QA & Peer Review Process
The QA process has evolved considerably over the years at the Henry Ford Department of Emergency Medicine (DEM). In the early years, a personal note from Dr. Tomlanovich (MCT) in your mailbox with the words, “See me MCT,” was the first step in the ER QA process. Things are quite different now. With the help of HFH ER Alum, Pratik Doshi ‘07, and current staff including Manu Malhotra ’04, Michelle Slezak ‘08, Seth Krupp and many others, the HFH DEM totally redesigned the process and implemented a new paradigm for reviewing cases for quality and performance improvement purposes over five years ago. A peer review process was introduced in 2016. These two processes, while having separate aims, cannot exist without one another.
Cases for review come from a variety of sources. Automatic triggers for review include: 72 hour returns with change in disposition, deaths in the ED, deaths within 24 hours, and transfers from the floor to ICU within 12 hours. Additional sources for referral include: self-referral, intradepartmental referral, interdepartmental referral (internal medicine, acute care surgery, stroke team), sentinel events, risk/safety reporting, and legal cases.
The QA committee is made up of staff physicians and residents, all participating on a voluntary basis. A group of cases is reviewed by a single reviewer prior to the monthly QA meeting. If there are no questions/concerns/issues, the case is designated as Care in Accordance. If there are concerns of any kind (process issues, management or disposition concerns), the case is discussed by the committee and a secure email is sent to involved providers. This secure email asks a clinical question and provides an opportunity for the provider to provide additional details or clarify any concerns. All case summaries and email responses are tracked in a secure database. In 2017, the QA committee reviewed 1397 cases representing 1.4% of the annual volume. Of these, 1124 were found to be Care in Accordance. 273 cases required QA emails. The QA process has been critical in discovering trends and patterns and has resulted in a variety of process improvement projects.
All cases that require a QA email are then sent to the Peer Review committee for review. The Peer Review committee is made up of staff physicians and one PA. A group of cases is reviewed by two providers prior to the bimonthly meeting. The responses to the QA emails are available to the reviewers when making their determination. If the reviewers are in agreement that the case is Care in Accordance, it is closed and designated as such. Otherwise, the case is discussed by the committee and a final decision is made via group vote. In 2017, of the 273 cases reviewed, 248 were found to be Care in Accordance, while 25 were found to be a Deviation from the Standard of Care (either minor or significant) or an Expected complication, appropriately managed. These 25 cases represent 0.025% of the HFH ER volume.