide variation in practice. The more effective programs had more features consistent with quality improvement principles. There were substantial opportunities for program improvement. The implication was that a new QI model for peer review seems to be evolving. While it is premature to judge the potential effectiveness of this model, a 2009 study confirmed these findings in a separate sampling of hospitals. It also showed that important differences among programs predict a meaningful portion of the variation on 32 objective measures of patient care quality and safety. These findings were extended by cohort follow-up studies conducted in 2011 and 2015–16. The 2015-16 study refined QI model identifying 20 features that distinguish the most effective programs. These include among other factors: aiming first and foremost at improving quality, standardizing review process, maintaining high quality of case review, promoting self-reporting of adverse events, near misses and hazardous conditions, identifying opportunities for improvement in the review process (as opposed to casting blame), providing timely clinical performance feedback, recognizing clinical excellence, and establishing effective program governance. as additional multivariate predictors of the impact of clinical peer review on quality and safety, medical staff perceptions of the program, and clinician engagement in quality and safety initiatives. The online supplement to the report includes a program self assessment tool which is also available as a free online utility. Despite a persistently high annual rate of major program change, about two-thirds of programs still have significant opportunity for improvement. It is argued that the outmoded QA model perpetuates a culture of blame that is toxic to efforts to advance quality and high reliability among both physicians and nurses.
== Legal and regulatory environment ==
=== United States === In the US, peer review activity is generally protected under state statutes. The protection may include confidentiality of the review process and protection to reviewers and institutions for good faith efforts to improve quality and safety through review activity. Such statutes may also specify whether or not the physician conducting the review must be in active practice. The nature of that protection varies widely. For example, Texas is generally considered to have fairly robust protections, whereas Florida protections were undermined by a constitutional amendment that exposed peer review data to discovery.