Promoting Patient Safety Through Peer Review

by Philip Goldstein, M.D.

From time to time the Director’s Forum will feature guest editorials on subjects of interest, present innovative patient safety ideas or programs, and report on important issues concerning medical liability. Phillip Goldstein, M.D., consultant to The Doctors Company and this quarter’s guest writer, is director of an innovative peer review program for OB-GYN departments known as the Voluntary Review of Quality of Care (VRQC), which is conducted under the auspices of the American College of Obstetrics and Gynecology’s (ACOG’s) Committee on Quality Improvement and Patient Safety. Ever since the 1999 Institute of Medicine report “To Err Is Human” was published by the National Academy of Sciences, the patient safety movement has emphasized that quality patient care results from an integrated health “team” approach—delivered within a safe health care “system.” ACOG supports this concept and provides this peer review program to promote patient safety in obstetrics and gynecology.
—David B. Troxel, M.D., Medical Director, Board of Governors

Many hospitals have difficulty providing objective peer review. For instance, some facilities and medical staffs are so small that it is difficult to assure objectivity and to protect confidentiality. In larger hospitals, physician-nurse communication issues are not addressed, which affects optimal provision of patient care. In some institutions, effective board oversight is lacking, and in others, appropriate investment in facility/technology development is lacking and hinders effective delivery of care.

In response to these issues, and because patient safety begins with quality patient care, VRQC was established 20 years ago to assist ACOG fellows in developing effective, objective, and nonpunitive peer review. Since its introduction, VRQC has reviewed OB-GYN services in more than 200 hospitals.

The program is conducted by active practicing physicians who are often from the region in which the hospital is located. These doctors are familiar with regional and geographical nuances. The team consists of three obstetricians-gynecologists, a nurse who is familiar with labor and delivery protocols, and a medical administrator. The team may be supplemented by a family practice doctor, an anesthesiologist, or a nurse midwife when the requesting institution feels that the additional personnel would be appropriate. The visit by the team is coordinated by an individual designated by the institution and the team administrator. When the hospital decides that it would like a review of its OB-GYN department, it must first complete a set of ACOG forms that generally describe the hospital and the community it serves, the structure and practice of the department, any apparent problems in the department, and any additional departmental issues that it feels the VRQC team should know about. A visit is scheduled for a convenient time, usually six to eight weeks from the first inquiry.

The team arrives as a group and initially meets with key people in the organization to review the VRQC process and to answer questions. The next day the team meets individually with several decision makers in the hospital organization, members of the OB-GYN department, and selected members of other departments with which the OB-GYN department interacts (e.g., anesthesiology, emergency room, and radiology). The VRQC nurse meets with nurse leadership and with nurses working on the obstetrics and gynecology floors. The next day the team reviews medical records that focus on the range of issues that the hospital wants to study. In addition, the team will review medical records of some common procedures, such as induction of labor and laparoscopic surgery. Usually four to six procedures are studied. The medical records are selected at random, based on ICD 9 codes. Some specific records will be studied at the request of the hospital. On the last day, the team again meets with the key organization and departmental individuals to discuss the findings of the review.

The report is then written by the team administrator in collaboration with the on-site clinical team and edited for accuracy and confidentiality by staff at ACOG. The final report is sent to the hospital four to six weeks after the site visit. The practices of the department are compared to published local and national standards of care. The review is objective, confidential, nonpunitive, and evidence-based.

A detailed description of this program was published by Paul Gluck, M.D., former program director and current chair of the National Patient Safety Foundation Board. In his analysis of the first 100 site visits,¹ departmental and health system departures from commonly accepted medical practices were more common than clinical concerns. The most common system deficiencies were lack of an effective peer review and quality assessment program, poor documentation, lack of CME, poor privileging and credentialing, and poor policy and procedures. Obstetrical issues were more common than gynecologic issues—with induction and augmentation of labor leading the list, followed by anesthesia coverage and quality, cesarean section for fetal distress, cesarean section for failure to progress, and vaginal birth after cesarean. Surprisingly, similar problems occurred in all hospitals irrespective of their size or available resources.