Avoiding Conflict at the Expense of Patient Safety: Implications for Physician Peer Review
Physician peer review holds tremendous potential to improve quality and reduce risk. But without trust, peer review can be a nightmare. It is widely held that only when peer review is non-threatening to physicians can trust be built and maintained, allowing peer review to achieve its objectives. If the core of peer review strategy is to reduce or eliminate threats it poses to physicians, do we not actually increase the threat to patient safety and the best care? To answer this question, let us examine two common peer review philosophies; peer review must not be punitive, and care should not be scored.
Corrective (punitive) action: No doubt, if trust is damaged, the great potential peer review holds to improve quality and reduce risk falls away. It is very difficult to recover from damaged trust. But trust that is based on assurance that peer review will never be punitive is trust that is not only fragile, but also damaging to effective peer review. Such “trust” reeks of a culture that puts conflict avoidance ahead of patient safety and quality of care. When such trust collides with proper practice, which sometimes requires corrective action (see your bylaws), it’s obliterated. Committing to an objective that peer review will not be punitive is unreasonable and unrealistic.
Care or clinical patterns can be so dangerous that a physician must have privileges modified or revoked altogether, either temporarily or permanently. Sometimes the underlying causes are not repairable. We also know that uncorrected behavioral issues can be so damaging that corrective action must be taken. Yet substandard care and disruptive behavior shouldn’t be the primary drivers of corrective action. Rather, corrective action should be targeted at a physician’s unwillingness to respond by embracing a collegial process that seeks, finds, and implements necessary change. When physicians provide care that is not up to established standards, it should be viewed as an opportunity. Rather than building fragile trust on promises that often can’t and shouldn’t be met, real trust should be built on consistent, widespread appreciation for well-articulated peer review principles and expectations.
Scoring: Another common view is that we should avoid scoring a physician’s care. The reason typically given is that scores are offensive, especially when they are undesirable scores. They hurt feelings and bruise egos, leading to anger and diminished trust. But is it the score that’s the problem or the physician’s reaction to it? Scores allow us to track trends, measure improvement, aggregate data supporting systems assessment and root cause analysis, and affect both individual and systematic change that prevents problems from happening in the first place. To not score because of fear of physician reaction reflects a culture built on conflict avoidance rather than the open, honest, direct communication that drives real trust. Driving principles should place the patients’ interest above all others while demanding that we embrace criticism and be honest with ourselves. Only with these principles can we meaningfully work close undesirable performance gaps. It is leadership’s challenge to create a culture that actually embraces less than optimal performance because it presents an opportunity to improve.
Extreme avoidance of any punitive action and aversion to scoring is dangerous when it obstructs peer review’s primary objectives: Patient safety and optimal quality. Why? Because they are driven more by conflict avoidance than they are by the primary objectives themselves. We have to teach that mistakes and weaknesses are actually opportunities if addressed in a healthy, productive fashion—when we collectively strive to correct them and turn them into strengths. Will there be conflict? Of course. But healthy conflict is a necessary ingredient for organizational progress. We need to remind ourselves that continuous quality improvement isn’t a concept reserved only for the organization; it should also apply to every individual, every physician. Avoiding conflict obstructs optimal care. Closely examine the motivations behind your peer review policies, practices, behaviors, and actions that result. Every time you see conflict avoidance, you might just be looking at the tip of an iceberg.
– Jon Moses, President & CEO