A case for revisiting peer review: Implications for professional self-regulation and quality improvement

Background: Quality improvement in healthcare has often been promoted as different from and more valuable than peer review and other professional self-regulation processes. In spite of attempts to harmonize these two approaches, the perception of dichotomous opposition has persisted. A sequence of events in the troubled California prison system fortuitously isolated workforce interventions from more typical quality improvement interventions. Our objectives were to (1) evaluate the relative contributions of professional accountability and quality improvement interventions to an observed decrease in population mortality and (2) explore the organizational dynamics that potentiated positive outcomes. Methods: Our retrospective mixed-methods case study correlated time-series analysis of mortality with the timing of reform interventions. Quantitative and qualitative evidence was drawn from court documents, public use files, internal databases, and other archival documents. Results: Change point analysis reveals with 98% confidence that a significant improvement in age-adjusted natural mortality occurred in 2007, decreasing from 138.7 per 100,000 in the 1998–2006 period to 106.4 in the 2007–2009 period. The improvement in mortality occurred after implementation of accountability processes, prior to implementation of quality improvement interventions. Archival evidence supports the positive impact of physician competency assessments, robust peer review, and replacement of problem physicians. Conclusions: Our analysis suggests that workforce accountability provides a critical quality safeguard, and its neglect in scholarship and practice is unjustified. As with quality improvement, effective professional self-regulation requires systemic implementation of enabling policies, processes, and staff resources. The study adds to evidence that the distribution of physician performance contains a heterogeneous left skew of dyscompetence that is associated with significant harm and suggests that professional self-regulation processes such as peer review can reduce that harm. Beyond their responsibility for direct harm, dyscompetent professionals can have negative impacts on group performance. The optimal integration of professional accountability and quality improvement systems merits further investigation.