Despite decades of investment in patient safety, unintentional patient harm remains a major challenge in the health care industry. Peer-to-peer assessment in the nuclear industry has been shown to reduce harm. The study team’s goal was to pilot and assess the feasibility of this approach in health care. The team developed tools and piloted a peer-to-peer assessment at 2 academic hospitals: Massachusetts General Hospital and Johns Hopkins Hospital. The assessment evaluated both the institutions’ organizational approach to quality and safety as well as their approach to reducing 2 specific areas of patient harm. Site visits were completed and consisted of semistructured interviews with institutional leaders and clinical staff as well as direct patient observations using audit tools. Reports with recommendations were well received and each institution has developed improvement plans. The study team believes that peer-to-peer assessment in health care has promise and warrants consideration for wider adoption.
Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
2.
Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
3.
WachterRM.Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29:165-173.
4.
BohmerRMBloomJDMortEADemehinAAMeyerGS.Restructuring within an academic health center to support quality and safety: the development of the center for quality and safety at the Massachusetts General Hospital. Acad Med. 2009;84:1663-1671.
5.
ChassinR.The six sigma initiative at Mount Sinai Medical Center. Mt Sinai J Med. 2008;75(1):45-52.
6.
ClancyCMBerwickDM.The science of safety improvement: learning while doing. Ann Intern Med. 2011;154:699-701.
7.
KimCSLukelaMPParekhVIet al. Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. Am J Med Qual. 2010;25:211-217.
8.
WangYEldridgeNMeterskyMLet al. National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014;370:341-351.
9.
HudsonDWHolzmuellerCGPronovostPJet al. Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual. 2012;27:201-209.
10.
ReesJ.Hostages of Each Other: The Transformation of Nuclear Safety Since Three Mile Island. Chicago, IL: University of Chicago Press; 1996.
11.
StrickerLFelgateG.WANO Review 2009. London, England: World Association of Nuclear Operators; 2009:1-16.
12.
O’ConnorGTPlumeSKOlmsteadEMet al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA. 1996;275:841-846.
13.
HolmanWLAllmanRMSansomMet al. Alabama coronary artery bypass grafting project: results of a statewide quality improvement initiative. JAMA. 2001;285:3003-3010.
14.
PronovostPJHudsonDW.Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry. BMJ Qual Saf. 2012;21:872-875.
15.
GursesAPKimGMartinezEAet al. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf. 2012;21:810-818.
16.
MartinezEAMarstellerJAThompsonDAet al. The Society of Cardiovascular Anesthesiologists’ FOCUS initiative: locating errors through networked surveillance (LENS) project vision. Anesth Analg. 2010;110:307-311.
17.
ThompsonDAMarstellerJAPronovostPJet al. Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery. J Patient Saf. 2015;11:143-151.
18.
ChassinMRLoebJM.High-reliability health care: getting there from here. Milbank Q. 2013;91:459-490.
19.
SutcliffeKMPaineLPronovostPJ.Re-examining high reliability: actively organising for safety [published online March21, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004698.
20.
WeaverSJWeeksKPhamJCPronovostPJ.On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile. Am J Infect Control. 2014;42(10 suppl):S203-S208.
21.
PronovostPJMarstellerJA.Creating a fractal-based quality management infrastructure. J Health Organ Manag. 2014;28:576-586.
22.
BoyceJMPittetD.Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45.
23.
PronovostPNeedhamDBerenholtzSet al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
24.
The Joint Commission. 2010 Hospital Accreditation Standards. Oakbrook Terrace, IL: The Joint Commission; 2010:LD.01.01.01-LD.04.04.07.
25.
The Joint Commission. Comparison Between Joint Commission Standards, Malcolm Baldrige National Quality Award Criteria, and Magnet Recognition Program Components. Oakbrook Terrace, IL: The Joint Commission; 2013:1-14.
26.
DolanTC.ACHE and Baldrige. Program’s commitment to excellence has profound effect on U.S. healthcare’s quality, efficiency. Healthc Exec. 2011;26(2):6.
27.
GoonanKJMuzikowskiJ.Baldrige: myths and realities. Hosp Health Netw. 2008;82(5):84-85.
28.
ScottCGerardiD.A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 2. Jt Comm J Qual Patient Saf. 2011;37:70-80.
29.
ShieldsJAJenningsJL.Using the Malcolm Baldrige “are we making progress” survey for organizational self-assessment and performance improvement. J Healthc Qual. 2013;35(4):5-15.
30.
National Institute of Standards and Technology. Baldrige Performance Excellence Program: about Baldrige. http://www.nist.gov/baldrige/about/index.cfm. Accessed December 8, 2013.
31.
Together, Joint Commission hospital requirements and Baldrige performance excellence criteria support quality and safety improvement efforts. Jt Comm Perspect. 2013;33(7):17-18.
32.
Baldrige Performance Excellence Program. Health Care Criteria for Performance Excellence: 2013-2014. Gaithersburg, MD: National Institute of Standards and Technology; 2013.
33.
GursesAPOzokAAPronovostPJ.Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21:347-351.
34.
CarayonPSchoofs HundtAKarshBTet al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(suppl 1):i50-i58.
35.
PhamJCGoeschelCBerenholzSet al. CLABSI conversations: lessons from peer-to-peer assessments to reduce central line-associated bloodstream infections. Qual Manag Health Care. 2016;25:67-78.
36.
TarselliJHooperD.Comprehensive Program to Change Hand Hygiene Culture Improves Adherence to Disinfection Guidelines, Leading to Lower Infection Rates and Costs. Innovations Exchange. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
37.
PronovostPJCleemanJIWrightDSrinivasanA.Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf. 2016;25:396-399.
38.
MathewsSCDemskiRHooperJEet al. A model for the departmental quality management infrastructure within an academic health system [published online September16, 2016]. Acad Med. doi:10.1097/ACM.0000000000001380.
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