Peer Review in Anesthesia at BIDMC Steve Pratt, MD Chair, Peer Review Committee Director Quality Improvement Department of Anesthesia, Critical Care & Pain Management BIDMC

Goals of Peer Review Demonstrate competence of our staff (not root out bad performers) Find areas for individual improvement and assist with education Provided education between staff members Decrease tension between QA and peer review processes RARELY identify issues requiring disciplinary action

The Process Departmental peer review committee meets regularly to review reappointment files Specific data reviewed for each Ad hoc meeting may be called to deal with specific issues Complaints Behavior issues Serious complications potentially related to competence, professionalism, etc

Data for Re-appointment Total cases: OR, OB, ICU, Pain Subspecialty: TEE, Acupuncture, Pain procedures Complications: see below CME Complaints/Compliments Suits Hospital training: OSHA, Universal protocol, etc Incident reports being added

Other reviews All staff must participate in crisis simulation every 3 years Annual review with chief Academic work Administrative contribution Teaching Evaluations by: Residents Division director by staff Staff by division director Floor managers

Adverse outcomes Every case has a QA entry REQUIRED to close electronic record Indicators by division Most cases “None” All significant adverse events presented to full department at weekly complication meeting Structured review by 3 department members (see form) “Thank You” sent to file for presentation

Adverse Events & Peer Review Raw data on complication rates not tracked Can’t risk adjust Unclear of impact that management has on many complications Complications associated with clinical error are tracked Most cases not attributed to clinician error Significant error rates about 1:500-1000 cases Few repeat errors or trends Can identify outliers Reporting of complications tracked At least 2/cycle Compliment those who report more (Reynolds, Cohen)

Examples of individual support derived from process PA catheter placement with cardiac division Anger management Adjustment of individual staff call to locations where they are most comfortable

Culpability at BIDMC Anesthesia Intention to do harm Behavior that knowingly or repeatedly takes unacceptable risks Knowing or repeated violations of policies, protocols, or accepted standards of care. Knowing or repeated Failure to meet minimum standards. Failure to participate in Quality Assurance activities. This includes failure to report adverse events or errors Repeated errors of the same or similar type, or refusal to take appropriate steps at education when an error is made.

Potential future topics Accuracy of charting derived from AIMS Response to events as identified by AIMs Simulation 360o review with surgeons and nurses Completion of mandatory on-line training. Needs defining On-line summary of performance and other QA/QI data (adoption of Radiology web system)

Questions