Medical Staff

Peer Review Monthly: Peer review and the culture of safety

Medical Staff Leader Insider, January 7, 2009

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Dear medical staff leader or professional,

With the 2009 Joint Commission leadership standards calling for organizations to create a culture of safety, clients often ask me how peer review fits in. After all, isn’t this the hospital’s problem since the requirement isn’t in the medical staff chapter of the Comprehensive Accreditation Manual for Hospitals, 2009 Edition?

The contemporary definition of peer review is an evaluation of practitioner performance for all areas of competency using multiple sources of data. Given that definition, peer review plays an integral role in creating and maintaining a hospital’s safety culture. How? Peer review allows medical staffs to evaluate and improve physician performance according to the six general competencies that were defined by the Accreditation Council for Graduate Medical Education and adopted by the American Board of Medical Specialties and the Joint Commission. The competencies are:

  • Patient care
  • Medical knowledge
  • Practice-based learning and improvement
  • Interpersonal communication skills
  • Professionalism
  • Systems-based practice

While safety efforts are woven into all six competencies, system-based practice, communication and interpersonal skills, and professionalism directly relate to patient safety. 

Systems-based practice:
The systems-based practice competency fosters a culture of safety because it promotes compliance with safety policies and procedures system-wide. If physicians ignore safe practices, they will erode the hospital’s culture of safety. Conversely, if physicians actively comply with and coach the staff on safety practices, they can strengthen the hospital’s culture of safety.

Communication and interpersonal skills:
The communication and interpersonal skills competency relates to safety because the majority of clinical errors that cause patient harm result from a lack of clear communication. These errors can occur because a physician wrote illegibly or used unclear abbreviations in a patient’s record, or because members of the care team fail to relay information regarding verbal orders or patient status. By learning and practicing specific communication tools, such as using approved abbreviations, repeating back verbal orders, or initiating SBAR (situation, background, assessment, recommendation), physicians can decrease the likelihood of unintended patient harm.

Finally, the professionalism competency relates to safety because disruptive behavior creates an unsafe and intimidating atmosphere for the hospital staff. Professionalism also ties into The Joint Commission’s 2009 leadership standards that address disruptive behavior, which apply to everyone working within the hospital. Obviously, when a physician is disruptive, the staff members who experience it, either directly or indirectly, may become shaken and distracted from their patient care duties. But more subtly, when a physician is routinely rude or discourteous, the staff becomes hesitant to communicate with the physician when they see changes in a patient’s condition, making early intervention less likely.

The goal of peer review is to improve physician performance through systematic evaluation. A contemporary peer review program must evaluate all the general competencies, not just the technical aspects of patient care. This means that, for physicians practicing in the hospital, fostering a culture of safety is just as important as having the technical skills to provide care.


Robert Marder, MD, CMSL
Vice president
The Greeley Company

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