Streamline trauma peer review with just culture “pre-review”

Multidisciplinary peer review is a key element of trauma performance improvement. One major challenge is creating a peer review process that does not overburden the specialty liaisons to the trauma service. If too many cases are referred to the trauma multidisciplinary PIPS committee, overwhelm sets in, liaisons become disengaged, and the quality of review breaks down.

Trauma program leaders at Novant Health-New Hanover Regional Medical Center solved this problem by creating a “pre-review” process based on just culture concepts.

This strategy has cut down the number of cases that need to be reviewed during meetings of the multidisciplinary committee. As a result, it has improved liaison engagement and led to more substantive discussion on cases that truly need multidisciplinary peer review.

Overload in peer review

New Hanover Regional Medical Center is a Level II trauma center in Wilmington, North Carolina. In 2020, trauma medical director Timothy Novosel, MD, and trauma services director Terri DeWees DNP, RN, CEN, TCRN, NE-BC, became increasingly concerned about the quality of peer review discussions.

At each monthly meeting of the trauma multidisciplinary PIPS committee, anywhere from 20 to 30 cases were on the agenda for peer review.

“We had so many cases that we thought ‘needed to go to peer review’ that the meeting became ineffective,” DeWees said. “We obviously couldn’t do all these cases justice in a one-hour meeting, so we started looking for a more efficient process.”

Both DeWees and Dr. Novosel had previously received training in just culture. They theorized that just culture principles could be used to resolve more cases outside of peer review by means of a pre-review process.

Creating a just culture form for reviewing trauma cases

Their first step was to develop a form that specialty liaisons could use to review cases in the light of just culture principles. The form is based on the Just Culture Algorithm created by safety engineer David Marx.

The first half of the form consists of a guided threshold investigation. The specialty liaison summarizes a case by answering six questions:

• What happened?
• What normally happens?
• What does the procedure require (if applicable)?
• Why did it happen? (individual choices that may have contributed)
• How was the organization managing the risk? (system issues that may have contributed)
• Recommend case brought to Trauma Peer Review? (if yes, reason why)

The second half of the form consists of a professional practice evaluation. The liaison evaluates the practitioner in terms of six just culture categories:

• No practitioner issues identified
• Human error
• At-risk behavior
• Reckless behavior
• Repetitive behavior
• System issues

The form briefly explains each category and lists appropriate corrective actions for each. For example, for cases that involve human error, possible actions include monitoring performance trends, sending the practitioner an informational letter to reiterate policy or procedure, and a “collegial intervention” involving a discussion between the practitioner and the department chair.

To download a generic version of the just culture form developed at Novant Health-New Hanover Regional Medical Center, click below:

Trauma Peer Review Just Culture Pre-Review Form (PDF)

Trauma Peer Review Just Culture Pre-Review Form (Word)

Cases sent to liaisons for pre-review

When a concerning case comes to the attention of the trauma leadership team, the trauma medical director enters the initial details into a just culture form and sends the form to the appropriate specialty liaison. The liaison then reviews the case, using the form to evaluate the actions in terms of the Just Culture Algorithm.

For example, the liaison might categorize a case as at-risk behavior — a behavioral choice that increases risk where risk is not recognized or a behavior that is mistakenly believed to be justified. The liaison might thenTrauma Peer Review Just Culture Pre-Review Form select a corrective action involving practitioner education, such as conducting a literature review and presenting the findings at a department meeting.

“The liaison decides on the corrective action and then — via the form — they tell us what they did from the corrective action standpoint,” DeWees said. “If we can see that the loop was closed, then from our point of view that is sufficient to close the case.”

Questionable cases, or those for which the liaison requests peer review, are added to the monthly peer review agenda for adjudication. Cases may also be referred, as appropriate, to the trauma operations/systems committee or a hospital-wide quality or patient safety committee.

Just culture forms are sent to liaisons two weeks before the monthly peer review meeting with a strict deadline for return, typically 7 days before the meeting. The forms are sent via Docusign, which provides security and enables forms to be signed electronically.

The trauma medical director always has the discretion to forward any case for peer review. According to DeWees, however, the vast majority of liaison assessments are appropriate.

“We get back really strong reviews from our liaisons,” she said. “And they do a very good job of identifying whether a case involved human error versus risky or reckless behavior versus a systems issue.”

Fewer cases, more robust discussion

Trauma program leaders at New Hanover Regional introduced the just culture pre-review process during the first quarter of 2021. Within a few months, the average number of cases needing discussion at peer review decreased by more than 80 percent.

“We’ve gone from an average of about 25 cases needing to be discussed in peer review to one or two per meeting, or in a busy month maybe three,” DeWees said. “This has created additional time to fully discuss and close more challenging cases during peer review meetings. As a result, loop closure is improving.”

DeWees noted that the new system has been incorporated into the hospital’s Ongoing Professional Practice Evaluation (OPPE) process. “We track how many just culture forms each liaison was sent each quarter and how many were completed accurately and returned on time,” she said.

She also noted that the overall response from peer review participants has been positive: “Liaisons are now engaging in more robust discussion of the cases that make it to peer review, and our attendance rates are better.”