In this issue, we talk with Jennifer C. Broder, MD, Vice Chair of the ACR® Commission on Quality and Safety and Chair of the new Peer Learning Committee, about the critical role of just culture and peer learning in improving quality and safety — without judgment or blame.
Q. As the new Vice Chair of the Quality and Safety Commission, tell us what opportunities you're most excited about for the future.
A. One of the most exciting initiatives is our new Peer Learning Committee, in which we will be working to establish best practices for peer learning and help more practices establish peer learning programs. We’re developing the Peer Learning Committee in response to the growing momentum across the country and internationally among practices to implement peer learning. The goal of the committee is to look at what's being done, establish best practices and define what constitutes a rigorous peer learning program. Then we’ll work to support implementation of new peer learning programs across varied types of radiology practices through education, outreach and mentorship. Eventually, we hope to coordinate formal adoption of peer learning as a pathway for peer review in the accreditation process.
To accomplish these objectives, we are pulling together an amazing group of people to form the Peer Learning Committee who are committed to the concept and who have established exemplary peer learning programs themselves.
Q. How would you describe peer learning?
A. Peer learning is a system in which we share learning opportunities with each other without judgment and then use those opportunities to improve our practice collectively and systemically. By avoiding judgment and focusing on learning, we promote collegiality and collaboration that, in turn, fosters a culture of learning and improvement. It is a process that helps practice members commit to improving performance as individuals, as a group and as a system. I describe peer learning briefly in this Voice of Radiology blog post, "Peer Learning Is Paving the Way Toward Continuous Improvement". For those who want more detail, the white paper "Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit", recently published in the JACR®, provides a great overview of why peer learning has been developed, how it is being implemented and how we envision its future.
Q. What are the benefits of peer learning?
A. The primary benefit of peer learning is that it cultivates an environment in which we're all working together to learn without judgment. The beauty of a well-functioning peer learning system is that everyone in the practice understands it's their responsibility to help their peers learn and improve, and they don’t mind doing it because it helps build relationships and improve their own practice as well. In practices with robust peer learning programs, we not only learn from our mistakes, we also identify times when people do a great job and help everyone else learn from that experience. I call it “learning from the masters” — we use the opportunities when people are really doing well to help everyone else learn how to succeed in the future.
Beyond individual and group learning, the second major benefit of peer learning is that a well-organized program will consistently find ways to translate learning opportunities into systems improvements. For example, at our institution the review of one neuroradiology case led to the creation of a hospital-level diagnostic pathway involving multiple disciplines.
Q. Why has peer learning started to come more to the forefront of quality and safety?
A. The value of peer learning is that it allows people to focus on how to improve without the negative side effects of judgment or blame. Medicine is traditionally set up to review each other's work with a heavy hand. Many people who come into medicine are perfectionists, and we take great pride in our work. When judgment is associated with times we haven't succeeded, it results in shame. That shame has two consequences. One: It makes people feel terrible, which really destroys an opportunity for learning. We all know that we don't learn well when we are shrouded in negative feelings. Two: It makes other people not want to bring up mistakes, errors or opportunities for improvement, because we don’t want to make each other feel bad.
A lot of judgment among peers in medicine ends up working against what we want to promote, which is collegial, close working relationships. To achieve the most benefits from peer learning programs, to create highly functional collegiality, it’s critical to eliminate all opportunities for peer-to-peer judgment. It’s also important to note that a key starting point for peer learning is to establish a just culture.
Q. What is just culture and how does it work?
A. The most important part of improving quality and safety in your practices is to establish a just culture, where people can trust their errors will be treated fairly, humanely. At Lahey Hospital and Medical Center, we have been working for several years to implement a just culture model, which is a method of investigating why errors happen and how to address them in a consistent, fair and transparent way. This model is used to review errors across all aspects of our work in the department, from administrative to clinical.
The just culture method directs management through a set of guiding questions to determine the underlying causes of an unfavorable event: Was the mistake the result of human error, at-risk behavior or reckless behavior? Once we determine the intent behind the person’s actions, the model outlines appropriate responses for each scenario. Human error results in consolation, at-risk behavior results in coaching and reckless behavior results in disciplinary action. Our efforts to establish a just culture are described in more detail in the Imaging 3.0 case study: "Bringing Errors to Light".
While it is more challenging to apply an algorithmic approach to reviewing interpretive errors, rather than, for instance, errors in technologist workflow, the tenets of a just culture establish the ground rules for our peer learning program. Peer learning is, in essence, the manifestation of a just culture for our clinical work.
Q. What should radiologists do to become more engaged in peer learning?
A. There are a lot of available resources on peer learning to help people better understand the principles of peer learning. Once you have checked those out, start thinking about what a program might look like in your practice and map it out. It’s important to understand that there’s no one way to do this. While you need to remain faithful to the guiding principles, each program can be operationalized to meet the needs of the individual practice. If you have questions, we’ll be holding a breakout session on Peer Learning at the 2020 ACR Virtual Conference on Quality and Safety, or you can reach out to the ACR Q&S team, and they will connect you with peer learning experts who can help you sort things out.
ACR Peer Learning Resources
- ACR National Peer Learning Summit (January 2020, full recording).
- ACR Peer Learning Webinar (June 2020, full recording).
- Peer Learning Is Paving the Way Toward Continuous Improvement (ACR Blog Post).
- “Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit” (white paper).
- “Bringing Errors to Light” (ACR Imaging 3.0 Case Study).