Physician participation in quality management. Expanding the goals of peer review to detect both practitioner and system error.

BACKGROUND: The goals of peer review are to improve the quality of medical care and to provide fair review of individual practitioner actions, judged against the local standard of medical care. A new system for conducting peer review was evaluated which included in every case a root cause analysis to identify latent system flaws and a consideration of performance improvement projects to remedy these flaws.
METHODS: The peer review committee of the medical service in a tertiary care, affiliated Department of Veterans Affairs Medical Center, which conducted the evaluation, was familiar with the local standards of care and the systems issues relevant to each case. Four questions were answered for each case: Was the quality of care less than ideal? If so, was the practitioner negligent? What system flaws contributed to the error or to the severity of injury? How could the system flaws be eliminated?
RESULTS: Compared with the prior method of peer review, expanding the scope of review identified four times as many system problems (in 46% of cases versus 11%) without changing the incidence of finding provider negligence (21% preintervention versus 25% postintervention). Performance improvement projects were generated in 36 of 89 of these cases during the three-year period. DISCUSSION: Expanding the scope of peer review to include both root cause analysis and performance improvement thinking increased the detection of latent system flaws and the number of performance improvement projects without compromising the peer review committee's ability to identify negligence.