Patients continue to experience significant preventable harm. Some common approaches to improve quality include empirically measuring it and pressuring clinicians to improve performance, implementing quality improvement efforts, conducting internal physician peer review and requiring regulatory accreditation.1
The incentives for these approaches generally separate into those driven by external forces, largely from regulators, and those motivated by internal forces, largely professional norms within a professional society or provider organisation.
Quality and patient safety efforts encounter the same issues as clinical medicine. There may be strong evidence that a treatment works (eg, preventing venous thromboembolism) and a recommended process of care (eg, assessment and prophylaxis), but we need effective strategies to persuade providers to use them. There are several externally driven strategies that promote uptake, such as regulated safety standards (eg, The Joint Commission mandate for medication reconciliation) and accreditation, economic incentives (eg, pay for performance programs) and the regulatory requirement that hospitals perform peer review to evaluate a physician's competence and performance.
Such regulatory approaches are needed and beneficial in establishing minimum standards and accountability in healthcare. Yet, they also have limitations, and are unlikely to create a healthcare system that optimises outcomes and continuously improves; indeed, patient harm continues seemingly unabated. For example, hospital peer reviews are limited by a lack of valid measurement tools and too few reviewers with the requisite ability to provide completely objective ratings.2
Moreover, reviews usually focus on physician performance, failing to assess the systems in which care is delivered. Some professional societies are changing physician peer review through audit and feedback, simulation, academic detailing and multisource feedback.3
To date, regulation has driven most efforts to improve the uptake of patient safety interventions, although internally motivated efforts are growing rapidly. Local clinician-led efforts that work through communities and change social norms are extremely effective, yet the most underdeveloped in healthcare.4
Communities of practice5
and quality improvement clinical communities6
are examples of local efforts that build relationships, network, learn and share, and have resulted in successful improvement efforts. Quality improvement collaboratives attempt to corral clinicians, provide a common goal and interventions to reach this goal, and network these communities to support each other in achieving this goal. Examples include learning collaboratives (eg, Institute for Healthcare Improvement Breakthrough work7
) and quality improvement clinical communities, in which interventions are created with, rather than over, clinicians (eg, the Michigan Keystone ICU Project and the national On the CUSP: Stop BSI program to reduce bloodstream infections,8
and the Vermont Oxford Network to improve care for newborn infants10
Another type of internally driven improvement method is organisational peer-to-peer review, in which one provider organisation (without formal regulatory authority) evaluates another organisation, offering an authentic and objective assessment of opportunities to improve. Unlike physician peer review, an organisational review focuses largely on systems. There are several outstanding examples of this approach. The Northern New England Cardiovascular Study used organisational peer-to-peer review to improve the care of cardiac surgery patients11
and the National Health Service in the UK used it to improve the care of patients with lung disease.12
Beyond these examples, formal organisational peer-to-peer reviews are relatively rare in healthcare.
Informal reviews are frequent but sporadic occurrences in healthcare. Healthcare organisations commonly invite outside consultants to informally evaluate a clinical program or individual clinician. Such assessments, however, are usually ad hoc, seldom use validated evaluation tools, and infrequently disseminate learning on a broad scale. Professional societies have developed guidelines, self-assessment tools and performance measures, but they rarely conduct formal assessments of healthcare organisations.
While a mixture of regulatory and internally motivated improvement efforts are needed to ensure high quality care, the majority of improvement efforts are driven by external forces. Such forces will likely ensure adherence to minimum standards, but they will not promote innovation, optimise care or continuously improve. Internally motivated efforts have promoted innovation to increase the routine practice of recommended care and had significant success in reducing infection rates and mortality.13–15
A more formal internal effort is needed to evaluate system issues and improve safety, and the nuclear power industry may provide a model.
The nuclear power industry has a compelling history of improving and sustaining safety from which healthcare could learn. While this industry is well known for strict regulatory bodies, they also have a mature internally driven peer-to-peer assessment program that promotes the sharing of best practices among power plants and personnel worldwide. They have used this program, which fosters information exchange and cooperative organisational learning, coupled with regulatory and other approaches, to achieve substantial and sustainable safety improvements. This commentary explores how the nuclear power industry's learning-based peer-to-peer assessment approach can be expanded in healthcare.