H David Reines1, Amber W Trickey2, Jean Donovan2. 1. Department of Surgery, Inova Health System, Falls Church, VA, 22042, USA. Electronic address: hdavid.reines@inova.org. 2. Department of Surgery, Inova Health System, Falls Church, VA, 22042, USA.
Abstract
BACKGROUND: Physician Peer Review (PPR) is required by The Joint Commission to assure examination of individual and group outcomes. Although surgeons may utilize Morbidity and Mortality (M&M) conference, applying these data to determine Focused Professional Practice Evaluations involves outcomes review. A PPR Committee of senior surgeons was created. This report describes one institution's surgical PPR process and results. METHOD: A two-year (2014-2015) retrospective review of significant non-trauma complications and unanticipated deaths evaluated by PPR was performed. A faculty questionnaire evaluated perceptions of quality outcomes reporting. RESULTS: Of 395 reviewed cases, almost half (48.9%) demonstrated no care improvement opportunities, 48.6% revealed possible improvements, 2% were deviations from standard of care, and 0.5% represented unacceptable care. Although most surgeons (94%) wanted to know their complication rates, only 41% reported maintaining an outcomes database. CONCLUSIONS: As a complement to M&M, PPR is a valuable tool in the evaluation of individual surgical quality and can be the basis for further quality improvement opportunities. This process has been largely successful; only a small number of significant concerns were discovered.
BACKGROUND: Physician Peer Review (PPR) is required by The Joint Commission to assure examination of individual and group outcomes. Although surgeons may utilize Morbidity and Mortality (M&M) conference, applying these data to determine Focused Professional Practice Evaluations involves outcomes review. A PPR Committee of senior surgeons was created. This report describes one institution's surgical PPR process and results. METHOD: A two-year (2014-2015) retrospective review of significant non-trauma complications and unanticipated deaths evaluated by PPR was performed. A faculty questionnaire evaluated perceptions of quality outcomes reporting. RESULTS: Of 395 reviewed cases, almost half (48.9%) demonstrated no care improvement opportunities, 48.6% revealed possible improvements, 2% were deviations from standard of care, and 0.5% represented unacceptable care. Although most surgeons (94%) wanted to know their complication rates, only 41% reported maintaining an outcomes database. CONCLUSIONS: As a complement to M&M, PPR is a valuable tool in the evaluation of individual surgical quality and can be the basis for further quality improvement opportunities. This process has been largely successful; only a small number of significant concerns were discovered.
Authors: Amit K Mathur; Cynthia Stemper-Bartkus; Kevin Engholdt; Andrea Thorp; Melissa Dosmann; Hasan Khamash; Kunam S Reddy; Bashar Aqel; Adyr Moss; Harini Chakkera; D Eric Steidley; Octavio Pajaro; Sadia Shah; Elizabeth J Oakley; David Douglas Journal: Mayo Clin Proc Innov Qual Outcomes Date: 2019-07-19