Moving from quality assurance to performance improvement

I recently visited a hospital where the medical staff is proud of its new centralized multidisciplinary peer review committee. The medical staff made the intuitive leap from traditional departmental peer review, where issues identified within a department stayed within the department, to a more inter-disciplinary approach. In the interdisciplinary approach, individuals from multiple specialties discuss performance issues that cross specialty borders and oversee improvement plans that benefit physicians, non-physician practitioners, nurses, and the hospital at large.

Unfortunately, all is not well at this hospital. There is a vocal minority of physicians who do not trust the new interdisciplinary  peer review process and ask for multiple external reviews to be performed.  There is angst throughout the peer review process with multiple stories of the peer review committee “not getting it right.” There are complaints of the negative, demeaning, and punitive nature of peer review and how few cases make it to the peer review committee. Of those cases that do make it to the peer review committee, few ever demonstrate inappropriate care.

This medical staff has the right committee, the right structure, and the right process. Why isn’t it working?

Change can be difficult because you can change what you do, but if you do not also change how you do it, then everything pretty much stays the same. This medical staff has an efficient committee structure, they are doing the right things, but peer review still generates fear, defensiveness, and a difficulty to accept the committee’s findings and recommendations.

At the root, the problem is not what they are doing but how they are doing it. They ask the question, “What went wrong?”  or “Who’s to blame?” rather than “How can we handle this situation better tomorrow than we were able to do it today?” This is moving from quality assurance to performance improvement and is a difficult transition to make.

Quality assurance is the search for negative outliers. Healthcare inherited this technique from other industries in the 1960s. At that time, most industrial operations had an inspector who walked up and down the assembly line overseeing a crew that searched for defective products to eliminate. We applied this in healthcare by searching for negative outliers and labeling them “standard of care not met.” It was a symbolic exercise in drafting a letter of finding, concern, admonition, or sanction. We asked a colleague to attend continuing medical education and to not make the same mistake again. The physician often defended his/her position and felt a little humiliated. Because of the embarrassment, the physician certainly didn’t welcome the opportunity to address issues of concern. Nothing much changed; and nobody felt very good about the entire process.

Performance improvement is a significantly different approach. Under this methodology, the peer review process is an opportunity to improve individual performance, aggregate performance, nursing performance, and the performance of the system as a whole. It looks at ways to support and improve performance, rather than demean it. It refers nursing issues to nursing management, refers systems issues to the hospital-based quality committee, and asks for measurable solutions that are meaningful and significant. It is a problem solving exercise, rather than a problem identification exercise. Quality assurance identifies performance improvement measures, analyzes those measures, and then improves identified issues so that they are less likely to recur in the future.

Physicians are excellent problem solvers and analytic thinkers and this type of approach is far more appealing than the “find the negative outliers and determine who is responsible” approach of the past. Performance improvement also saves physicians time. Physicians are pressured to work harder and longer and they refuse to take precious time away from their practices to engage in a process that they cannot whole heartedly support as meaningful and significant to their colleagues and patients.

Ideally, the peer review committee should produce annually a  spreadsheet with measurable individual, department, medical staff, nursing staff, and system improvements. This is something to proudly report to one’s peers, the board, surveyors, and the public as the result of expert problem solving put to the highest service.

Quality assurance was a stage of development that our field had to go through and now there is something better. I hope that your medical staff will embrace performance improvement as something positive and meaningful and a way to provide benefit to not only your colleagues but to all of the patients you collectively serve.

Wishing you continued success,

Jon Burroughs, MD, MBA, FACPE, CMSL is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Danvers, MA.