Clinical Peer Review and Just Culture

Clinical peer review is the process whereby medical providers evaluate the quality of their colleagues’ clinical work (World J Gastroenterol 2014;20:6357-63). It may also be referred to as medical peer review, quality review, patient safety review, or simply peer review. Clinical peer review focuses on patient care and is separate from issues surrounding professionalism or aberrant behavior. These types of nonclinical issues are generally handled by the department chair and vice chair using the organization bylaws as a guide. Ultimately, the medical executive committee or similar committee is responsible for enforcing the bylaws. Clinical patient care concerns should be handled through a designated peer review committee.

“The common initial reaction when an error occurs is to find and blame someone” (asamonitor.pub/3Ob3mML). The concept of “Just Culture” directly opposes the outdated blame-and-shame model of patient safety. The goal is fair and balanced accountability. After a safety event occurs, the focus should be on how to improve the system to prevent future errors. However, this does not mean we have completely moved to a “no blame” approach for individuals (N Engl J Med 2009;361:1401-6). Instead, we focus on the choices and system-shaping factors that led to the safety event. Human error cannot be prevented with punishment. At-risk behavior is best served by coaching and opportunities for improvement. Disciplinary sanction is only used for reckless behavior. Providers should not be held accountable for mistakes made in a system they cannot control (Ochsner J 2013;13:400-6).

Taking the bottom line up front (BLUF) approach, the following are recommendations for moving your peer review process toward a Just Culture:

1. Encourage physician anesthesiologists to become part of peer review and quality improvement at your institution, and follow a standardized peer review process.
2. Learn about and use Just Culture principles, using the National Patient Safety Foundation’s (NPSF’s) “A Just Culture Tool” as a guide.
3. Focus on improving the system, using the Institute for Healthcare Improvement’s (IHI’s) “Action Hierarchy Tool” as a guide.

Encouraging physician anesthesiologist involvement in patient safety activities has several benefits. Anesthesiologists are uniquely qualified for this role given their extensive training, breadth of education, and focus on patient safety in many procedural environments. Two of the most common causes of adverse events, medication-related and surgical services, fall under our area of expertise (Health Serv Res 2018;18:521; QJM 2015;108:273-7; World J Gastroenterol 2014;20:6357-63). Anesthesiologists routinely work with a wide range of specialists and thus understand how most departments within the hospital function. Physician involvement in peer review helps ensure cases are reviewed by like providers. Anesthesiologist representation in this role can be beneficial for their department as well as all perioperative care.

Ideally, each department will be empowered to choose their peer review leader or have the default choice be someone already in a leadership role (e.g., chair or vice chair). Given the sensitive nature of peer review and concerns about sham peer review processes, departments should identify individuals who can be fair and impartial (World J Gastroenterol 2014;20:6357-63). The Code of Conduct for United States Judges can provide some insight into characteristics fitting of a peer review committee member (asamonitor.pub/3IFCzag). Committee members should work to establish trust, show respect, and promote inclusion (asamonitor.pub/3PqW2gQ). Although blueprints exist for creating a culture of safety, unfortunately there is no universal standard process for peer review (World J Gastroenterol 2014;20:6357-63).

Medical peer review is required by The Joint Commission as well as the Centers for Medicare & Medicaid Services (asamonitor.pub/3IGGVOe). Modern patient safety organizations recommend non-punitive peer review and the Just Culture approach. ECRI, a large patient safety organization formerly called the Emergency Care Research Institute, provides a list of resources and guidance for structured peer review at your institution (asamonitor.pub/3AUDIc1).

One way to structure peer review at your hospital is to mimic the U.S. Department of Justice. Federal courts have three main levels: district courts, circuit courts, then the Supreme Court. For hospitals, each department could have their own peer review committee (district court). Next is a hospital-wide multidisciplinary peer review committee (circuit court). Issues that could not be resolved at a lower level, are controversial, or involve reckless behavior, would move to the multidisciplinary committee. Each department would report all cases, including resolved cases, to the multidisciplinary committee to ensure transparency. It would be the goal of the multidisciplinary committee to resolve most cases, known as adjudication. That committee could recommend focused professional practice evaluation (FPPE), a confidential review process handled by the department chair. Escalation to the next level, the medical executive committee (Supreme Court), is reserved for repeated reckless behavior and impaired practices.

This model, of course, will not fit every institution, and there are some adjustments that may be needed. For example, a department with only three physicians risks bias during review as well as concerns about targeting individuals. In this case, similar departments could be combined so there are more physicians involved in decision-making. A hypothetical scenario might include forming an endovascular peer review committee involving cardiology, vascular surgery, and neuroendovascular staff. If enough physicians exist within a larger department, choosing different members to serve on the department peer review committee and the multidisciplinary committee can reduce bias. At our institution, the vice chairs serve on the multidisciplinary peer review committee and the chairs are reserved for review of conflict-of-interest cases (e.g., involving the vice chairs) and for review at the medical executive committee level. If it is feasible to have a provider from every department on the multidisciplinary committee, these can be assigned ad hoc.

Just Culture should be the overarching theme for all members and levels of peer review within the institution. Peer reviewers should keep in mind that medical providers are human, and humans will occasionally make mistakes (Whack-a-Mole: The Price We Pay For Expecting Perfection. 2009). Dr. Lucian Leape, considered the founder of patient safety, has been quoted as saying, “the single greatest impediment to error prevention is that we punish people for making mistakes” (Qual Saf Health Care 2006;15:i72-5). Recklessness is another matter, of course, and merits discipline (asamonitor.pub/3o7QMDf).

Let’s take a look at the NPSF’s Just Culture Tool. In keeping with the system improvement focus, every safety event is an opportunity to fix the system. As shown by the Just Culture Tool, we try to separate the outcome from the behavior that led to that outcome. Just because a bad outcome occurred does not mean the provider did something wrong. Likewise, reckless behavior should not be tolerated even if there is no harm to the patient. An example of the latter would be drunk driving, where this behavior is not appropriate even if the driver makes it home safely.

When there is a bad outcome, but the provider met the standard of care, this is deemed a blameless adverse event. Importantly, we should recognize that the provider is at risk for second-victim effect, and thus we should reach out and provide support if necessary (Adv Med Educ Pract 2019;10:593-603). When a safety event occurs involving impaired practices, regardless of severity, the case should be immediately escalated. An example would be a provider intoxicated at work.

As shown in the Just Culture Tool, we ask two questions when the standard of care was not met. In the substitution test, we ask whether other providers with a similar level of training would have done the same in the same situation. In the intention test, we ask whether the provider knowingly violated the standard of care. This should not be confused with intentional harm to the patient, which requires immediate escalation. Some clinical examples help illustrate this framework:

A 21-year-old man arrives to the trauma bay unconscious and hypotensive after a motor vehicle crash. He is intubated by the anesthesia team with ketamine and succinylcholine. The patient is volume resuscitated, undergoes splenectomy, and is transferred to the ICU. Over the next few hours, the patient develops a fever with increasing temperatures. Sepsis is suspected, and the usual protocol is followed. Multiple ICU providers are involved in the care of the patient. Fever does not improve despite these measures, and vasopressors are started for presumed septic shock, but the patient does not survive. Autopsy and genetic testing reveal a missed diagnosis of malignant hyperthermia. The case is submitted for peer review.

Applying the Just Culture Tool, the anesthesia team did not deviate from standard of care. While one can theoretically debate succinylcholine versus rocuronium, there is no defined standard of care that dictates avoiding succinylcholine. This case should be closed at the anesthesia department committee level. What about the possible missed diagnosis by the ICU team? The patient had signs consistent with sepsis, and care for the common diagnosis was appropriate. Further discussion about the substitution test finds that the diagnosis was missed by multiple providers. This is clearly human error. However, there may be an opportunity for further education given the identified knowledge gap. Either way, disciplinary sanction is not necessary.

Now let us take a case involving a 65-year-old woman undergoing upper endoscopy then lower endoscopy under propofol using a nasal cannula for oxygen delivery and ETCO₂ measurement. During the upper endoscopy, the gastroenterologist discovers a stomach full of food and aborts the procedure after notifying the anesthesiologist. The gastroenterologist would now like to perform the colonoscopy. The gastroenterologist suggests intubation, but the anesthesiologist declines and proceeds with moderate sedation. During the colonoscopy, the patient aspirates and has a severe hypoxic event requiring hospitalization.

Using the Just Culture Tool, it is likely that most providers would not proceed with sedation in the setting of a known full stomach (substitution test). Further, the provider was aware of known standard of care for patients with full stomachs. The provider knowingly violated that standard. This event would be deemed reckless behavior and warrant escalation. Resolution may involve Focused Professional Practice Evaluation, or FPPE, where the department chair reviews the provider’s cases for the next three months to ensure they are following the standard NPO practice guidelines.

When a system issue is found, we can use system engineering principles and human factors analysis to improve safety and reliability. When trying to find the best error-reduction strategy, a hierarchy of controls framework is used (asamonitor.pub/3aFy032). The National Institute for Occupational Safety and Health has a national initiative called Prevention through Design (PtD), and hierarchy of controls is part of the PtD strategy. To find solutions that will be more effective and reliable, we must rely less on humans because we are too fallible. The Institute for Safe Medication Practices has a risk-reduction hierarchy to this effect and emphasizes that “Education is predictably disappointing and should never be relied upon alone to improve safety” (asamonitor.pub/3APQ8lz). The IHI has a more generalized Action Hierarchy Tool to help with finding effective solutions to system problems identified through peer review and safety event analysis (asamonitor.pub/3zdVW78).

Looking at the IHI Action Hierarchy Tool, what are some solutions we could consider for the malignant hyperthermia case? Would an email to all ICU team members be effective? Maybe for a brief period, but this would be considered a weaker action. Intermediate actions such as a required lecture on malignant hyperthermia would be more effective than an email. Even more effective would be a software enhancement. For example, the EMR could identify specific criteria highly associated with malignant hyperthermia then notify the provider to consider this in their differential.

Creating a structured peer review system with escalating levels helps ensure cases are reviewed by like providers and cases are seen by multiple providers prior to adjudication, which reduces bias. We should encourage physician anesthesiologists to become involved in this process and provide them with the time and education to be successful. An excellent patient safety education program is the Certified Professional in Patient Safety course, with resultant board certification (asamonitor.pub/3P61dDj).