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2018 ; 13
(6
): e0199961
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A case for revisiting peer review: Implications for professional self-regulation
and quality improvement
#MMPMID29953510
Hill TE
; Martelli PF
; Kuo JH
PLoS One
2018[]; 13
(6
): e0199961
PMID29953510
show ga
BACKGROUND: Quality improvement in healthcare has often been promoted as
different from and more valuable than peer review and other professional
self-regulation processes. In spite of attempts to harmonize these two
approaches, the perception of dichotomous opposition has persisted. A sequence of
events in the troubled California prison system fortuitously isolated workforce
interventions from more typical quality improvement interventions. Our objectives
were to (1) evaluate the relative contributions of professional accountability
and quality improvement interventions to an observed decrease in population
mortality and (2) explore the organizational dynamics that potentiated positive
outcomes. METHODS: Our retrospective mixed-methods case study correlated
time-series analysis of mortality with the timing of reform interventions.
Quantitative and qualitative evidence was drawn from court documents, public use
files, internal databases, and other archival documents. RESULTS: Change point
analysis reveals with 98% confidence that a significant improvement in
age-adjusted natural mortality occurred in 2007, decreasing from 138.7 per
100,000 in the 1998-2006 period to 106.4 in the 2007-2009 period. The improvement
in mortality occurred after implementation of accountability processes, prior to
implementation of quality improvement interventions. Archival evidence supports
the positive impact of physician competency assessments, robust peer review, and
replacement of problem physicians. CONCLUSIONS: Our analysis suggests that
workforce accountability provides a critical quality safeguard, and its neglect
in scholarship and practice is unjustified. As with quality improvement,
effective professional self-regulation requires systemic implementation of
enabling policies, processes, and staff resources. The study adds to evidence
that the distribution of physician performance contains a heterogeneous left skew
of dyscompetence that is associated with significant harm and suggests that
professional self-regulation processes such as peer review can reduce that harm.
Beyond their responsibility for direct harm, dyscompetent professionals can have
negative impacts on group performance. The optimal integration of professional
accountability and quality improvement systems merits further investigation.
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