The moment that an accreditation team shows up unannounced can spike the pulse of even the most seasoned hospital executive. The next several days will amount to one big exam for the safety and quality of care, as surveyors meet with executives, managers and care teams, and watch first-hand as care is delivered. Make the wrong move or give a wrong answer, have them see rust on a ceiling sprinkler, and your hospital may get dinged. Get dinged too many times or have findings of serious patient risks, and your accreditation (and the federal funds attached to that) may be in jeopardy.
This is a useful and essential exercise. It makes sure that hospitals are doing what they’re supposed to. For example, do they have an infection prevention and control plan? Do they conduct fire drills? Do they inspect, test and maintain medical equipment? Do doctors sign their orders and notes?
Regulators have been innovating how they evaluate hospitals to make their reviews more meaningful and impactful for patient safety. Yet, if we truly want to strive for the best possible care, end preventable patient harm and reduce needless costs, meeting regulations alone isn’t nearly enough. Regulations may help identify the “bad apples” and ensure compliance with minimum requirements. Yet these regulations alone have not been enough to transform a health care system that still harms patients too often, improves too slowly, wastes too much and innovates too little. How do we help hospitals to excel?
One approach with great potential is peer-to-peer assessment, a concept borrowed from the nuclear power industry. In peer-to-peer, a team of reviewers — executives, managers, frontline clinicians, researchers and others — visit another hospital for a structured, confidential and nonpunitive review of its safety and quality efforts. While it would be foolhardy to show your flaws to regulators, in peer-to-peer assessments it is encouraged. The goal is to create an environment of learning, not judging, for both sides. The organization being reviewed discusses its weaknesses, while highlighting its successes, which can then be shared more broadly.
This is not theoretical. For several years we at The Johns Hopkins Hospital have adapted the peer-to-peer approach to help intensive care units to reduce their rates of catheter-related bloodstream infections. We also had an “exchange program” with Massachusetts General Hospital — they assessed us in Baltimore and we assessed them in Boston, using structured surveys that we developed together. The experience helped both organizations to see areas for improvement, plus innovations they can borrow from each other.
Within three months of the visit, both hospitals already made some changes at the bedside and at the organization level. For instance, at Johns Hopkins we realized we needed a better structure in place to ensure that quality and safety targets were met at the departmental level. So shortly after the assessment, we borrowed a strategy from Mass General and created positions for vice chairs of quality at each department. Such discoveries about robust management practices come more readily when teams have an environment of transparency and deep trust.
Peer-to-peer review helps hospitals to discuss their problems in a safe environment, when it isn’t a crisis. We should strive for a day when a hospitals voluntarily and routinely take part in these exercises. It’s been said that change progresses at the speed of trust; trust among peer organizations can accelerate improvement that saves patients’ lives.