This is the transcript of Part 1 of my recent podcast interview with Dr. Robert Wachter and Dr. Arpana Vidyarthi.
David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with Dr. Robert Wachter, Chief of the Division of Hospital Medicine as UCSF and Dr. Arpana Vidyarthi, Director of Quality. Thanks for your time today.
Dr. Arpana Vidyarthi: Thank you.
Dr. Robert Wachter: Pleasure.
Williams: What is the medical peer review process?
Vidyarthi: David, every hospital, every division, every group, large or small, reviews cases on a regular basis. Bad things happen everywhere, and bad things and perceived bad things also happen in the hospital. And when those happen, you need to take a look at what the details of the case were.
They’re usually based on some patient complaint or there is something that we didn’t expect to happen in the hospital that did happen. So someone in my position or someone in a clinic or any health care system reviews cases to identify the cause of what went wrong and also to assess the individuals. Was there something that the individual could have done differently to change what happened or what didn’t happen? So that’s what case review broadly is – just trying to use the experience of the patients and their cases to be able to assess what’s happening and try to make the system and individuals better.
Wachter: I’ll chime in and say something contextual. This is an extraordinarily challenging thing to do in medicine generally. We know that errors harm and kill many patients in United States medicine and that reviewing cases where things didn’t go as well as they should have becomes extraordinarily important. The question then is how do you that?
You want an environment where doctors and nurses and others are comfortable raising concerns even saying: here is something that didn’t go well. In a case of mine I like it to be reviewed because I like to learn from it. You’d like there to be accountability and responsibility if someone really screwed up.
On the other hand we understand that most errors relate to systems that are dysfunctional. Then you build into that the problem of peer review. These cases in general in American medicine are reviewed by colleagues or peers who know a lot about that kind of medicine. Peer review is fundamentally tricky in that this person who is reviewing your case may be someone you work with all the time or in some environments might actually be a competitor. This is a hot issue in patient safety where we both work. Part of why we’re so enthusiastic about the kind of work that we’re doing is we’re trying to move the ball forward here, not only in the technology and the process, but also these larger, socio-cultural issues of how do you get it right.
Williams: How are cases typically identified for review? What’s the typical time lag between something happening and the review process being initiated and then completed?
Vidyarthi: So traditionally, and I would say in the great majority of places across the country, what happens is that someone in Bob’s position might hear about a case. It would come either from patient relations or someone mentioning something or sending him an e-mail saying something just didn’t go right. He will either pull the chart and review the case himself or ask me to do it or have someone else in our group do it.
It’s really individualized. I would individually be reviewing a case and trying to figure out what went wrong. It’s independent, so I wouldn’t necessarily be speaking with Bob or even a number of other folks working with us to be able to come up with solutions together.
It’s a little bit haphazard. It’s kind of one-off and you deal with cases in this individualized or independent manner. So I would review a case. It might take me a day or two. I would come up with a solution, whether that is a discussion with the family because they have some questions or an analysis of what went wrong. Then we would just come up with solutions in this one-off manner.
But in the Division of Hospital Medicine we’ve re-engineered our case review and peer review process, taking this haphazard system of reviewing cases and trying to bring some standardization to it and trying to push forward. We built a system where there is a centralized process where the cases all come to one person, where Bob hears about it or patient relations hears about it or there is quality initiative that means that we have to review certain trigger points.
It comes to one place. Then we have a committee of folks who are trained to review cases. We give them a format to be able to do it, to systematically go through the case and answer certain questions that we actually think are important in understanding these cases and then they come together with that information after doing that independent review and we talk about it in our committee. It is a committee of our peers and a larger group who then have input into what went wrong, assessing the system and also the individual and then also having a say in what are we going to do about it. What are the next action items?
That allows us to do this in a more systematic, efficient, and effective manner and actually learn more from our cases. A second aspect of it is that we were then able to think about cases pushing forward our quality improvement strategy. Let me tell you what I mean by that. There are a lot of things that we need to do in terms of quality improvement all across the country from a small clinic of two people to the largest of institutions. Much of what we put our time and effort into is externally driven. The Joint Commission comes out with something new that we need to take a look at and manage. Those sorts of things are where we put our efforts – the core measures.
There are many other external forces, but what we have determined through the tremendous research that we’ve been doing in the Division of Hospital Medicine at UCSF is that culture is local. The fact that culture is local means that a lot of your issues will be locally defined as well. Because we have the systematic case review process, we’re able to analyze what’s happening. We can find trends and figure out what areas of improvement we’ve doing again and again. We can take those pieces of data –once we define the trends– and then have that feed into where we’re going to be putting more and more of our efforts. Not only are we using it to review cases, but we’re also using this more systematized process to push forward our quality priorities and our quality agenda.
Williams: A lot of what you’re describing sounds like a change in the process and making it more robust. I also understand that you have introduced a software platform that helps enable some of this. Can you give me a sense of what that platform does and whether you’re just automating and simplifying the existing paper process that you have or does using a software platform add something extra?
Vidyarthi: It definitely adds something extra. I’ll explain a couple of aspects of that – the first caveat is that there’s really no tech solution that can improve a bad process. So you can automate something and make something that doesn’t work well, not work well faster. But it can also help you understand your process, help you with your process re-engineering and bring more value to that process. That’s really what Acesis has done for us.
We started the restructuring of our case review process slightly before we found Acesis and we developed a partnership with them. As we developed our case review tool, which we call iCare, we were also thinking about how to best use that tool and how to pool these resources of people and how this whole process would run. Bringing in the Acesis platform really forced us to think about process re-engineering in a much more discreet fashion, because when you bring a tech solution in, it leaves little room for hand waving.
A great example was when Acesis asked us to put together a decision matrix of how everything runs. We couldn’t just say, “Well we might hear about a case from here or there and then I might take it or somebody else might take it.” It forced us to be incredibly specific in how this process runs, what are the best practices and how we would do that. That partnership of process improvement plus the tech platform really helped us focus on process improvement.
Acesis allows us to do a couple other things. One is that it really added efficiency into this whole system. All of the case reviews are now done using Acesis. They’re logged into this platform, so in real time I am able to see the information the independent reviewers are using. I’m able to look at any supporting information, which is all logged into Acesis, and I’m able to track actions.
It not only has the assessment aspect, it also brings all the information into one virtual place for the conversations. It actually acts as a project management tool. Once we move from the assessment into the improvement aspect of things, it allows us to track these improvements and trend these improvements. Acesis also gives us access to the data in real time. At any given time I can look into our database and identify trends. I can take a look and say, “Hey, what have we been seeing? What are the causes of some of these? Where has it actually been happening?”
And it allows me to say, “You know what? We’ve had about five cases where we’re having some trouble with our transition from the ER to the floor or we’re having some readmissions within certain patient populations.” It allows us to slice and dice this data in many different ways in real time. And a newer aspect of what Acesis has done for us, which was unanticipated, but has been a huge boon, is that it allows all of this to happen in a very secure environment.
So traditionally, as I mentioned, in the haphazard way of doing this, much of this information was communicated over e-mail and phone calls. Really e-mail was the way we would exchange information. There have been tremendous changes recently in physician and hospital practices around security, but with Acesis we don’t have to worry about information transfer in non-secure fashion, because everything is held within Acesis in a secure manner. We always log in to get that information, so we’re not sending patient information or information about case review through e-mail or other unsecure means.
Williams: Are there aspects of your new process or the fact that you’ve got this secure tool to enable it that have helped in terms of getting cases to come forward that might not otherwise have been there? Have you improved the analysis or sped up the analysis of the cases to find trends that previously you wouldn’t have seen at all?
Vidyarthi: All of the above with the exception of one. The cases that we hear about and we see, that really hearkens back to what Bob was talking about initially around the contextual framework. This is about culture. This is about creating a culture where people are able to report.
The great majority of our cases come from our own physicians — our physicians, our residents, our chief residents– that just let us know that something didn’t go right or could have gone better. Those folks that let us know about these challenges, they have to know that it’s a safe place to report, but they also have to know that something is going to be done about it.
That’s where the link is between our culture and our process and software platform. But I think the great majority of the reporting culture is about hard work and making sure people understand what you’re doing and really creating something where they’re comfortable in reporting, along with accountability. What it has done in the latter couple of pieces is it has definitely helped us with efficiency.
Everything is done online now. You log into Acesis to find out what your action items are. Acesis automatically tells you that you have a case to review. It gives you a deadline, it sends you reminders, it allows you to efficiently and effectively go through the online tool, which is fairly easy and efficient as opposed to coloring in different boxes and photocopying different pieces of paper. It also has helped out with our efficiency, not only with the assessment piece as I’m describing, but also helps track improvements. We give action items to certain people, “Go talk to so and so, gather more information about this,” or, “Let’s talk to another department about X, Y, or Z and find out what the solution is.”
Acesis allows us to more efficiently push some of those together by keeping people on task with project management. One of the keys that we found in this platform is understanding the data. It allows us to capture all these pieces in their tool and the data analysis piece is easy to use, not rocket science statistics. It is also available to us in real time so that we can quickly take a look at whatever data is in that and cross match the person to the floor or the root cause to the severity of illness. We can examine at these data from many different vantage points, which allows us to make decisions, to put further resources into things where we may not have otherwise. It just gives us a view into what’s going on in our division in terms of our local culture and the patients that we’re taking care of.
Continue reading Part 2.January 27, 2010