The Power of Peers

Over the years, the identification, evaluation and management of “quality in EMS” has been a virtual roller-coaster of ups and downs, as different approaches were tried and either kept, modified or dropped. We have worked our way through a variety of approaches, such as Quality Assurance (QA), Quality Improvement (QI), Total Quality Management (TQM) and Continuous Quality Improvement (CQI), each with its pros and cons.

In my opinion, one of the simplest and least expensive ways to get a handle on how well your service is providing patient care is through the use of a peer-review team, and that is the focus of this month’s BTB adventure.

What Is Peer Review?

Peer review is a process that involves a grass roots approach to one of the key elements of assessing and managing quality: run review/critique. Being able to objectively look at real life provision of care is essential in the pursuit of excellence in medicine. Bringing in an outside person or persons to evaluate performance should, at least in theory, increase the objectivity of the evaluation process. Unfortunately, there is a tradeoff when using outside evaluators. First, they don’t know an individual provider’s strengths or weaknesses, adding a impersonal feel to the event. In addition, those being evaluated invariably have a medium to high level of mistrust, because, after all, “the evaluators are outsiders.”

While using in-house personnel does increase the risk of subjective evaluations, peer review team members should come with a vested interest: improving the care provided by their own agency. Hopefully, their vested interest helps to reduce their subjectivity.

I, for one, would rather work with that vested interest and assist team members to reduce subjectivity and raise objectivity, rather than looking outside for a solution.

Setting Up a Team

For the sake of simplicity, keep the peer review team small—using three or four providers works best. Initially, the team should have staggered terms of service. If you use the three-person format, one member serves for one month, the next serves for two months, and one member serves for three months.

After that, all oncoming members of the team serve a three-month term. By staggering terms, a new team member comes on board each month to join two members who have been serving and have gained experience, thus promoting continuity of the review team and the review process itself. This is far superior to replacing the entire peer review team every three months, which thrusts them into this role with no other experienced team members to turn to for insights thus requiring a steep learning curve.

Philosophy Matters

If you think back to the original concept of QA, it was almost doomed from the outset because of its one-sided approach to quality management. Find and fix problems was pretty much the mantra of QA. Problems were invariably linked to personnel, thus creating the attitude that people are the problem. In turn, when a provider was notified that one of his calls was being reviewed at the upcoming QA meeting, he immediately knew that he had made a mistake and would be punished publicly for his transgression(s). For that matter, a phone call or letter from an unhappy patient can also result in a call being reviewed. There is not much positive about that experience, especially from a learning perspective. If the event is felt to be punitive, providers leave the critique with a bad taste in their mouth. This is hardly a way to encourage behavior modification, which is one of the primary goals of run reviews/critiques.

If you take the concept of CQI and broaden the review team’s tasks to include identification of both problems and exemplary behavior, you create a more balanced assessment of the overall operation. In addition to identifying mistakes in patient care, or deviations from protocol, identifying excellence in documentation or compliance with protocol or excellence in patient care gives the event balance rather than the feel of a QA witchhunt. To that end, any call should be able to be pulled into the review process at the request of the medical director, the peer review team or any field provider. Collectively, this also increases objectivity of the process, knowing that no one person or group controls the calls that are pulled for review.

The philosophy or attitude of individual peer review team members is also an important part of the process. While they are on one side of the table as peer review team members, they know that, at some point, their term will expire and they will change sides of the table. Asking themselves how they would like to be treated when their turn to be reviewed comes around helps them maintain a professional attitude and a positive demeanor in the reviewer role.

Last, but by no means least, in the quest to make a peer review team work well is to recognize two key issues. Always keep in mind that the review process is not a personal matter, but a professional matter. Don’t get mad or defensive about having a call critiqued. If the individuals whose call is being reviewed take a professional attitude and approach to the table, i.e., “What can I do to improve my provision of patient care?” the process instantly strengthens. Whether someone did or did not make a mistake is really of less consequence than how a given decision was reached. Helping them understand how to think differently and make better decisions and choices on behalf of the patients they serve truly reaches deeper into the area of behavior modification. Second, never lose sight of the real goal: continuously improving the quality of service and care you provide for your patients.

A professional, focused, objective peer review team is an inexpensive and efficient way for agencies to manage a key part of their quality of care. You’ll be surprised how much peer power your agency has just sitting there waiting to be tapped. Until next month…