A powerful idea from the nuclear industry

Where health care has fallen short in significantly improving quality, our peers in other high-risk industries have thrived. Perhaps we can adapt and learn from their lessons.

For example, health care can learn much from the nuclear power industry, which has markedly improved its safety track record over the last two decades since peer-review programs were implemented. Created in the wake of two nuclear crises, these programs may provide a powerful model for health care organizations. 

Following the famous Three Mile Island accident, a partial nuclear meltdown near Harrisburg, Pennsylvania in spring 1979, the Institute of Nuclear Power Operators (INPO) was formed by the CEOs of the nuclear companies. That organization established a peer-to-peer assessment program to share best practices, safety hazards, problems and actions that improved safety and operational performance. In the U.S., no serious nuclear accidents have occurred since then.

A more devastating nuclear incident in Chernobyl, Ukraine in 1986 spurred the creation of the World Association of Nuclear Operators (WANO), which serves a similar purpose but on an international scale. Since WANO’s inception, no severe nuclear accidents had occurred until the nuclear accident in Fukushima, Japan, caused by a devastating earthquake and tsunami in March 2011.

These programs have succeeded because their purpose and approach is very different from review processes by regulatory agencies. Instead of a punitive process that monitors compliance with minimum standards, peer-to-peer evaluations are thorough, confidential and—importantly—voluntary. They are viewed as mutually beneficial and help advance industry best practices, which are shared widely. The goal is to learn and improve rather than judge and shame. The reviews are done by experts, using validated tools and are ruthlessly transparent  yet confidential.

Peer-to-peer review has not been widely used in health care. A couple notable exceptions are the Northern New England Cardiovascular Study, which used organizational peer-to-peer review to improve the care of cardiac surgery patients, and the National Health Service in the UK, which used it to improve the care of patients with lung disease. While provider-level reviews are more common in health care organizations, they fail to capture the scale needed to achieve system-wide improvements.   

At the Armstrong Institute, we have been pilot testing peer-to-peer review and early results are encouraging. We have evaluated specific outcomes, like blood stream infections; specific areas, like the operating room; and whole quality and safety programs.      

Dan Hudson, a risk and reliability engineer for the U.S. Nuclear Regulatory Commission, and I shared our vision for an INPO-like model for health care in a BMJ Quality & Safety article published last spring:

“Healthcare could benefit from building upon successful and internally motivated peer-to-peer programs, thereby creating a structured, clinician-led, industry-wide process to openly review, identify and mitigate hazards, and share best practices that ultimately improve patient safety. A healthcare version of the INPO program could supplement the current approaches to improving safety, including efforts by regulators, and provide constructive and trusted feedback, allowing providers to assess and improve their safety, helping to unify the industrial morality and, if coupled with the appropriate tools, evaluate patient outcomes and individual clinician performance.”

In that paper, we argue five attributes would be necessary for the success of such a model: a systems-based scope, multidisciplinary peer reviewers, voluntary participation, and a non-punitive and mutually beneficial review process.

Dan and I invite you to join us for a discussion of what a successful peer-to-peer review model for health care could look like at Johns Hopkins’ first Forum on Emerging Topics in Patient Safety, to be held Sept. 23-25 in Baltimore. This event will bring together thought leaders in health care and other high-reliability industries to accelerate efforts to overcome the critical challenges facing the effort to improve patient safety. For more details, please visit the event web site.

Designing safe systems is one of three content tracks in Johns Hopkins’ first Forum on Emerging Topics in Patient Safety, to be held Sept. 23-25 in Baltimore. Experts from a wide range of backgrounds will gather to help generate ideas around this crucial issue. Among the speakers on this track are Dan Hudson, a risk and reliability engineer for the U.S. Nuclear Regulatory Commission; Bryan O’Connor, former chief of office of safety and mission assurance for NASA; and Thomas Eccles, recently retired chief engineer and deputy commander for Naval Sea Systems Command. A Johns Hopkins team will present on Project EMERGE, an effort to tap into the wisdom of a diverse group—engineers, nurses, doctors, bioethicists, and patients and their loved ones, among others—to design a safer intensive care unit. If you are interested in the topic of designing safe systems and would like to contribute to the recommendations that come from the forum, please join us in September.

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Jim Perkins September 16, 2013 at 4:32 pm

I think nuclear power is an unfortunate analogy to use, although I get the idea. On the surface over the past thirty years there has been a facade of an effort to improve peer to peer communication, but at site after site, in this country and elsewhere, there are recurring examples of institutional efforts to silence internal dissent. At Vermont Yankee, the owner talked openly about small reductions in plant staffing levels less than a month before announcing the entire plant would be shut down in one year. Forty-nine of fifty plants are currently shut down in Japan. Is that the image Hopkins is hoping to borrow from? Of course not. The NRC, in most cases, bends to the will of the plant owners and overrides concerns of citizens, workers and lower-level regulatory staff. I think there is still a visceral reaction to the sight of those cooling towers - "big medicine" does not need to borrow an icon of "big energy". It alienates me and likely alienates or confuses most who would see it.

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Kirsten B September 18, 2013 at 11:00 pm

A system approach is great but it does not take away the necessity that health care providers feel personally responsible for what they do - despite sign outs, hand-overs, shift work, work hour limitations. Taking every effort to make sure patients are safe and well throughout one's actions - looking up details, knowing the medical history, calling for help if necessary. So many possibilities for "short cuts" these days - no system approach will be able to eliminate the shortcomings created by them. Unfortunately JH's Department of Anesthesiology has been the most disappointing in this respect. Nothing can substitute for health care providers feeling a personal responsibility for patients.

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