1. Case Based Learning Through
Interprofessional Peer Review
Presented at the
Global Community Engaged Medical Education Muster
Uluru, Northern Territory
27-30 October, 2014
By
Nancy W Dickey, MD
Professor, Department of Family Medicine
Texas A&M University Health Science Center College of
Medicine
2. Faculty/Presenter
Disclosure
Slide 1
• Faculty: Nancy W Dickey, MD
• Relationships with commercial
interests:
– Consulting Fees: Association
of Academic Health Centers
– Others: Employee of Texas
A&M University Heatlh
Science Center College of
Medicine
3. Disclosure of Commercial Support
Slide 2
• This program has received in-kind
support from Texas A&M University
Health Science Center in the form of
travel support
• AAHC consulting is not related to this
forum.
• Potential for conflict(s) of interest:
None
Nancy W Dickey, MD, has received
funding from Texas A&M University
Health Science Center supporting this
program.
4. Mitigating Potential Bias
Slide 3
• The AAHC consulting is not related
to curriculum development or this
conference.
• The support of the University is in
support of an expectation of
developing curriculum and sharing
best practices across the globe. A
full report will be made back to
the university regarding my
presentation and additional
lessons learned for incorporation
into university curriculum.
5. Learning Objectives
• Discuss ways to engage students in real-world,
outcomes driven teamwork
• Case based learning is known to provide
meaningful retention
• Describe an interprofessional opportunity to
learn from constructive feedback
• A process intended to teach students to give
and receive constructive feedback
6. Safety & Quality Background
• The goal of health care providers and expectation of
patients is perfection. Every day, every provider, every
patient.
• Suboptimal outcomes are an inevitable part of
medicine.
– “To Err is Human”
• How do we teach this paradox to health care students?
• How do we attain a safer health care system while
recognizing the fallibility of clinicians?
IOM 1999
7. Peer Review As A Tool
• Morbidity and Mortality Conference (M&M)
• Originated in 1900s (surgeons & anesthesiologists)
• Process by which a professional review body looks at cases to determine
whether standards of care have been met
– Liability protections have evolved –
• Confidentiality
• Privileged and inadmissible in court
• Process has transformed over the years
– Discussion of individual errors to systems based approach
– Physicians only to interprofessional review
– Highlighting mistakes as a means to sensitize professionals to be more careful to systems perspective
and learning from error
– Closed conference rooms to teleconferences & web conferencing
8. George Bernard Shaw…
on medicine
• “A conspiracy, not a
profession...Every doctor
will allow a colleague to
decimate a whole
countryside sooner than
violate the bond of
professional etiquette by
giving him away.”-.
• being forced by a hospital
and credentialing
organizations to give
subjective decisions that
can ruin careers
• existing peer
relationships, probable
conflicts of interest, and
busy practices
• substandard care
becomes acceptable in
the interest of "getting
along.
9. Motivating Texas A&M to try
a new approach….
• Despite, doctors reluctantly participate. Some feel that
by participating in a peer review panel they are. As a
result, peer reviews often aren't completed — or
worse, “
• public sentiment that physicians tend to protect each
other to the detriment of the public, behind what is
often called a “white wall of silence,” is growing.
• The goal of medical peer review is to improve quality
and patient safety by learning from past performance,
errors, and near misses.
• .
10. History of
RCHI Peer
Review: • Rural and Community Health Institute
(RCHI) created a process to meet a need
for M&M in rural Texas
• Started with 2 rural hospitals and have
expanded to 59
• Records are submitted to RCHI
– Redacted so reviewers do not know
patient name, provider name, or even
location of facility
– Redacted records are available for
download online
• Teleconferences scheduled each month
– Surgery, Emergency Care, Ob-gyn,
Family Medicine, Ortho
– May have targeted session like Heart
Failure or Quality Collaborative Practice
Educational peer review,
for both the doctor and
the hospital…
a tool for
identifying, tracking, and
resolving inappropriate
clinical performance
and medical errors in their
early stages thereby
increasing patient safety
and overall quality of care
12. Incorporation of students
• Movement in higher education to replace traditional didactic lecture with
active learning
• The Peer Review process allows selection of REAL cases selected for the
issue at hand
– End of life discussions
– Power gradients between professionals
– Medication errors
• In Health Care education a case based approach is an effective active
learning
– Clinical situation + key patient information = consolidation & integration of
learning activities
– Real life application of knowledge draws students in
– Peer Review engages students because the patients, the errors, and the
outcomes of these errors are real
• Benefit of completed cases is students do not feel pressure to make a decision at that moment so
these cases lend themselves well to learning opportunities
14. Impact on students
• “Participating in this peer review helped me be more confident because
my opinions were seriously considered concerning the medications.”
– Students have been allowed to participate in the actual peer review call – not
just a simulation
• “The actual teleconference was the most useful part of the process for
me. I appreciated hearing the opinions…from other members of the
health care team….”
– Recognition that construction feedback WILL NOT stop just because one
finishes the formal education process
– Opportunity post call to discuss not only WHAT was said but HOW it was said
• “I believe Peer Review helped me improve on interprofessional
communication.”
– Start early in one’s career to respect and appreciate the breadth of the team
and its potential power
15. What worked for students
• Distance makes a comfortable buffer
• Incorporate teachable moments rather than
“find the error”
• Think bigger on a systems scale – find a way to
make a safer system rather than point out an
individual shortcoming
• Provide students a LOT of time to review and
re-review
• Practice interprofessional discussions before
the 1st call
• Practice with retrospective chart review a
useful skill for QI and outcomes research
16. References
• Institute of Medicine. (1999). To Err is human: Building a safer health system.
Available at https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
• Orlander JD. The morbidity and mortality conference: The delicate nature of
learning from error. Acad Med 2002; 77:1001-6.
• Harbison SP, Regehr G. Faculty and resident opinions regarding the role of
morbidity and mortality conference. Am J Surg 1999; 177:136-9.
• Dies et al. Transforming the Morbidity and Mortality Conference into an
Instrument for Systemwide Improvement. Advances in Patient Safety, 2(8), 2008.
Accessed at http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-
Deis_82.pdf.
• Rosenfeld JC. Using the morbidity and mortality conference to teach and assess
the ACGME general competencies. Curr Surg. 2005;62(6):664-9.
• Jayasankar SJ. Medical peer review and risk management. American Academy of
Orthopaedic Surgeons, AAOS Now September 2014, Vol 8(9)
17. References
• Prose NS, Brown H, Murphy G, Nieves A. The morbidity and Mortality
conference: a unique opportunity for teaching empathic
communication. JGME 2010: 505-7.
• Gawande A. Complications: A Surgeon’s Notes on an Imperfect
Science. New York; Henry Holt; 2002: 47-74.
• Institute of Medicine. (2012). Core Principles and Values of Effective
Team-Based Health care.
http://www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx
• Blouin R, Riffee W, Robinson E, et al. AACP curricular change summit
supplement: roles of innovation in education delivery. Am J Pharm
Educ. 2009;73 (8):Article 154.
• Jesus A, Gomes M, Cruz A, et al. A Case Based Learning Model in
Therapeutics. Innovations in pharmacy. 2012:3(4): Article 91.
• Interprofessional Education Collaborative Expert Panel. Core
Competencies for Interprofessional Collaborative Practice: Report of
an expert panel. Washington, D.C., Interprofessional Education
Collaborative. 2011. Available at
https://ipecollaborative.org/uploads/IPEC-Core-Competencies.pdf
A time honored method of learning from error can be found in the Morbidity and Mortality Conference (M&MC). The M&MC originated in the early 1900s as a forum for surgeons and anesthesiologists to discuss and learn from their respective errors (1,2). While many places hold M&M Conferences, they are not all conducted in the same manner. It requires a delicate hand to moderate an effective conference (1). The goal is not to criticize and humiliate practitioners but rather to identify learning opportunities thru the inevitable errors so that all participants can improve their skills as well as patient outcomes (1,2,5). The M&MC has transformed over the years as it has been adopted by different groups of health care providers. A new twist on the traditional forum is to have multidisciplinary groups review adverse events to identify system failures rather than individual errors (3). The thought being that when an error occurs, it is usually not the result of an isolated poor decision but rather the culmination of a series of failures (6). A systems based approach is not a novel concept in business or quality control. The exciting new twist is having interprofessional health care providers applying Deming’s principles to see the interrelationships of their practices. This application fosters patient safety initiatives, partnerships to improve systems of care, enhanced effectiveness of communication between the professions, and even increased professionalism (3,4,5). The inclusion of other health disciplines was a major step away from the traditional power structure of physicians on top and all others below
RCHI was requesting an interdepartmental collaboration in order to bridge gaps and disparities in patient safety and quality improvement in small and rural communities via a Physician Peer Review program.
the professional working relationships among doctors make peer review difficult. Doctors do not want to review colleagues for fear of criticizing their friends and possibly being censured in return.
Despite existing peer relationships, probable conflicts of interest, and busy practices, doctors reluctantly participate. Some feel that by participating in a peer review panel they are being forced by a hospital and credentialing organizations to give subjective decisions that can ruin careers. As a result, peer reviews often aren't completed — or worse, substandard care becomes acceptable in the interest of "getting along."
With the peer review process – each and every call we are working/assessing interprofessional communication as well as teamwork. Depending on the chart, we may also have the opportunity to explore roles/responsibilities and values/ethics.
Students work up chart prior to the call and discuss with me so that we make sure information is accurate = confidence to engage in interprofessional communication. After call, we’ll have an informal discussion and bring up anything we want to discuss as just pharmacists.
Initially some participant discomfort with students reviewing and offering recommendations to providers on errors
Student perception that this was just “one more task”
