Specialty Department Peer Review
The Foundation has performed on-site department reviews covering most medical specialties for both teaching and community hospitals. Examples include departments of: anesthesiology, emergency medicine, gastroenterology, general and cardiovascular surgery, general and interventional cardiology, neurological surgery, orthopedic surgery, nuclear medicine, obstetrics and gynecology, ophthalmology, otolaryngology, pediatrics (including special care nurseries), radiology, radiation oncology, pathology and psychiatry.
Teams of Experts Join to Improve Quality in Peer Review of Cardiac Surgery
Specialty department review helps identify factors contributing to adverse outcome data or adverse quality of care statistics in comparison to other institutions. These include hospitals with both medico-legal and quality problems. For example, review of a cardiac surgery service may include analysis of the qualifications and past performances of the surgical and associated medical staff, physical resources, patient mix, and quality of ancillary and support services, such as internal medicine, cardiology (including echo, EKG, Holter and stress monitoring), interventional cardiology, nuclear cardiology, pacemaker implantation, anesthesia, nursing, perfusionists, procedures used for monitoring quality of care, policies regarding continuing education and problems identified by the institution.
Evaluation forms have been developed for cardiac surgery, interventional cardiology and other specialty programs. Prior to the site visit, data from the department are collected, utilizing the AMF evaluation forms for the specific specialty or subspecialty, along with both problem and randomly selected charts. The Foundation organizes a team of leading experts to review the data prior to the site visit of one to several days to observe procedures, interview staff and develop recommendations specific to the needs of that department.
Finding the Real Causes for Excess Cardiac Surgical Mortality
A community hospital affiliated with a national health system was disturbed by a cardiac surgical mortality rate several times that expected and that of other hospitals in the system. Administration wished a review of the practice of the surgeons. AMF experts looked at all aspects of cardiac surgery including the surgeons; but also administration, anesthesia, OR personnel, quality review mechanisms, ICU staffing, step-down unit staff and referral patterns from cardiology. They found that technically, the surgeons were performing at a satisfactory level, but that cardiac anesthesia was deficient, patients referred by interventional cardiologists were unduly high risk and several deaths occurred in the step-down unit as a direct result of deficient staffing and training in postoperative care of cardiac surgery patients. The AMF Team was able to make the appropriate recommendations for system improvement instead of the assumed sanction of the surgeons. Read More
Forming a Cancer Center
Quality management can reconfigure an entire specialty service
A group of four, small, loosely aligned hospitals with varying degrees of support in cancer chemotherapy and radiation oncology were considering consolidation. Because of prior competitive allegations of lack of quality, they needed assurance that this consolidation was among quality providers. AMF brought the decision makers within each hospital together and strategize with them on creating the highest quality service. We interviewed people to determine referral patterns and performed peer review to identify the quality providers for appropriate referrals in the defined catchments area. Identifying quality providers allowed the group to join together and form a major cancer center. Once the quality issues were laid to rest, they became collaborators instead of competitors.
An interventional cardiology service was struggling with quality issues and lack of communication among the physicians and between cardiology and administration. Diminished quality of service and poor physician morale was the result. The Foundation began with an extensive peer review conducted by internationally known cardiologists, followed by a series of cardiac catheterization conferences and individual proctoring sessions carried out at the hospital. Although the cardiologists were unenthusiastic at first, they ultimately welcomed the opportunity to discuss their difficult cases and to receive direct interventional laboratory coaching where it was needed. After the Foundation review, the group reported that the overall quality of service had improved substantially, with an unexpected, but highly welcome improvement in the relationship between the cardiologists and hospital administrators. This was a major cause for the service’s turnaround, and they were “profoundly grateful” for the assistance the Foundation gave them. They are now voted one of the top 100 cardiology services in the U.S. Read more
A large medical center was concerned about the quality and accuracy of reporting by their radiology staff and requested a comprehensive evaluation in areas of general radiography and fluoroscopy, ultrasonography, body computed tomography (CT), body magnetic resonance imaging (MRI), and neurological CT and MRI. An AMF site visit team found that although the overall quality of services and interpretations provided by the department as a whole was good, two physicians had higher than average overall error rates. Instances of unacceptably high error rates in certain subspecialty areas were documented, indicating a need for a greater emphasis on sub specialization in the department. Also, there was general deficiency in reporting due to varied and inconsistent reporting styles and lack of impressions compromising the clinical utility of reports. Recommendations by AMF resulted in successful action on the part of the hospital to address these deficiencies. Read more
On occasion, a medical staff may have some reservations about the quality of their pathology services with particular reference to accuracy and the formats of the reports. Through a review of laboratory organization, staffing, quality assurance mechanisms in place and actual evaluation of surgical and cytopathology slides, AMF can determine the accuracy of diagnosis and the completeness and timeliness of reports. A recent evaluation determined that diagnostic accuracy was quite good, but that the lack of standardized reporting formats and excessive verbiage in the reports was causing the medical staff great difficulty in determining the final diagnosis and important prognostic indicators for the management of patients. The site visit team was also able to determine that potential weak areas within the handling of small biopsies from the endoscopy suite had resulted in some sentinel mislabeling of patient samples. Recommendations by AMF pathology team resolved these issues for the department. Read more
The Emergency Department of a suburban community hospital suffered several sentinel events; preventable deaths. These drew attention to multiple problems such as a frequent need to divert ambulance cases to other hospitals, prolonged lengths of stay, difficult relations with related hospital departments, diagnostic test result delays and financial loss.
AMF experts reviewed the sentinel events as well as emergency department operational data and organization. They interviewed representatives of all the services interacting with the emergency department and did extensive on-site observation. The reviewers recommended a number of process improvements including better visibility of patients in the waiting area, redesign of the triage area, improved participation in risk management, changes in physician staffing patterns and responsibilities, and a more accurate and comprehensive billing system. The solution was “hands on” leadership. Read more
