Clinical Peer Review Research Articles

Moderating Content Moderation: A Framework for Nonpartisanship in Online Governance

Internet platforms serve two important roles that often conflict. Facebook, Twitter, YouTube, and other internet platforms facilitate the unfettered exchange of free speech by millions of people, yet they also moderate or restrict the speech according to their “community standards,” such as prohibitions against hate speech and advocating violence, to provide a safe environment for their users. These dual roles give internet platforms unparalleled power over online speech—even more so than most governments. Yet, unlike government actors, internet platforms are not subject to checks and balances, such as courts or agencies that must follow well-defined procedural rules, affording notice, due process, and appellate review. Internet platforms have devised their own policies and procedures for content moderation, but the platforms’ enforcement remains opaque—especially when compared to courts and agencies. Based on an independent survey of the community standards of the largest internet platforms, this Article shows that few internet platforms disclose the precise procedural steps and safeguards of their content moderation—perhaps hoping to avoid public scrutiny over those procedures. This lack of transparency has left internet platforms vulnerable to vocal accusations of having an “anti-conservative bias” in their content moderation, especially from politicians. Internet platforms deny such a bias, but their response has not mollified Republican lawmakers, who have proposed amending, if not repealing, Section 230 of the Communications Decency Act to limit the permissible bases and scope of content moderation that qualifies for civil immunity under the section. This Article provides an alternative solution to this perceived problem—a model framework for nonpartisan content moderation (NCM) that internet platforms should voluntarily adopt as a matter of best practices. The NCM framework provides greater transparency and safeguards to ensure nonpartisan content moderation in a way that avoids messy government entanglement in enforcing speech codes online. The NCM framework is an innovative approach to online governance that draws upon safeguards designed to promote impartiality in various sectors, including courts and agencies, clinical trials, peer review, and equal protection under the Fourteenth Amendment.

P1548THE VALUE OF BEING A NETWORK: CLINICAL GOVERNANCE AND DIALYSIS CLINIC PERFORMANCE MANAGEMENT IS ASSOCIATED WITH IMPROVED PATIENTS SURVIVAL

Abstract Introduction. In order to help facilitate the uptake of best clinical practices, improve outcomes, enhance efficiency and reduce costs, few healthcare organizations have introduced Continuous Quality Improvement (CQI) programs. Since September 2014, dialysis centers belonging to the EMEA Fresenius Medical Care (FME) network have introduced a CQI policy called Medical Peer Review (MPR) based on key performance indicators (KPI) related to patient’s clinical status. We exploit the quasi-experimental setting generated by the introduction of FMC CQI policy, to evaluate the association between improvement in intermediate outcomes (key performance indicators) and prolonged survival among dialysis patients registered in the EMEA FME network. Methods. We conducted a historical cohort study. We included adult patients on chronic dialysis with less than 90 days between renal replacement therapy (RRT) initiation date and first treatment date in FME clinics. We compared KPI target achievement (P-BSC score) and 2-year mortality for patients enrolled prior to MPR-CQI policy onset (Cohort A) and a cohort of patients enrolled after MPR-CQI policy onset (Cohort B). Structural Equation model was adopted to estimate the association of MPR-CQI policy on patients’ survival through changes in intermediate outcomes (P-BSC score). Results. The Cohort A and Cohort B consisted of 2397 and 1873 patients, respectively. We observed no difference across groups concerning the distribution of age (63.1 vs 62.8 years), gender (59% vs 60% males) and body mass index (27.6 vs 26.4 kg/m2); Cohort A showed lower Charlson’s comorbidity index (3.3±1.5 vs 3.8±1.9, p<0.01) and higher dialysis vintage (32.9±27.0 vs 21.3±22.2 days, p-value<0.01) compared to Cohort B. P-BSC scores over the 6-month ascertainment period was 5.25±1.47 in the pre CQI-MPR policy cohort, while it was significantly higher (6.67±1.63) in the post CQI-MPR policy cohort. Mediation analysis demonstrated a strong indirect effect of CQI-MPR implementation on mortality trough improvement of P-BSC rating score occurring in the post-implementation era (OR=0.70, p<0.001) Conclusion. We showed that, after discounting for potential unmodifiable confounding factors and potential unmeasured selection/chronological bias, improvement of intermediate outcomes and performance indicators occurred after MPR-CQI policy implementation, was associated to a strong improvement in survival. Figure:

Guidelines for the use of WhatsApp groups in clinical settings in South Africa.

In everyday clinical practice, healthcare professionals (HCPs) are exposed to large quantities of confidential patient information, and many use WhatsApp groups to share this information. WhatsApp groups provide efficient mechanisms for clinical management advice, decision-making support and peer review. However, most HCPs do not fully understand the legal and ethical implications of sharing content in a WhatsApp group setting, which is often thought to be hosted on a secure platform and therefore removed from public scrutiny. In our paper, we unpack the legal and ethical issues that arise when information is shared in WhatsApp groups. We demonstrate that sharing content in this forum is tantamount to the publication of content; in other words, those who share content are subject to the same legal ramifications as a journalist would be. We also examine the role of the WhatsApp group administrator, who bears an additional legal burden by default, often unknowingly so. We consider the recommendations made by the Health Professions Council of South Africa in their guidelines for the use of social media, and highlight some areas where we feel the guidelines may not adequately protect HCPs from the legal repercussions of sharing content in a WhatsApp group. Finally, we provide a set of guidelines for WhatsApp group users that should be regularly posted onto the group by the relevant group administrator to mitigate some of the legal liabilities that may arise. We also provide guidelines for group administrators.

Developing a clinical nurse-led peer review committee.

Developing a clinical nurse-led peer review committee.

Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center.

Although many health care institutions believe that clinical peer review is vital for identifying and improving quality of care, peer review is perceived by many clinicians as variable and inherently punitive. Successful peer review requires institutional leadership and adoption of a just culture approach to investigating and determining accountability for medical errors that result in harm. We describe how an academic medical center implemented and adapted its clinical peer review processes to be consistent with just culture theory and provide a roadmap that other institutions may follow. Specific examples of peer review are highlighted to show how the process improved patient safety in the departments of emergency medicine, internal medicine, and pediatrics. The most significant process improvement was shifting from a tradition of assigning letter grades of "A," "B," or "C" to determine whether preventable adverse events were caused by "human error," "at-risk behavior," or "reckless behavior." This categorization of human behaviors enabled patient safety officers within 3 departments to develop specific interventions to protect patients and enlist physician support for improving clinical systems. Each department's success was due to recognition of different patient and provider cultures that offer unique challenges. The transformation of peer review was a crucial first step to shift perceptions of peer review from a punitive to a constructive process intended to improve patient safety. Our experience with reengineering clinical peer review shows the importance of focusing on just culture as a key method to prevent patient harm.

Use of Clinical Decision Support and Peer Review to Increase NCCN Guideline Adherence

Use of Clinical Decision Support and Peer Review to Increase NCCN Guideline Adherence

Using Epidemiology, Pediatric Medical Director and Peer Review to Inform Quality Improvement and Education in a Regional Adult and Pediatric Trauma Based Flight Program

Using Epidemiology, Pediatric Medical Director and Peer Review to Inform Quality Improvement and Education in a Regional Adult and Pediatric Trauma Based Flight Program

Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance.

To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance. All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant. Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI. In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.

BPI19-013: Use of Clinical Decision Support and Peer Review to Increase NCCN Guidelines Adherence

Background: eviCore healthcare uses the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) to support its proprietary program for medical oncology drug management. All treatment regimens assigned NCCN Category of Evidence 1, 2A, or 2B are considered NCCN-adherent treatment selections in the eviCore program. The purpose of this study was to evaluate the pattern of NCCN adherence during the first year following program launch in regional payer markets. Methods: All cancer drug treatment authorization requests submitted in month 1 and month 12 following program launch for 4 regional third-party payers representing 13 different states were included, each of whom had management of high cost oncology drugs in place prior to eviCore program launch. Month 1 data were used as a surrogate for pre-program NCCN adherence, which is an overestimate as there is significant eviCore program impact on patients initiating therapy during that time. Requests with incomplete clinical data were excluded from analysis. Included requests were stratified by month 1 or month 12 from initial program launch date for each health plan. NCCN adherence was assigned based on the results of the clinical decision support and peer consultation processes utilized by eviCore to adjudicate the treatment request. NCCN adherence rate was calculated for each subgroup and a cumulative NCCN adherence rate for all included cases was calculated using weighted average accounting for volume differences by market. Results: There were 2,028 treatment regimen requests that were fully evaluable, with 1,285 occurring in month 1 and 743 occurring in month 12 following program launch. The rate of NCCN adherence increased for each health plan during the first program year, ranging from 69%–84% in month 1 and rising to 79%–91% in month 12. The weighted cumulative NCCN adherence during month 1 for all included plans was 75% and rose to 88% at month 12 following program launch. Conclusions: Use of clinical decision support supplemented by peer consultation is an effective means of increasing oncologists’ adherence to NCCN-recommended therapies across a broad range of regional provider markets. Additional study is warranted to determine whether this methodology can be applied to NCCN Categories of Preference to direct more patients toward preferred regimens with superior efficacy, safety, and affordability to further improve quality of care and lower total medical costs.

Abstract TP387: Development and Implementation of a Comprehensive Stroke Center Clinical Peer Review Process

Background: Comprehensive Stroke Centers (CSC) are required by The Joint Commission to have an interdisciplinary peer review process. Most hospitals structure their peer review programs, also known as morbidity and mortality meetings, by specialty and not by Centers of Excellence. Often these meetings are closed, with minimal information sharing for making program-wide improvements. Purpose: To develop and implement a process for conducting morbidity and mortality reviews for a CSC based on best practices to foster improved clinical outcomes. Methods: A literature review was performed to establish best practices for such reviews. An interdisciplinary team including key stakeholders was developed for a non-biased comprehensive chart review. All deaths within 30-days, sentinel events, serious incidents, adverse events, close calls, stroke mimics treated with alteplase, delays in care, complications, and major complaints were reviewed. Cases were captured by formal and informal processes (see diagram). Outcomes and trends are monitored. Recommendations are made for changes in clinical processes. Results: Between January 2016 - June 2018, 853 charts were reviewed for the criteria discussed above. A total of 89 charts were referred to the committee for further chart review, of which, 3 were identified for department peer review. Of those 3 cases, all were determined to be outliers, and no trends have been identified . While there were no blatant opportunities identified for improvement, the review process provides helpful information regarding the quality of the program. Members of the interdisciplinary team feel that the process is robust and valuable. Conclusion: Establishing a succinct process for chart evaluation and interdisciplinary team review has proven effective in identifying cases for referral to peer review. These data have been helpful in improving performance and monitoring patient-centered outcomes.

A Dozen Years, A Dozen Roses

Twelve years have passed since my first editorial for the Philippine Journal of Otolaryngology Head and Neck Surgery, on the occasion of the silver anniversary of our journal and the golden anniversary of the Philippine Society of Otolaryngology – Head and Neck Surgery (PSO-HNS).1 Special editorials have similarly marked our thirtieth (pearl)2 and thirty-fifth (coral or jade)3 journal anniversaries, punctuating editorials on a variety of themes in between. Whether they were a commentary on issues and events in the PSO-HNS or Philippine Society, or on matters pertaining to medical research and writing, publication and peer review, I have often wondered whether my words fell on deaf ears. But write, must I-- despite my writer’s doubt.
 
 What then, do a dozen years symbolize? As a baby boomer, I am all too familiar with what “cheaper by the dozen” meant in daily life, outwardly displayed in the matching attire my siblings and I wore on special occasions -- such as Yuletide when we would sing the carol “twelve days of Christmas.”4 We read the comedy “Twelfth Night”5 in school, although I admittedly enjoyed “The Dirty Dozen”6 more than Shakespeare. College ROTC introduced me to the “Daily Dozen” and the grueling Navy count- 1,2,3, ONE! One, two, three, TWO! (One, two, three, four! I love the Marine Corps!) And that is as far as my list of memorable dozens goes, covering five dozen years of life.
 
 Of these, one fifth or 20% of my life has been devoted to our journal. From that perspective, I cannot help but wonder whether, or how it mattered. After 12 years, the day-to-day routine has hardly changed; neither have the periodic problems that precede the birth of each issue. I still find it difficult to solicit and follow-up reviews, and I still burn the midnight oil on weekends and holidays, patiently guiding authors in revising their manuscripts. Nevertheless, our journal has come a long way from where it was when we started (although it has not reached as far and as quickly as I would have wanted it to). Much depends on our authors and the caliber of their contributions, and our reviewers and the quality and timeliness of their reviews. However, despite our efforts to conduct education and training sessions on Medical Writing and Peer Review, the new batch of submissions and reviews each year evinces the need to repeat these regularly. In this regard, the increasing response-ability of our associate editors and continuing support of our society are needed to ensure our progress.
 
 This year, we welcome Dr. Eris Llanes as our new Managing Editor as we thank and congratulate Dr. Tony Chua (who retains his position as Associate Editor) for serving in that role for the past 12 years. We have finally migrated from our previous platform to the Public Knowledge Platform - Open Journal Systems (PKP-OJS) available from https://pjohns.pso-hns.org/index.php/pjohns/index. The PSO-HNS has become a member of the Publishers International Linking Association (PILA), which manages and maintains, deposits and retrieves, Metadata and Digital Identifiers inclusive of associated software and know-how. This will enable us to register Digital Object Identifiers (DOIs) for all our content using the Crossref® system (https://www.crossref.org/about/), making our “research outputs easy to find, cite, link, and assess.”7 We are also subscribing to the Crossref® Similarity Check plagiarism detection software service powered by iThenticate® (https://www.crossref.org/services/similarity-check/)7 and are exploring ways and means of converting all our articles to eXtensible Markup Language (XML) format. These steps reflect our continuing efforts to comply with the requirements for indexing in the Directory of Open Access Journals (DOAJ)8 and our re-application for indexing in Scopus®.9 These steps would not have been possible without the full support of the PSO-HNS Board of Trustees under the leadership of our President, Dr. Aggie Remulla, for which we are truly grateful.
 
 Indeed, the past 12 years may represent a complete cycle (such as 12 hours on a clock, or months in a year, or 12 signs of the zodiac), the first steps in the rebirth of our journal. Although they may not count among the “memorable dozens” of my life, each of these years may be likened to a rose (with its attendant thorns) – a bouquet of a dozen roses that I offer to all of you.
 “for there’s no rose without a thorn,
 no night without the morn,
 no gain without some meaningful loss …”10

Reasons for Screen Failure among Patients Identified as Candidates for a Phase 2 Study of 5-fraction Stereotactic Body Radiation Therapy (SBRT) for Oligometastatic Cancer

The term oligometastatic (OM) was introduced to describe patients with a limited number of clinically detectable metastases for which local ablative therapy could potentially provide improved disease-free survival or even cure. The incidence of an oligometastatic disease distribution is difficult to estimate. The purpose of this analysis was to describe the reasons precluding trial participation in our trial of SBRT for oligometastatic cancer. We retrospectively audited all patients who were screened for participation in a single-arm phase II trial designed for patients with OM cancer (up to 5 sites of extra-cranial metastases). Study participants received local ablative therapy to all known sites of disease and at least one index lesion was treated with 5 fraction SBRT (study intervention). Eligibility criteria required baseline computed tomography (CT) ≤1 month prior to enrolment, and all cases were discussed at peer-review rounds to confirm eligibility. Between Mar 7 2013 and Nov 17 2017, 236 patients were screened and 145 (61%) enrolled to the study. The reasons for screen failure included patients declining study participation in 4% (9/236) [n = 9; 4 with <5 mets, and 5 with uncertain number] and 12% (29/236) having >5 metastases upon restaging baseline scans. Of the remaining 53 patients who had ≤5 metastases but were not enrolled, reasons for screen failure included uncertainty that the primary tumor was controlled (n=9), lesions where alternative ablative therapy was recommended (n=10), not suitable for SBRT (n=18; size n=3, non-SBRT strategy preferred n=8, toxicity risk n=4, previous RT field overlap n=3), high subjective risk of systemic relapse (n=9; progressive disease during restaging scans n=4, not suitable for comprehensive ablative therapy n=1, plan for systemic therapy n=4) or other reasons (n=7; e.g. index lesion resolution, index lesion was a primary tumor, presence of cranial metastases). In our review of a cohort of patients flagged to be potential candidates for enrollment in a clinical trial of SBRT for OM cancer, 87% of patients were confirmed to have <5 metastases. The screen failure rate was high. The most common reason for exclusion was detection of >5 metastases (12%) while a small group of patients (5%) were deemed to be at high risk of systemic relapse based on clinical factors and peer review rounds. Reporting of the characteristics of screen failed patients are important in the interpretation of trial results.

An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals

In pursuit of high reliability, numerous organizations have promoted Just Culture, but its impact has never been assessed. This report combines data from a longitudinal survey-based study of clinical peer review practices in a cohort of 457 acute care hospitals with 43 measures from the Hospital Compare database and interprets them in relation to the long-term trends of Agency for Healthcare Research and Quality (AHRQ) data on the Hospital Survey of Patient Safety Culture. In all, 211 of 270 respondents (79%) indicated that their hospital has adopted Just Culture. More than half believe that it has had a positive impact. Just Culture implementation and its degree of impact are associated with somewhat better peer review process, but not with objective measures of hospital performance. Non-Punitive Response to Error has consistently been the lowest scoring category (45% positive) in the AHRQ database. Widespread adoption of Just Culture has not reduced reluctance to report or the culture of blame it targets.

In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.

Gather normative data on the goals of clinical peer review; refine a best-practice model and related self-assessment inventory; identify the interval progress towards best-practice adoption. Online survey (2015-16) of a cohort of 457 programs first studied by volunteer sampling in either 2007 or 2009 on 40 items assessing the degree of conformance to a validated quality improvement (QI) model and addressing program goals, structure, process, governance, and impact on quality and safety. Acute care hospitals of all sizes in the USA. Physicians and hospital leaders or hospital staff with intimate program knowledge. None. Subjectively-rated program impact on quality and safety; QI model score. Two hundred and seventy responses (59% response rate) showed that clinical peer review most commonly aims to improve quality and safety. From 2007 to 2015, the median [inter-quartile range, IQR] annual rate of major program change was 20% [11-24%]. Mean [confidence interval, CI] QI model scores increased 5.6 [2.9-8.3] points from 46.2 at study entry. Only 35% scored at least 60 of 80 possible points-'C' level progress in adopting the QI model. The analysis supports expansion of the QI model and an associated self-assessment inventory to include 20 items on a 100-point scale for which a 10-point increase predicts a one level improvement in quality impact with an odds ratio [CI] of 2.5 [2.2-3.0]. Hospital and physician leaders could potentially accelerate progress in quality and safety by revisiting their clinical peer review practices in light of the evidence-based QI model.

The Development of a Clinical Peer Review Tool.

Faculty evaluation for the purpose of promotion and tenure frequently includes peer review as a part of the process. Faculty review by a peer may provide an assessment of teaching effectiveness and information related to the faculty member's professional development activities. This article presents an innovative, evidence-based approach using selected National League for Nursing core competencies and International Nursing Association for Clinical Simulation and Learning clinical simulation standards in the development of a faculty peer review tool to gather data on clinical teaching to be used during the promotion and tenure process.

Institution of Just Culture Physician Peer Review in an Academic Medical Center.

For academic medical centers to improve quality outcomes, identification and optimization of opportunities for improvement are necessary. Effective clinical peer review frequently has limitations on timeliness, transparency, and consideration of system processes related to untoward clinical outcomes. We developed a process to overcome these barriers and capture opportunities for process improvement identified within the clinical peer review system. A multidisciplinary committee was formed to evaluate the current process of physician peer review at Magee Womens Hospital of the University of Pittsburgh Medical Center. Evaluation of current peer review triggers, processes, communication, transparency, and actionable outcomes was performed. A new approach was established that incorporated a protected electronic portal to improve communication and provider engagement, as well as initiation of a Just Culture peer review algorithm to realize opportunities for system improvements. The new process has been operative for 2 years. After initiation, the average time necessary for full case review decreased by 66% (6-2 months). Provider engagement and input have increased to 71%, from less than 10% before implementation. Most cases (51%) were identified as having more than one causative factor, with systems issues being the most frequent contributor to untoward outcomes. Given the recognized benefits, this approach is being considered for implementation on a broader scale within service-line quality initiatives across the University of Pittsburgh Medical Center health system. Although first implemented among faculty, consideration of incorporation into graduate medical education programs is ongoing.

176 How Common are Cognitive Errors in Cases Presented at Emergency Medicine Resident Morbidity and Mortality Conference?

Cognitive errors are increasingly recognized as a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conference. We aim to describe the frequency of cognitive errors relative to other error types, in cases presented at an emergency medicine resident M&M conference. We conducted a retrospective study of all cases presented at the Beaumont Emergency Medicine residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record and peer review committee notes by two emergency physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for cognitive and non-cognitive factors that contributed. Finally, when a cognitive error occurred, the case was reviewed and classified into faulty knowledge, faulty data gathering, or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third emergency physician. 87 M&M cases were reviewed; the two reviewers were in agreement on 73 cases, and 14 cases required mediation by a third reviewer. No medical error was identified in 22 cases. 48 cases involved diagnostic errors, 2 cases involved procedural errors, 5 cases involved inappropriate disposition errors, 6 cases involved inappropriate or delayed therapy errors, 1 case was due to inappropriate or delayed testing error, and 3 cases due to other. Of the 48 cases with primary diagnostic error, 47 were due to cognitive errors. Of these 47 cases, 39 cases were due to faulty synthesis, 22 cases were due to faulty data gathering, and 11 cases were due to faulty knowledge. 20 cases contained more than one type of cognitive error. Resident emergency physicians are presented with an important opportunity to learn from errors at M&M conferences. Although a core competency of residency training is mastering a fundamental body of knowledge, our review of 87 M&M cases shows that diagnostic errors are less likely due to deficient knowledge, and more likely due to cognitive errors. In order to reduce future medical errors and improve patient care, residency training should include education on identification of cognitive errors and how to avoid them.

Formalising multidisciplinary peer review: developing a haematological malignancy-specific electronic proforma and standard operating procedure to facilitate procedural efficiency and evidence-based clinical practice.

Multidisciplinary team (MDT) meetings aimed at facilitating peer review have become standard practice in oncology. However, there is scant literature on the optimal structure and conduct of such meetings. To develop a process for formal peer review of patients with haematological malignancies and to audit any resulting changes made to the management recommendations of the treating physician. A standard operating procedure (SOP) for MDT meetings was developed essentially to integrate clinical peer review with weekly pathology and radiology meetings. The centrepiece is the electronic submission of a patient-specific proforma (Microsoft InfoPath) prior to the meeting. It serves as the template for presentation, discussion and recording of recommendations and conclusions. The final verified document is stored in the electronic patient record, and a copy is sent to the general practitioner. The proposed management plans were compared to the consensus recommendations of the meeting for the first 4 years since inception. Both SOP and proforma underwent continual improvements. These provided the framework for the conduct of a robust weekly MDT meeting for peer review of the management of patients with haematological malignancies. On 20% of occasions, patient management plans were altered to optimise patient care as a direct consequence on peer review at the MDT. Our streamlined process, in its ultimate format, has provided a mature and efficient forum for formal peer review in a genuine multidisciplinary environment. Both initial data and informal feedback support its ongoing activity as an integral component of delivering quality patient care.

Tongue Ulcers, Abdominal Pain, and Fever in a Kidney Transplant Recipient

Tongue Ulcers, Abdominal Pain, and Fever in a Kidney Transplant Recipient

A Systematic Approach to Clinical Peer Review in a Critical Access Hospital.

Purpose:Clinical provider peer review (CPPR) is a process for evaluating a patient's experience in encounters of care. It is part of ongoing professional practice evaluation and focused professional practice evaluation—important contributors to provider credentialing and privileging. Critical access hospitals are hindered in CPPR by having a limited number of providers, shortages of staff resources, and relationships among staff members that make unbiased review difficult. Small departments within larger institutions may face similar challenges.Methods:A CPPR process created at Mayo Clinic Health System is described. It involved a case review questionnaire built on the Institute of Medicine “Six Aims for Changing the Health Care System,” a standardized intervention algorithm and tracking tool.Outcomes:During 2007 through 2014, a total of 994 cases were reviewed; 31% led to provider dialog and education or intervention. Findings were applied to core measure processes with success rate going from 87% to 97%. Changes were adopted in end-of-life care, contributing to a 50% reduction in all-cause mortality rate.Conclusions:Providing peer review tools to a critical access hospital can keep peer review within a group with knowledge of the individual provider's practice and can make process improvement the everyday work of those involved.