Richard E. Sharpe, MD, MBA: Peer Learning—Why the Time Is Now

Get a peer learning program started next week; relinquish the fascination with misses; seek to identify and spread learning opportunities.

Richard E. Sharpe, MD, MBA,
Chair, Breast Imaging, Mayo Clinic Arizona
July 27, 2022

In urging our member practices to get started on the transition from peer review to peer learning during Strategic Radiology’s Quality Forum in May, Richard E. Sharpe Jr, MD, MBA, chair, breast imaging, Mayo Clinic Arizona, had a list of the limitations of the typical peer review process:

  • Random—not curated—reviews of previously reviewed studies
  • Selected cases focus on misses
  • Closed door meetings
  • Limited participation
  • Discussions focus on need to make judgement
  • Little to no evidence presented
  • Patient/radiologist identifiers present
  • Outcome often discussed before voting
  • Voting by show of hands
  • Results only discussed with involved radiologist
  • Learning opportunity not distributed to team members

The peer review process is “not really producing any meaningful impacts but has nonetheless been the requirement until lately,” he said. “Let’s get to a better place together and start a peer learning program instead!”

Begin with research at your practice. How do people feel about the current program. What are its strengths and limitations?

Create your vision. What are the goals and opportunities for transitioning to peer learning? Discuss the need for change with your team and leaders, identify champions and feed their interest; and identify people’s concerns about the program.

Engage your army. “Realize that all of you have in your practice an untapped army of people who are ready to make care better in your practice tomorrow than it is today,” he said. They just need to be engaged.

Create a program that will channel radiologist interests. Identify a few learning opportunities and set ground rules—for example, you can’t say the word “malpractice,” it is not constructive. You can’t say “everybody should catch that.”

Create a peer learning policy that includes goals, targets, workflow, and QI efforts. And don’t forget to think about how you are going to document all of this. Dr. Sharpe recommended accessing the template for this purpose provided by the ACR.

Don’t be too ambitious in setting your case review requirement, because if you don’t meet it, you will need to undergo an extra step to reduce the number. “You can tell your radiologists, you would like them to submit two cases a month, but make the policy one,” Dr. Sharpe recommended. “That way, when the ACR comes to accredit your program, you’ve met your policy. If you set your policy high and you don’t meet it, then you must go through a remediation step.”

Submitting and curating learning opportunities does not need to be costly, elaborate, or require custom software. “There are a variety of ways that you can take the learning opportunities that are in your case mix in the cases your radiologists are reading and convert them into practice improvement,” Dr. Sharpe advised. “One of the workflows that some practices use is a simple email or a PHI-compatible web form such as Microsoft Office forms or a PHI-compatible Survey Monkey.”

Ideally, the peer learning leader will curate all of the learning opportunities that come in and prioritize the areas that the team needs to be aware of and that will improve the practice. “Some places send a PDF of learning opportunities every quarter,” he said, adding that it is best to assess what is best for your practice. “Everyone does this a little differently.”

In considering your program format, you will need to decide whether it is done monthly or quarterly, and whether to meet online or in person. “Plenty of people do it through PACS,” he said. “Peer learning conferences are a forum for learning opportunities to be surfaced by team members, and then, in team discussions, potentially result in collaboration, standardization, or other efforts to consistently improve quality.”

Standardized reports, a change in protocols or patient scheduling, and moving patients to different modality are potential improvement efforts that could be taken. “You also want to document all of these improvements made and cases discussed,” he said. These will need to be communicated to the group as well.

When Dr. Sharpe was at Kaiser Permanente, radiology standardized the entire interpretation of femoraacetabular impingement. “The orthopedists said, ‘You guys are all over the place,’ so we said, ‘Let’s talk about it.’” The orthopedists were invited to the peer learning conference, and Dr. Sharpe’s team created a tool that everyone could agree on. “We also organized thyroid nodule reporting—anyone else struggling with that,” he chuckled.

In debunking perceived barriers to peer learning, Dr. Sharpe maintains that it does not require extra funding or extra resources, it is not time intensive, and it is supported by accrediting bodies. The former inter-regional chair of radiology in charge of quality improvement for Kaiser Permanente and an early adopter of peer learning seven years ago, Dr. Sharpe emphasized that in transitioning from peer review to peer learning, you are starting a social movement. “People may have disengaged from peer review, and they can’t imagine that peer learning is different,” he said. “The focus on policing is leading to unintended consequences and causing us to not capture improvement opportunities in our midst. That is why you have to bring the people along with you.”

All you need is this, he said:

  • A team of radiologists
  • Peer learning leader and leadership in support
  • A process for submitting learning opportunities and time and space for discussion

 “All of you have those five things,” he said. “You have to make them understand that what you’re moving to is better than what you are doing today.”

Dr. Sharpe shared some tools for having those conversations with the hospital c-suite:

Focus on the big picture. Radiologists could use limited resources and time to judge each other’s work to be satisfactory, or to collaborate with each other and other stakeholders to improve quality of the care provided.

Relate Peer Learning to IOM Imperatives. The IOM supports the type of efforts we are talking about, particularly the last report—Improving Diagnosis in Health Care, 2015.

Relate Peer Learning to Hospital Mission. We are going to improve quality.

Accrediting Bodies Are Onboard. ACR, Joint Commission, CMS, ABR, CMS, Stroke Certification, American College of Surgery Trauma Certification

Give Them New Metrics: The old metrics are flawed and biased estimates of provider error rates; new metrics—number of learning opportunities submitted, percentage of radiologists submitting learning opportunities, number of peer learning programs held, % percentage of rads attending peer learning programming, number of learning opportunities discussed, number of improvements implemented.

In conclusion, he said: “Get a peer learning program started next week; relinquish the fascination with misses; seek to identify and spread learning opportunities.”

Access the ACR Peer Learning Resources 

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