- Email: [email protected]
Survey of Radiologist Attitudes and Perceptions Regarding the Incorporation of a Departmental Peer Review System
ADDITIONAL RESOURCES
Survey of Radiologist Attitudes and Perceptions Regarding the Incorporation of a Departmental Peer Review System Michael Loreto, MDa, Daniel Kahnb, Phyllis Glanc, MDc,d
Purpose: The aim of this study was to investigate the attitudes and perceptions of staff radiologists regarding the incorporation of a nonanonymous peer review system at an academic hospital. Methods: A questionnaire gauging knowledge of, attitudes toward, and perceptions regarding peer review was distributed to all staff radiologists at a large academic hospital. The survey was distributed before the implementation of a nonanonymous peer review system. Data were analyzed using descriptive statistics. Responses were cross-tabulated according to subspecialty and number of years in practice. Results: The majority of respondents agreed that peer review is important for improving patient care (31 of 36 [86%]) and professional development (29 of 36 [81%]), but the vast majority (33 of 36 [92%]) believed that peer review should be anonymous. Twenty-six of 36 respondents (72%) believed that peer review will not be safe from malpractice issues, 24 of 36 (67%) agreed that it has the potential to damage interpersonal relationships within the department, and 15 of 36 (42%) believed that it may influence their job security or rankings within the department. Significant differences were identified between radiologists with more and fewer years of practice experience. Conclusions: The incorporation of a nonanonymous peer review system generates anxiety and uncertainty within a radiology department. The investigation of physicians’ attitudes toward and perceptions about peer review is important for understanding the potential impact not only on patient care but also on radiologists’ relationships and psychology in the workplace. Key Words: Peer review, patient safety, quality assurance, radiology errors, radiologist attitudes J Am Coll Radiol 2014;11:1034-1037. Copyright © 2014 American College of Radiology
INTRODUCTION
The attitudes and perceptions of radiologists regarding the incorporation of peer review systems have not been extensively investigated. Peer review in radiology typically involves the assessment of diagnostic accuracy, on the basis of perception, interpretation, or communication skills [1]. Traditional peer review processes have focused on individual physicians who either self-critique or critique their a
Department of Medical Imaging, Health Sciences North, Greater Sudbury, Ontario, Canada.
b Department of Physical Sciences at the Sunnybrook Research Institute, Toronto, Ontario, Canada. c
University of Toronto, Toronto, Ontario, Canada.
d
Obstetrical Ultrasound Center @ Sunnybrook, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Corresponding author and reprints: Phyllis Glanc, MD, Obstetrical Ultrasound Center @ Sunnybrook, Department of Medical Imaging, Room MG160, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; e-mail: [email protected].
1034
colleagues’ performance on an ad hoc, voluntary basis. The scope and importance of errors in modern medical practice was brought into the collective consciousness of medical professionals and the general public in 1999, when the Institute of Medicine reported that errors account for nearly 100,000 preventable deaths per year [2]. Beyond the loss of life, preventable errors were also estimated to have other significant costs on the health care system and the affected individuals, estimated in the tens of billions of dollars per year. Since that time, significant efforts have been focused on quality improvement mechanisms as a means of decreasing medical error rates and improving patient care [3]. Because human errors generally occur in relatively predictable patterns and frequencies, there is an opportunity to use peer review systems to enable a group of physicians to systematically identify and reduce errors by sharing strategies directed at reducing those specific errors [4,5]. Numerous audits of radiologist performance have demonstrated error rates in the range of 3% to 5% for all errors in daily practice [6-10]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.04.015
Loreto, Kahn, Glanc/Departmental Peer Review System 1035
In response to concerns about quality improvement, the ACR developed the RADPEER system in 2002 [11]. The ACR has made the implementation of formal systems of peer review a key component of hospital accreditation. The majority of physicians and their governing bodies agree that peer review processes address an important gap in quality assurance [12]. Despite this, peer review systems (eg, the ACR’s RADPEER system) continue to be limited by poor compliance [13]. The purpose of this study was to investigate the attitudes and perceptions of staff radiologists regarding the incorporation of a peer review system (PeerVue; Qualitative Intelligence Communication System, Sarasota, Florida) as a quality assurance measure. The PeerVue system is integrated with the department’s Agfa PACS and randomly chooses 3% of cases for review. The system is nonanonymous in that it is characterized by retrospective review of comparison studies previously reported by colleagues. In addition, all major discrepancies are reviewed and discussed on a quarterly basis by departmental heads, who are aware of the identities of the involved radiologists. The review is submitted online using a grading system similar to that used in the ACR’s RADPEER system [13]. Questions were designed to investigate the basic knowledge and attitudes about peer review processes in general, in addition to questions specific to the system being implemented. Understanding the concerns of radiologists regarding the implementation of formal peer review systems may lead to strategies that will translate into improved compliance rates in the future.
Fig 1. Survey respondents according to number of years in practice.
Perceived Value and Need for Peer Review
Thirty-one respondents (86%) agreed that peer review improves patient care, and 29 (81%) agreed that peer review is important for their own professional development. The majority of all respondents (n ¼ 29 [81%]) routinely advise colleagues of misdiagnoses or errors, but in the group of radiologists who do not, there was a disproportionate representation of staff with <10 years’ experience (Fig. 2). Not unexpectedly, more experienced radiologists (>10 years) felt more comfortable disclosing errors than less experienced radiologists (<10 years) (Fig. 3). Perceived Concerns About Peer Review
METHODS
An anonymous 26-question SurveyMonkey (http:// www.surveymonkey.com) questionnaire was designed to gauge radiologists’ knowledge about, attitudes toward, and perceptions regarding peer review (Online Appendix 1). It was distributed to all 39 staff radiologists at Sunnybrook Health Sciences Centre, an academic center affiliated with the University of Toronto, before the implementation of the PeerVue peer review system in the late fall of 2012 [14]. Data were analyzed using descriptive statistics, and responses were cross-tabulated according to subspecialty and number of years in practice.
Thirty-two respondents (89%) indicated that they felt that performance-related data acquired in a peer review system should be immune from discovery if legal
RESULTS Survey Participation
The survey was circulated to all staff radiologists in the department, with a response rate of 36 of 39 (92%). Broad participation was achieved across the various subspecialties and between radiologists with varying years of experience (Fig. 1). Responses to the survey questions were analyzed using descriptive statistics and cross-tabulated with the various radiology subspecialties and number of years in practice. No significant variance in responses was identified for the subspecialty cross-tabulation.
Fig 2. Do you routinely advise your colleagues of misdiagnoses/errors? Respondents answered this question either “yes” (blue) or “no” (red). Responses were calculated as percentages and cross-tabulated according to the relative number of years of experience.
1036 Journal of the American College of Radiology/Vol. 11 No. 11 November 2014
Anonymity
Thirty-three respondents (92%) believed that peer review should be an anonymous process, with 31 (86%) indicating their concern that peer review systems that do not protect the anonymity of the radiologist who generated the report under current review adversely affect the objectivity of evaluation by reviewers. Furthermore, 21 respondents (58%) did not believe that they could be unbiased in reviewing a case reported by someone with whom they work closely. DISCUSSION
Fig 3. Equally comfortable disclosing errors made by radiologists with more or less experience? Respondents answered this question either “yes” (blue) or “no” (red). Responses were calculated as percentages and dichotomized according to the relative number of years of experience (<10 or >10 years).
proceedings are brought against a radiologist. Respondents indicated concerns that a peer review system would adversely affect workflow, would not be safe from malpractice concerns, and had the potential to damage job ranking or security (Table 1). The latter concern was more prevalent among the more experienced members of the department, with 8 of 16 respondents (50%) with >10 years of experience sharing this concern, whereas only 7 of 20 of their less experienced counterparts (35%) shared this particular concern. PeerVue-Specific Knowledge
Twenty-five respondents (69%) indicated that they felt that they had not received adequate explanation about the specifics of the system before its implementation. This was reflected in the answers to 4 PeerVue-specific questions, to which 47% of all responses were incorrect. For example, 11 respondents (31%) incorrectly believed that PeerVue is an anonymous system. Table 1. Perceived concerns regarding a peer review system Agree Perceived Concern About Peer Review (%) Participation in peer review will add time to workday and affect departmental workflow Peer review is not safe from malpractice Peer review has the potential to damage interpersonal relationships Peer review has the potential to influence job security/departmental ranking
75 72 67 42
Note: Results presented in the table represent the percentage of all respondents in agreement with the stated potential negative effect of peer review.
This survey demonstrates that the implementation of a formal peer review system in a radiology department is associated with both anxiety and uncertainty. Although the intent of peer review is to be educational and enhance patient care, physicians remain concerned that peer review processes may be biased, potentially punitive, and open to medicolegal liability. The majority of respondents believed that peer review should be an anonymous process and expressed their concern that nonanonymous peer review systems would not protect the anonymity of reporting radiologists and might even compromise their ability to perform unbiased peer review on colleagues with whom they work closely. The majority of individuals surveyed believed that peer review systems have the potential to damage interpersonal relationships. As well, the majority of respondents were concerned that peer review data will not be safe from malpractice issues, whereas most of the respondents believed that it should be. Another concern held by a significant number of respondents is the potential influence on job security or departmental ranking. Interestingly, this concern was more prevalent among the more experienced radiologists in the department, possibly because they feel, having more seniority, that they also have more to lose. Another practical concern associated with formal peer review systems is that they will add to an already heavy departmental workload and interfere with the efficiency of reporting. Although the majority of respondents did acknowledge this, the vast majority indicated that they thought the imposition would be minimal, representing <3 hours of additional work per week. It should be noted that the PeerVue system is integrated into the PACS, and studies are selected for review as part of the radiologists’ daily work lists, as opposed to “add-on” studies, in an attempt to render the system as time efficient as possible. Historically, radiology departments have relied on the voluntary participation of staff members in an informal system of peer review whereby errors discovered on previously reported studies were either discussed among the individual radiologists involved or brought up anonymously in the setting of departmental morbidity and mortality rounds. Although some individuals cite the existence of these activities as being sufficient and doubt the need for a formal peer review system to be put in place, this survey identified that approximately 1 in 5 radiologists do
Loreto, Kahn, Glanc/Departmental Peer Review System 1037
not routinely advise colleagues of errors, providing support for the argument that formal peer review systems are required to ensure equal participation among all members of a radiology department. Interestingly, but perhaps not surprisingly, there was disproportionate representation of less experienced staff radiologists among the group of individuals who do not routinely advise their colleagues of errors. Regardless of the collegiality of members in a department, there is inevitably a hierarchy, and more junior members likely find it difficult to broach the subject of errors with their more senior colleagues. One of the survey questions directly addressed this issue, and nearly half of all respondents with <10 years of experience said that they did not feel equally comfortable disclosing errors to radiologists with more experience than themselves, whereas only a quarter of radiologists with >10 years of experience expressed the same sentiment. Our study is not without limitations, one of which is the fact that this research describes a single radiology department’s experience with peer review and may not be representative of all radiology department experiences. The very high response rate has served to minimize any possible participation bias, and a conscious effort was made to use neutral language in the creation of survey questions and response options in an attempt to minimize response bias. Formal peer review systems are becoming more prevalent in radiology departments, and although their intended effects of improving patient care and facilitating professional development are valued by radiologists, their implementation is also surrounded by anxiety about the potential personal and professional ramifications for individuals. We believe it is important to understand the attitudes and perceptions that may influence an individual’s participation in a peer review process. This understanding may lead to strategies to improve compliance and participation in peer review systems. To our knowledge, this is the first published survey to formally look at these attitudes before the institution of a peer review system within a medical imaging department. CONCLUSIONS
The investigation of radiologists’ attitudes toward and perceptions about peer review is important for understanding the potential impact not only on patient care but also on radiologists’ relationships and psychology in the workplace. Peer review is a necessary quality assurance activity, and understanding the concerns of radiologists surrounding the incorporation of formal peer review systems may help translate into future improved compliance rates. TAKE-HOME POINTS
The majority of radiologists agree that peer review is important for improving patient care and professional development, but 20% do not routinely advise colleagues of errors.
The incorporation of a nonanonymous peer review system generates anxiety and uncertainty within a radiology department. The investigation of radiologists’ attitudes toward and perceptions about peer review is important for understanding the potential impact on radiologists’ relationships and psychology in the workplace. Understanding the concerns of radiologists surrounding the incorporation of formal peer review systems may help translate into future improved compliance rates. ACKNOWLEDGMENTS The authors thank the staff of the Medical Imaging Department of Sunnybrook Health Sciences Centre. ADDITIONAL RESOURCES
Sunnybrook Radiology PeerVue Implementation Survey: http://www.jacr.org/article/S1546-1440(14)002208/fulltext. REFERENCES 1. Mahgerefteh S, Kruskal J, Yam C, Blachar A, Sosna J. Peer review in diagnostic radiology: current state and a vision for the future. Radiographics 2009;29:1221-31. 2. Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Washington, District of Columbia: National Academies Press, 1999. 3. Altman D, Clancy C, Blendon R. Improving patient safety—five years after the IOM report. N Engl J Med 2004;351:2041-3. 4. Halsted MJ. Radiology peer review as an opportunity to reduce errors and improve patient care. J Am Coll Radiol 2004;1:984-7. 5. Edwards MT. Peer review: a new tool for quality improvement. Phys Exec J 2009;35:54-9. 6. Radiology Quality Institute. Diagnostic accuracy in radiology: defining a literature-based benchmark. Beachwood, Ohio: Radiology Quality Institute; 2012. 7. Berlin L. Radiologic errors: acceptable practice or malpractice. InPractice 2007;1:5-7. 8. Siegle R, Baram E, Reuter S, Clarke E, Lancaster J, McMahan A. Rates of disagreement in imaging interpretation in a group of community hospitals. Acad Radiol 1998;5:148-54. 9. Borgstede J, Lewis R, Bhargavan M, Sunshine J. RADPEER quality assurance program: a multifacility study of interpretive disagreement rates. J Am Coll Radiol 2004;1:59-65. 10. Soffa D, Lewis R, Sunshine J, Bhargavan M. Disagreement in interpretation: a method for the development of benchmarks for quality assurance in imaging. J Am Coll Radiol 2004;1:212-7. 11. Jackson V, Cushing T, Abujudeh H, et al. RADPEER scoring white paper. J Am Coll Radiol 2009;6:21-5. 12. American College of Radiology. New accreditation physician peer-review requirements effective April 1 2007. Available at: http://gm.acr.org/ SecondaryMainMenuCategories/quality_safety/radpeer/new_requirements. aspx. Accessed May 6, 2014. 13. Swanson J, Thapa M, Lyer R, Otto R, Weinberger E. Optimizing peer review: a year of experience after instituting a real-time commentenhanced program at a children’s hospital. AJR Am J Roentgenol 2012;185:1121-5. 14. PeerVue. Available from: www.peervue.com. Accessed January 22, 2014.
Survey of Radiologist Attitudes and Perceptions Regarding the Incorporation of a Departmental Peer Review System Michael Loreto, MDa, Daniel Kahnb, Phyllis Glanc, MDc,d
Purpose: The aim of this study was to investigate the attitudes and perceptions of staff radiologists regarding the incorporation of a nonanonymous peer review system at an academic hospital. Methods: A questionnaire gauging knowledge of, attitudes toward, and perceptions regarding peer review was distributed to all staff radiologists at a large academic hospital. The survey was distributed before the implementation of a nonanonymous peer review system. Data were analyzed using descriptive statistics. Responses were cross-tabulated according to subspecialty and number of years in practice. Results: The majority of respondents agreed that peer review is important for improving patient care (31 of 36 [86%]) and professional development (29 of 36 [81%]), but the vast majority (33 of 36 [92%]) believed that peer review should be anonymous. Twenty-six of 36 respondents (72%) believed that peer review will not be safe from malpractice issues, 24 of 36 (67%) agreed that it has the potential to damage interpersonal relationships within the department, and 15 of 36 (42%) believed that it may influence their job security or rankings within the department. Significant differences were identified between radiologists with more and fewer years of practice experience. Conclusions: The incorporation of a nonanonymous peer review system generates anxiety and uncertainty within a radiology department. The investigation of physicians’ attitudes toward and perceptions about peer review is important for understanding the potential impact not only on patient care but also on radiologists’ relationships and psychology in the workplace. Key Words: Peer review, patient safety, quality assurance, radiology errors, radiologist attitudes J Am Coll Radiol 2014;11:1034-1037. Copyright © 2014 American College of Radiology
INTRODUCTION
The attitudes and perceptions of radiologists regarding the incorporation of peer review systems have not been extensively investigated. Peer review in radiology typically involves the assessment of diagnostic accuracy, on the basis of perception, interpretation, or communication skills [1]. Traditional peer review processes have focused on individual physicians who either self-critique or critique their a
Department of Medical Imaging, Health Sciences North, Greater Sudbury, Ontario, Canada.
b Department of Physical Sciences at the Sunnybrook Research Institute, Toronto, Ontario, Canada. c
University of Toronto, Toronto, Ontario, Canada.
d
Obstetrical Ultrasound Center @ Sunnybrook, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Corresponding author and reprints: Phyllis Glanc, MD, Obstetrical Ultrasound Center @ Sunnybrook, Department of Medical Imaging, Room MG160, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; e-mail: [email protected].
1034
colleagues’ performance on an ad hoc, voluntary basis. The scope and importance of errors in modern medical practice was brought into the collective consciousness of medical professionals and the general public in 1999, when the Institute of Medicine reported that errors account for nearly 100,000 preventable deaths per year [2]. Beyond the loss of life, preventable errors were also estimated to have other significant costs on the health care system and the affected individuals, estimated in the tens of billions of dollars per year. Since that time, significant efforts have been focused on quality improvement mechanisms as a means of decreasing medical error rates and improving patient care [3]. Because human errors generally occur in relatively predictable patterns and frequencies, there is an opportunity to use peer review systems to enable a group of physicians to systematically identify and reduce errors by sharing strategies directed at reducing those specific errors [4,5]. Numerous audits of radiologist performance have demonstrated error rates in the range of 3% to 5% for all errors in daily practice [6-10]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.04.015
Loreto, Kahn, Glanc/Departmental Peer Review System 1035
In response to concerns about quality improvement, the ACR developed the RADPEER system in 2002 [11]. The ACR has made the implementation of formal systems of peer review a key component of hospital accreditation. The majority of physicians and their governing bodies agree that peer review processes address an important gap in quality assurance [12]. Despite this, peer review systems (eg, the ACR’s RADPEER system) continue to be limited by poor compliance [13]. The purpose of this study was to investigate the attitudes and perceptions of staff radiologists regarding the incorporation of a peer review system (PeerVue; Qualitative Intelligence Communication System, Sarasota, Florida) as a quality assurance measure. The PeerVue system is integrated with the department’s Agfa PACS and randomly chooses 3% of cases for review. The system is nonanonymous in that it is characterized by retrospective review of comparison studies previously reported by colleagues. In addition, all major discrepancies are reviewed and discussed on a quarterly basis by departmental heads, who are aware of the identities of the involved radiologists. The review is submitted online using a grading system similar to that used in the ACR’s RADPEER system [13]. Questions were designed to investigate the basic knowledge and attitudes about peer review processes in general, in addition to questions specific to the system being implemented. Understanding the concerns of radiologists regarding the implementation of formal peer review systems may lead to strategies that will translate into improved compliance rates in the future.
Fig 1. Survey respondents according to number of years in practice.
Perceived Value and Need for Peer Review
Thirty-one respondents (86%) agreed that peer review improves patient care, and 29 (81%) agreed that peer review is important for their own professional development. The majority of all respondents (n ¼ 29 [81%]) routinely advise colleagues of misdiagnoses or errors, but in the group of radiologists who do not, there was a disproportionate representation of staff with <10 years’ experience (Fig. 2). Not unexpectedly, more experienced radiologists (>10 years) felt more comfortable disclosing errors than less experienced radiologists (<10 years) (Fig. 3). Perceived Concerns About Peer Review
METHODS
An anonymous 26-question SurveyMonkey (http:// www.surveymonkey.com) questionnaire was designed to gauge radiologists’ knowledge about, attitudes toward, and perceptions regarding peer review (Online Appendix 1). It was distributed to all 39 staff radiologists at Sunnybrook Health Sciences Centre, an academic center affiliated with the University of Toronto, before the implementation of the PeerVue peer review system in the late fall of 2012 [14]. Data were analyzed using descriptive statistics, and responses were cross-tabulated according to subspecialty and number of years in practice.
Thirty-two respondents (89%) indicated that they felt that performance-related data acquired in a peer review system should be immune from discovery if legal
RESULTS Survey Participation
The survey was circulated to all staff radiologists in the department, with a response rate of 36 of 39 (92%). Broad participation was achieved across the various subspecialties and between radiologists with varying years of experience (Fig. 1). Responses to the survey questions were analyzed using descriptive statistics and cross-tabulated with the various radiology subspecialties and number of years in practice. No significant variance in responses was identified for the subspecialty cross-tabulation.
Fig 2. Do you routinely advise your colleagues of misdiagnoses/errors? Respondents answered this question either “yes” (blue) or “no” (red). Responses were calculated as percentages and cross-tabulated according to the relative number of years of experience.
1036 Journal of the American College of Radiology/Vol. 11 No. 11 November 2014
Anonymity
Thirty-three respondents (92%) believed that peer review should be an anonymous process, with 31 (86%) indicating their concern that peer review systems that do not protect the anonymity of the radiologist who generated the report under current review adversely affect the objectivity of evaluation by reviewers. Furthermore, 21 respondents (58%) did not believe that they could be unbiased in reviewing a case reported by someone with whom they work closely. DISCUSSION
Fig 3. Equally comfortable disclosing errors made by radiologists with more or less experience? Respondents answered this question either “yes” (blue) or “no” (red). Responses were calculated as percentages and dichotomized according to the relative number of years of experience (<10 or >10 years).
proceedings are brought against a radiologist. Respondents indicated concerns that a peer review system would adversely affect workflow, would not be safe from malpractice concerns, and had the potential to damage job ranking or security (Table 1). The latter concern was more prevalent among the more experienced members of the department, with 8 of 16 respondents (50%) with >10 years of experience sharing this concern, whereas only 7 of 20 of their less experienced counterparts (35%) shared this particular concern. PeerVue-Specific Knowledge
Twenty-five respondents (69%) indicated that they felt that they had not received adequate explanation about the specifics of the system before its implementation. This was reflected in the answers to 4 PeerVue-specific questions, to which 47% of all responses were incorrect. For example, 11 respondents (31%) incorrectly believed that PeerVue is an anonymous system. Table 1. Perceived concerns regarding a peer review system Agree Perceived Concern About Peer Review (%) Participation in peer review will add time to workday and affect departmental workflow Peer review is not safe from malpractice Peer review has the potential to damage interpersonal relationships Peer review has the potential to influence job security/departmental ranking
75 72 67 42
Note: Results presented in the table represent the percentage of all respondents in agreement with the stated potential negative effect of peer review.
This survey demonstrates that the implementation of a formal peer review system in a radiology department is associated with both anxiety and uncertainty. Although the intent of peer review is to be educational and enhance patient care, physicians remain concerned that peer review processes may be biased, potentially punitive, and open to medicolegal liability. The majority of respondents believed that peer review should be an anonymous process and expressed their concern that nonanonymous peer review systems would not protect the anonymity of reporting radiologists and might even compromise their ability to perform unbiased peer review on colleagues with whom they work closely. The majority of individuals surveyed believed that peer review systems have the potential to damage interpersonal relationships. As well, the majority of respondents were concerned that peer review data will not be safe from malpractice issues, whereas most of the respondents believed that it should be. Another concern held by a significant number of respondents is the potential influence on job security or departmental ranking. Interestingly, this concern was more prevalent among the more experienced radiologists in the department, possibly because they feel, having more seniority, that they also have more to lose. Another practical concern associated with formal peer review systems is that they will add to an already heavy departmental workload and interfere with the efficiency of reporting. Although the majority of respondents did acknowledge this, the vast majority indicated that they thought the imposition would be minimal, representing <3 hours of additional work per week. It should be noted that the PeerVue system is integrated into the PACS, and studies are selected for review as part of the radiologists’ daily work lists, as opposed to “add-on” studies, in an attempt to render the system as time efficient as possible. Historically, radiology departments have relied on the voluntary participation of staff members in an informal system of peer review whereby errors discovered on previously reported studies were either discussed among the individual radiologists involved or brought up anonymously in the setting of departmental morbidity and mortality rounds. Although some individuals cite the existence of these activities as being sufficient and doubt the need for a formal peer review system to be put in place, this survey identified that approximately 1 in 5 radiologists do
Loreto, Kahn, Glanc/Departmental Peer Review System 1037
not routinely advise colleagues of errors, providing support for the argument that formal peer review systems are required to ensure equal participation among all members of a radiology department. Interestingly, but perhaps not surprisingly, there was disproportionate representation of less experienced staff radiologists among the group of individuals who do not routinely advise their colleagues of errors. Regardless of the collegiality of members in a department, there is inevitably a hierarchy, and more junior members likely find it difficult to broach the subject of errors with their more senior colleagues. One of the survey questions directly addressed this issue, and nearly half of all respondents with <10 years of experience said that they did not feel equally comfortable disclosing errors to radiologists with more experience than themselves, whereas only a quarter of radiologists with >10 years of experience expressed the same sentiment. Our study is not without limitations, one of which is the fact that this research describes a single radiology department’s experience with peer review and may not be representative of all radiology department experiences. The very high response rate has served to minimize any possible participation bias, and a conscious effort was made to use neutral language in the creation of survey questions and response options in an attempt to minimize response bias. Formal peer review systems are becoming more prevalent in radiology departments, and although their intended effects of improving patient care and facilitating professional development are valued by radiologists, their implementation is also surrounded by anxiety about the potential personal and professional ramifications for individuals. We believe it is important to understand the attitudes and perceptions that may influence an individual’s participation in a peer review process. This understanding may lead to strategies to improve compliance and participation in peer review systems. To our knowledge, this is the first published survey to formally look at these attitudes before the institution of a peer review system within a medical imaging department. CONCLUSIONS
The investigation of radiologists’ attitudes toward and perceptions about peer review is important for understanding the potential impact not only on patient care but also on radiologists’ relationships and psychology in the workplace. Peer review is a necessary quality assurance activity, and understanding the concerns of radiologists surrounding the incorporation of formal peer review systems may help translate into future improved compliance rates. TAKE-HOME POINTS
The majority of radiologists agree that peer review is important for improving patient care and professional development, but 20% do not routinely advise colleagues of errors.
The incorporation of a nonanonymous peer review system generates anxiety and uncertainty within a radiology department. The investigation of radiologists’ attitudes toward and perceptions about peer review is important for understanding the potential impact on radiologists’ relationships and psychology in the workplace. Understanding the concerns of radiologists surrounding the incorporation of formal peer review systems may help translate into future improved compliance rates. ACKNOWLEDGMENTS The authors thank the staff of the Medical Imaging Department of Sunnybrook Health Sciences Centre. ADDITIONAL RESOURCES
Sunnybrook Radiology PeerVue Implementation Survey: http://www.jacr.org/article/S1546-1440(14)002208/fulltext. REFERENCES 1. Mahgerefteh S, Kruskal J, Yam C, Blachar A, Sosna J. Peer review in diagnostic radiology: current state and a vision for the future. Radiographics 2009;29:1221-31. 2. Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Washington, District of Columbia: National Academies Press, 1999. 3. Altman D, Clancy C, Blendon R. Improving patient safety—five years after the IOM report. N Engl J Med 2004;351:2041-3. 4. Halsted MJ. Radiology peer review as an opportunity to reduce errors and improve patient care. J Am Coll Radiol 2004;1:984-7. 5. Edwards MT. Peer review: a new tool for quality improvement. Phys Exec J 2009;35:54-9. 6. Radiology Quality Institute. Diagnostic accuracy in radiology: defining a literature-based benchmark. Beachwood, Ohio: Radiology Quality Institute; 2012. 7. Berlin L. Radiologic errors: acceptable practice or malpractice. InPractice 2007;1:5-7. 8. Siegle R, Baram E, Reuter S, Clarke E, Lancaster J, McMahan A. Rates of disagreement in imaging interpretation in a group of community hospitals. Acad Radiol 1998;5:148-54. 9. Borgstede J, Lewis R, Bhargavan M, Sunshine J. RADPEER quality assurance program: a multifacility study of interpretive disagreement rates. J Am Coll Radiol 2004;1:59-65. 10. Soffa D, Lewis R, Sunshine J, Bhargavan M. Disagreement in interpretation: a method for the development of benchmarks for quality assurance in imaging. J Am Coll Radiol 2004;1:212-7. 11. Jackson V, Cushing T, Abujudeh H, et al. RADPEER scoring white paper. J Am Coll Radiol 2009;6:21-5. 12. American College of Radiology. New accreditation physician peer-review requirements effective April 1 2007. Available at: http://gm.acr.org/ SecondaryMainMenuCategories/quality_safety/radpeer/new_requirements. aspx. Accessed May 6, 2014. 13. Swanson J, Thapa M, Lyer R, Otto R, Weinberger E. Optimizing peer review: a year of experience after instituting a real-time commentenhanced program at a children’s hospital. AJR Am J Roentgenol 2012;185:1121-5. 14. PeerVue. Available from: www.peervue.com. Accessed January 22, 2014.