Peer review is a mandatory process for all hospitals in the United States. It was developed to ensure that patients receive a consistent level of care and to promote standardization in practice. It involves retrospective chart reviews in which adherence to hospital guidelines and assessment of overall care is evaluated (Bader et al, 2021). Most often, cases are referred if they meet certain maternal or neonatal triggers defined by the organization or if there are concerns regarding substandard management.
The following are examples of maternal and neonatal triggers:
- elective delivery at less than 39 weeks gestation
- massive postpartum hemorrhage (requiring transfusion of > 4 U packed red blood cells)
- maternal admission to an intensive care unit
- unplanned operative injury
- shoulder dystocia with birth injury
- neonatal birth injury
- term newborn transfer to a neonatal intensive care unit
TJC requires a peer review process to be in place for hospital accreditation. There is no standard in how peer review is conducted. For example, it is not required for physicians to conduct the reviews. This presents a disadvantage due to a lack of physician perspective in the management provided. A structure that includes physicians and those with similar training would allow for this perspective to be assessed. Some hospitals have committees with both physician and non-physician members including nurses and nurse practitioners. The value in bringing other disciplines into this process is they present a different viewpoint and a more comprehensive picture can be obtained (Bader et al, 2021).
Once the case is reviewed, if there are any concerns in the management of the patient the providers involved are sent a letter with specific questions regarding their actions and/or care. Hence, providers need to reflect on and describe the rationale for their actions. The group makes final decisions based on the provider’s response. The end result may be recommendations for individual practice changes or education, or systems/process changes. As such, it can be a good learning opportunity for providers being reviewed and those on the committee.
Challenges with Peer Review
One of the challenges with peer review is the potential for hindsight and outcome bias. Hindsight bias involves looking back on an event, with knowledge of the outcome, and overestimating one’s ability to have predicted the outcome at the time (Britannica, n.d.). Outcome bias refers to the influence that knowing the outcome has on assessing the quality of care delivered. Suggested strategies to reduce both hindsight and outcome bias include: withholding outcome discussion until reviewers have provided their own predictions, and considered all potential diagnoses (Bader et al, 2021). The only caveat to using the strategy of withholding outcome information is that often when bad outcomes occur, the information is widely known by staff on the unit.
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Bader, H., Abdulelah, M., Maghnam, R., & Chin, D. (2021). Clinical peer Review; A mandatory process with potential inherent bias in desperate need of reform. Journal of Community Hospital Internal Medicine Perspectives, 11(6), 817–820. https://doi.org/10.1080/20009666.2021.1965704
Britannica (n.d.) Hindsight bias. Retrieved from https://www.britannica.com/topic/hindsight-bias
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS