Peer evaluation and feedback for invasive medical procedures: a systematic review.

BACKGROUND: There is significant variability in the performance and outcomes of invasive medical procedures such as percutaneous coronary intervention, endoscopy, and bronchoscopy. Peer evaluation is a common mechanism for assessment of clinician performance and care quality, and may be ideally suited for the evaluation of medical procedures. We therefore sought to perform a systematic review to identify and characterize peer evaluation tools for practicing clinicians, assess evidence supporting the validity of peer evaluation, and describe best practices of peer evaluation programs across multiple invasive medical procedures. METHODS: A systematic search of Medline and Embase (through September 7, 2021) was conducted to identify studies of peer evaluation and feedback relating to procedures in the field of internal medicine and related subspecialties. The methodological quality of the studies was assessed. Data were extracted on peer evaluation methods, feedback structures, and the validity and reproducibility of peer evaluations, including inter-observer agreement and associations with other quality measures when available. RESULTS: Of 2,135 retrieved references, 32 studies met inclusion criteria. Of these, 21 were from the field of gastroenterology, 5 from cardiology, 3 from pulmonology, and 3 from interventional radiology. Overall, 22 studies described the development or testing of peer scoring systems and 18 reported inter-observer agreement, which was good or excellent in all but 2 studies. Only 4 studies, all from gastroenterology, tested the association of scoring systems with other quality measures, and no studies tested the impact of peer evaluation on patient outcomes. Best practices included standardized scoring systems, prospective criteria for case selection, and collaborative and non-judgmental review. CONCLUSIONS: Peer evaluation of invasive medical procedures is feasible and generally demonstrates good or excellent inter-observer agreement when performed with structured tools. Our review identifies common elements of successful interventions across specialties. However, there is limited evidence that peer-evaluated performance is linked to other quality measures or that feedback to clinicians improves patient care or outcomes. Additional research is needed to develop and test peer evaluation and feedback interventions.

The quantitative impact of joint peer review with a specialist radiologist in head and neck cancer radiotherapy planning.

OBJECTIVES: Radiologist input in peer review of head and neck radiotherapy has been introduced as a routine departmental approach. The aim was to evaluate this practice and to quantitatively analyse the changes made. METHODS: Patients treated with radical-dose radiotherapy between August and November 2020 were reviewed. The incidence of major and minor changes, as defined by The Royal College of Radiologists guidance, was prospectively recorded. The amended radiotherapy volumes were compared with the original volumes using Jaccard Index (JI) to assess conformity; Geographical Miss Index (GMI) for undercontouring; and Hausdorff Distance (HD) between the volumes. RESULTS: In total, 73 out of 87 (84%) patients were discussed. Changes were recommended in 38 (52%) patients: 30 had ≥1 major change, eight had minor changes only. There were 99 amended volumes: The overall median JI, GMI and HD was 0.91 (interquartile range [IQR]=0.80-0.97), 0.06 (IQR = 0.02-0.18) and 0.42 cm (IQR = 0.20-1.17 cm), respectively. The nodal gross-tumour-volume (GTVn) and therapeutic high-dose nodal clinical-target-volume (CTVn) had the biggest magnitude of changes: The median JI, GMI and HD of GTVn was 0.89 (IQR = 0.44-0.95), 0.11 (IQR = 0.05-0.51), 3.71 cm (IQR = 0.31-6.93 cm); high-dose CTVn was 0.78 (IQR = 0.59-0.90), 0.20 (IQR = 0.07-0.31) and 3.28 cm (IQR = 1.22-6.18 cm), respectively. There was no observed difference in the quantitative indices of the 85 'major' and 14 'minor' volumes (p = 0.5). CONCLUSIONS: Routine head and neck radiologist input in radiotherapy peer review is feasible and can help avoid gross error in contouring. ADVANCES IN KNOWLEDGE: The major and minor classifications may benefit from differentiation with quantitative indices but requires correlation from clinical outcomes.

Escola de pais do Brasil: prevenção e promoção de práticas parentais positivas / Parents school of Brazil: prevention and promotion of positive parenting practices / Escuela de padres en Brasil: prevención y promoción de prácticas de crianza positivas

RESUMO A Escola de Pais do Brasil (EPB) realiza o Círculo de Debates, trabalho preventivo realizado com pais e cuidadores, em parceria com prefeituras e escolas das regiões dos municípios em que possuem seccionais. Esta pesquisa teve como objetivo descrever e analisar o Círculo de Debates através de um estudo observacional, com observação participante e registro em diário de campo, que resultou em análise temática e criação de três categorias mutuamente excludentes: prevenção, cotidiano dos pais/mães e valores e limites na educação. Apresenta ainda uma categoria transversal: a psicoeducação. Pela análise, o trabalho do Círculo de Debates da EPB foi considerado psicoeducativo, de prevenção e promoção de práticas parentais positivas.

ABSTRACT The Parent's School of Brazil (EPB) conducts the Debate Circle, preventive work with parents, mothers, and caregivers, in partnership with city halls and schools in the regions of the counties in which they have sections. This study sought to describe and analyze the Debate Circles through an observational study, with participant observation and the use of a field diary. Analyses were conducted via thematic analysis and three mutually exclusive categories were generated: prevention, parents' daily life and values, and limits in education. It also presents a transversal category: psychoeducation. According to the analysis, the work of the EPB Debate Circle was considered psychoeducative for the prevention and promotion of positive parenting practices.

RESUMEN La Escuela de Padres de Brasil (EPB) realiza el Círculo de Debate, trabajo preventivo con padres, madres y cuidadores, en alianza con ayuntamientos y escuelas de las regiones de los municipios en los que tiene secciones. Este estudio buscó describir y analizar los Círculos de Debate a través de un estudio observacional, con observación participante y el uso de diario de campo, que da como resultado el análisis temático y la creación de tres categorías mutuamente excluyentes: prevención, vida cotidiana de los padres y valores y límites en la educación. También presenta una categoría transversal: psicoeducación. Según el análisis, el trabajo del Círculo de Debate EPB se consideró psicoeducativo, para la prevención y promoción de prácticas parentales positivas.

Credentialing, Certification, and Peer Review Essentials for the Neurosurgeon.

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries.

Surgeons' Responses to a Surgical Mortality Audit: Accepting and Improving: A Cross Sectional Survey.

BACKGROUND: Surgeons strive to provide the best care possible to their patients. The Australian and New Zealand Audit of Surgical Mortality is a process for improving surgical care and outcomes via peer-review assessment of mortality cases. This article examines the acceptability of the assessments to Queensland surgeons, in addition to examining their impact on surgical care. METHODS: This study was a cross-sectional survey. Evaluation forms were sent to all Queensland surgeons who had received a first-line assessment with clinical incidents identified or a second-line assessment (with or without clinical incidents), between April 2018 and January 2020 (n = 484). A total of 102 evaluation forms were returned, giving a response rate of 21%. RESULTS: Most respondents agreed that their assessments were fair (78%) and informative (69%). Almost half (43%) agreed that their assessment improved the subsequent surgical care they provided. Comments supported this, with surgeons describing reflections, meetings and changes that had occurred following their assessments. Despite the strong proportion of positive comments, some surgeons disagreed with the opinions or recommendations of their assessors. A large percentage (41%) was neutral towards the ability of the assessments they had received to improve surgical care at the hospital level. CONCLUSIONS: There was a high degree of acceptance of the QASM peer-review assessment process. The assessments facilitated discussion, reflection and implementation of surgical care improvements in Queensland surgeons. Further research into this topic should involve refinement of the study tool with a larger, and therefore more representative, proportion of the surgical population.

Aspectos éticos de las periciales en la valoración de la praxis médica / Ethical aspects of the experts in the evaluation of medical praxis

Los médicos que realizan actividades médico-periciales deben o debemos detenernos a reflexionar sobre nuestra propia tarea, sobre los valores que desarrollamos, sobre el servicio que aportamos a la sociedad, sobre los fines que perseguimos, las consecuencias que podemos llegar a soportar, etc., y cómo orientar nuestra práctica hacia la calidad y la excelencia. En el entorno de la medicina pericial se hace necesaria esta reflexión, para tratar de evitar que determinados criterios o cuestiones sustituyan en buena medida al compromiso responsable con nuestra actitud médica, y que podamos llegar a dejar de lado los elementos que legitiman nuestra acción, en pro de un beneficio o de una labor de intercambio de servicios que es al menos digna de ser analizada en nuestro ámbito

Physicians who carry out medical-expert activities must pause to reflect on our work, on the values we develop, on the service we provide to society, on the goals we pursue, the consequences we can endure, etc., and how to guide our practice towards quality and excellence. In the area of expert medicine, this reflection is necessary, to prevent certain criteria or questions largely replacing responsible commitment with our medical attitude, and get rid of the elements that legitimize our action, in favour of a benefit or exchange of services that is at least worthy of being analysed in our field

Evidence Review for the American College of Surgeons Quality Verification Part I: Building Quality and Safety Resources and Infrastructure.

Decades of quality program development by the American College of Surgeons (ACS) have identified the key components of a successful program for optimal surgical care and quality improvement. These key principles have been developed into a verification program-the ACS Quality Verification Program-to guide hospitals to improve surgical quality, safety, and reliability across all surgical specialties. The aim of this review was to synthesize the evidence supporting the first 4 of 12 ACS Quality Verification Program core principles of building quality and safety resources and infrastructure. MEDLINE was searched for articles published from inception to January 2019 for studies describing principles of leadership commitment to surgical quality and safety, a surgical quality officer, a surgical quality committee, and a culture of safety and high reliability. Two reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 5,332 studies across the 4 principles were identified. After exclusion criteria, a total of 477 studies in systematic reviews and primary studies were included for assessment. Despite heterogeneous study design and lack of randomized controlled trials, the available literature supports the importance of committed top-level hospital leadership, mid-level leadership, and committee dedicated to surgical quality and culture of safety and high reliability. In conclusion, adequate resources and infrastructure integral to the ACS Quality Verification Program are critical to achieving safe and high-quality surgical outcomes.

Association between leniency of anesthesiologists when evaluating certified registered nurse anesthetists and when evaluating didactic lectures.

Daily evaluations of certified registered nurse anesthetists' (CRNAs') work habits by anesthesiologists should be adjusted for rater leniency. The current study tested the hypothesis that there is a pairwise association by rater between leniencies of evaluations of CRNAs' daily work habits and of didactic lectures. The historical cohorts were anesthesiologists' evaluations over 53 months of CRNAs' daily work habits and 65 months of didactic lectures by visiting professors and faculty. The binary endpoints were the Likert scale scores for all 6 and 10 items, respectively, equaling the maximums of 5 for all items, or not. Mixed effects logistic regression estimated the odds of each ratee performing above or below average adjusted for rater leniency. Bivariate errors in variables least squares linear regression estimated the association between the leniency of the anesthesiologists' evaluations of work habits and didactic lectures. There were 29/107 (27%) raters who were more severe in their evaluations of CRNAs' work habits than other anesthesiologists (two-sided P < 0.01); 34/107 (32%) raters were more lenient. When evaluating lectures, 3/81 (4%) raters were more severe and 8/81 (10%) more lenient. Among the 67 anesthesiologists rating both, leniency (or severity) for work habits was not associated with that for lectures (P = 0.90, unitless slope between logits 0.02, 95% confidence interval -0.34 to 0.30). Rater leniency is of large magnitude when making daily clinical evaluations, even when using a valid and psychometrically reliable instrument. Rater leniency was context dependent, not solely a reflection of raters' personality or rating style.

Peer review audit of non-specialist occupational physician reports.

BACKGROUND: With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood. AIMS: To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports. METHODS: A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1. RESULTS: Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex. CONCLUSIONS: Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

An Evidence-Based Approach to Increasing Nurses' Publication Rates.

BACKGROUND: Writing for publication in peer-reviewed journals is one of the most important types of writing that nurses engage in. It is essential for advancing the nursing profession, health care organizations, and individual nurses. Despite its importance, however, the rate of publication remains very low among nurses. At one large academic medical center, a baseline assessment of dissemination practices found a low publication rate. To address this, an evidence-based writing-for-publication program was designed to support professional dissemination of scholarly work. METHODS: A 12-week workshop was designed and writers were matched with a mentor. The workshop started with a four-hour kickoff session on the process of getting published, including choosing a journal, querying an editor, drafting a manuscript, and working with coauthors. Participants also began developing an outline for their manuscript. Drafts were due to the mentor every four weeks for editing and feedback. At the end of the 12 weeks a wrap-up session was held for participants to read each other's manuscripts and give peer feedback. OUTCOMES: As of this writing, five cohorts have completed the program, and 89 nurses participated. Twenty-nine manuscripts were completed and submitted to peer-reviewed journals; of these, 22 (76%) were accepted, four (14%) are still under review, and three (10%) were recommended for submission to a different journal. Among the 89 nurse participants, 84% reported being likely or very likely to write for publication again, and 96% reported improvement in their writing skills. CONCLUSIONS: Without more nurses acquiring the skills to engage in writing for publication, the body of advancing knowledge that drives clinical decision-making may wane as aging, experienced nurse authors leave the profession. To protect the future of nursing, a continuous commitment to developing nurse authors across all generations is necessary. Nursing leaders and health care organizations must commit to ensuring novice nurse authors are provided with the resources to engage in disseminating knowledge.

Quality improvement in paediatric radiation oncology through peer review.

INTRODUCTION: Around 300 children in Australia and New Zealand (ANZ) undergo a course of radiation treatment (RT) each year. A fortnightly videoconference for radiation oncologists managing children started in 2013. We conducted an audit of the videoconference to assess its influence on the care of children who receive RT in ANZ. METHODS: De-identified data from minutes (August 2013-December 2019) were analysed retrospectively using three categories: meeting participation, case presentations and management decisions. RESULTS: There were 119 meetings and 334 children discussed over the six-year audit period with regular attendance from four of 11 centres treating children in ANZ. Most cases (80%) were discussed prior to RT. A change in the overall management plan was recommended for around one in eight patients (35/334, 13%). RT plan reviews were performed in 79 cases (23%). Adjustments were made to the target volume contours or treatment plan in 8% (6/79). CONCLUSION: Increasing the frequency of the meeting to weekly and compliant with the RANZCR Peer Review Audit Tool has the capacity to review all paediatric RT patients in ANZ prior to RT and initiate changes for as many as one in eight children treated by RT each year. The meeting should be considered a core component necessary to maintain expertise in paediatric RT in all centres providing RT for children in ANZ while also acting as a proton referral panel as more children are referred abroad for proton therapy before the Australian Bragg Centre for Proton Therapy opens in Adelaide in 2024.

100% peer review in radiation oncology: is it feasible?

PURPOSE: Peer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. Despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. Our purpose is to analyze peer-review process at our institution. METHODS AND MATERIALS: Based on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. Prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. Items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. Cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session. RESULTS: Over a period of 4 weeks, 148 cases were reviewed. Median of attendants was six physicians, three in-training-physicians and one physicist. Median time per session was 38 (4-72) minutes. 59.5% of cases presented in 1-4 min, 32.4% in 5-9 min and 8.1% in ≥ 10 min. 79.1% of cases were accepted without changes, 11.5% with minor changes, 6% with major changes and 3.4% were rejected with indication of new presentation. Most frequent reason of change was contouring corrections (53.8%) followed by dose or fractionation (26.9%). CONCLUSION: Everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. This model is feasible within the normal operation of every radiation oncology Department.

Quality of teaching radiation oncology in Germany-where do we stand? : Results from a 2019 survey performed by the working group "young DEGRO" of the German Society of Radiation Oncology.

PURPOSE: Medical students' knowledge of radiation oncology (RO) is of increasing importance with a rising prevalence of malignancies. However, RO teaching in medical schools is heterogeneous and has not been analyzed at a federal level yet. Therefore, the following survey aims to provide a national overview of RO teaching in Germany. METHODS: A questionnaire containing multiple-choice and free-text questions covering the extent and topics of RO teaching was sent to RO departments of all university hospitals in Germany and was answered by the heads of department/main lecturers. RESULTS: 24/35 (68.6%) RO departments returned completed forms. Most faculties employ lectures (91.7%), seminars (87.5%), and practical/bedside training (75.0%), whereas training in radiation biology and medical physics are rare (25% and 33.3%, respectively). Main topics covered are general RO (100%), radiation biology (91.7%), and side effects (87.5%). Regarding RO techniques and concepts, image-guided and intensity-modulated radiotherapy are taught at all faculties, followed by palliative and stereotactic techniques (87.5% each). Notably, all departments offered at least a partial rotation in RO in conjunction with radiology and/or nuclear medicine departments in the last year of medical school, while only 70.8% provided a complete rotation in RO. In addition, 57.1% of the departments have taken measures concerning the upcoming National Competence-Based Learning Objectives Catalogue (NKLM) for medical education. CONCLUSION: RO plays an integral but underrepresented role in clinical medical education in Germany, but faces new challenges in the development of practical and competence-based education, which will require further innovative and interdisciplinary concepts.

Quality and access - Early experience of implementing a virtual stereotactic chart round across a national network.

INTRODUCTION: Stereotactic radiation therapy is a highly specialised technique which requires careful and structured implementation. As part of a national stereotactic programme implementation, protocols were developed and a national stereotactic chart round was formed, which strongly recommended attendance and presentation of all cases before treatment. Herein, we describe our experiences launching a national chart round and its importance in a stereotactic programme. METHOD: Stereotactic chart rounds were held via videoconference between July 2018 and July 2019. Data collected included attendances, patient-related information including, diagnosis, clinical background, treatment intent, prescribed dose and fractionation and technical approach. Consensus recommendations regarding changes to treatment approaches were also recorded. RESULTS: For the 12 months recorded, there were 1126 attendances, from 144 individual attendees, across 21 locations. In total, 285 cases (237 new cases, and 48 re-presentations) were presented by 27 radiation oncologists (ROs) from 13 different locations. From the cases presented, 65 changes were recommended from 53 patients (22.3%), including 27 (11.4%) changes to contours, 18 (7.6%) changes to dose prescription/fractionation, 9 (3.8%) changes to plan dosimetry, 1 (0.4%) changes to treatment technique and 10 (4.2%) recommendations for which stereotactic radiation therapy was not advised. A significant inverse relationship was found between frequency of recommended changes and the individual RO's stereotactic case load (P < 0.002). CONCLUSION: The implementation of a national stereotactic chart held via videoconference has ensured national protocol compliance across the network of locations. Furthermore, the chart rounds have allowed the entire multidisciplinary team to be provided with mentorship and guidance. Increasing number of cases presented was associated with lower rates of recommended changes highlighting the impact of experience and the need for continued mentorship.

Peer Review of Paediatric Endocrine Services in the UK: A Template for Quality and Service Improvement.

BACKGROUND: Independent peer review of healthcare services can complement existing internal-, institutional-, and national-level regulatory mechanisms aimed at improving quality of healthcare. However, this has not been reported for paediatric endocrinology services in the UK. We aimed to test feasibility and acceptability through a first cycle of a national peer review of paediatric endocrine services. METHODS: Tertiary centres in paediatric endocrinology across the UK were assessed against 54 quality standards, developed by the British Society for Paediatric Endocrinology and Diabetes (BSPED) in five domains of healthcare by a team comprising paediatric endocrinologists and specialist nurses. The evaluation was supported by a self-assessment. A post-peer-review questionnaire was used as feedback. RESULTS: All 22 centres in the UK underwent independent peer review between 2011 and 2017. Each served a median population of 2.6 million (range 1-8 million) and offered 1,872 (range 779-6,738) outpatient consultations annually. A total of 43 (range 30-49) standards were met in combined evaluation of all centres. Variance of adherence for essential standards ranged from 52 to 97% at individual centres with 90% adherence demonstrated by 32% of centres. Post-review feedback showed 20/22 (95%) validating the utility of the peer review. CONCLUSIONS: The BSPED peer review of all UK centres providing paediatric endocrine services is shown to be feasible and provides a quality benchmark for replication by national services.

Los peritos médicos, psiquiatras y psicólogos, y el nuevo Código Procesal Penal Federal. Su participación en el sistema penal acusatorio / Medical experts, psychiatrists and psychologists, and the new Federal Criminal Procedure Code. Their participation in criminal trials in adversarial system

En junio de 2019 comenzó a aplicarse el nuevo Código Procesal Penal Federal, que adopta como sistema de enjuiciamiento el modelo acusatorio. Este modelo implementa la oralidad, la inmediatez, la contradicción y la publicidad como guías de los procesos judiciales. En este sistema el rol de los peritos juega un papel fundamental para el que deben estar preparados. (AU)

In June 2019, the new Federal Criminal Procedure Code began to be used, which adopts the adversarial model as a system of prosecution. This model implements orality, immediacy, contradiction and publicity as guides to judicial processes. In this system the role of the experts plays a fundamental role for which they must be prepared. (AU)