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Quality in Health Care 1994;3:147-152 147

Quality improvement by peer review in primary

care: a practical guide

Richard Grol

The reluctance of people to have their work The effectiveness of peer review is evident in
evaluated is closely linked with their reluctance to several studies, 13 14 29-31 but many care
comment on, or to complain about the behaviour of providers remain hesitant about becoming
others. Most people 'live and let live'. This attitude, involved in peer review. This paper describes
we admit, is not only understandable: it is the method of peer review, its characteristics
invaluable. Social life depends on it. Who should
throw the first stone? Who indeed can really and opportunities, and some of the difficulties
distinguish between an honest mistake and culpable of setting it up.
negligence? This is why we believe that efforts to
improve performance must come from a desire for What is peer review?
self-improvement, a desire based on an essentially Peer review literally means evaluation by a
ethical insight. Audit must not be part of a colleague. It is used to describe, for instance,
disciplinary instrument; it must be a tool for the assessment of manuscripts for scientific
learning by feedback.' journals or the assessment of research pro-
posals. Used as an approach to control
One of the most challenging questions in performance in health care in the United
quality of care today is how to change the States in the 1970s and '80s, peer review
practice performance of care providers, and gained a dubious reputation among care
effective and feasible methods of improving providers there. In quality improvement in
performance are urgently required. Peer Europe peer review is currently understood as
review in small groups or teams of care a structured process with particular
providers seems to provide such a method2 characteristics.
and it matches the "profile" of effective * Peer review is undertaken by two or more
behaviour change in health care, as found in care providers (usually a group or a team of
the literature. Elements of this profile are as 5-10), for an extended period, with regular
follows. meetings and activities (at least once a
* Care providers are subject to powerful and month)
potentially determining influences from * A variety of subjects, interventions, and
opinion leaders and influential respected methods are used in a planned and
peers in their professional network and their structured way
local setting.3'-2 These influences can and * Setting criteria, data collection, evaluation
should be used in bringing about change of each other's work, exchange of
* Peer audit and feedback as well as mutual experiences, developing guidelines, solving
support by colleagues are crucial in problems in practice, and making specific
inducing change'3-19 arrangements for achieving changes may all
* A combination of interventions is probably be included in the process
more effective in improving care than * Collaboration with respected peers and
separate interventions5 17 20 their evaluation and support are central to
* The methods of quality improvement the process.
preferred by many care providers in primary Box 1 outlines the general structure of peer
care are small scale activities which relate to review, including the quality improvement
their own work, that include personal cycle and box 2 lists examples of peer review
contact with colleagues, and that do not methods, which each provide a different
take too much time and do not interfere emphasis. A systematic and continuous peer
unduly with daily routines. These activities review process can include all of the
should include reflection on performance approaches described, depending on the
and learning new skills and they should particular topic. Ideally, the different
reduce uncertainty in daily work.2' 25 approaches are integrated as part of a long
Peer review is defined as a "continuous, term process of continuous quality improve-
systematic, and critical reflection by a number ment - a process of continuously selecting
Centre for Research
of care providers, on their own and colleagues' problems, formulating goals for good care,
on Quality in Family performance, using structured procedures, measuring actual care, selecting necessary
Practice, with the aim of achieving continuous improve- changes, implementing them, and performing
Universities of ment of the quality of care." This definition is a follow up.
Nijmegen and
Maastricht, consistent with recent views on continuous
Postbox 9101, quality improvement which see quality WHO ARE PEERS?
6500 HB Nijmegen, assurance and audit as methods of continuous "A peer is a person who is equal in any stated
Netherlands
Richard Grol, learning and ask practitioners to be open to respect".32 Usually in the same branch of
coordinator evaluation and comments on performance.26 28 health care provision, with comparable
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148

develop their own peer review programme.

Preparing for peer review Experiences in the Netherlands, the United
-acquiring skills and becoming acquainted with it
making practical and organisational arrangements for peer review Kingdom, Republic of Ireland, and Germany
formulating a plan for 6-12 months are outlined briefly below.
Selecting suitable topics DL1(J1 i EPERIEN(E1
identifying relevant quality problems The first experiments with peer review in
discussing and selecting topics for peer review primary care were by myself and others in the
precisely defining these topics early '80s in the district of Nijmegen2 ' " in
Selecting and agreeing criteria groups of about 10 general practitioners (GPs)
agreeing on general goals for improving practice following a structured programme of monthly
selecting crucial indicators for these goals sessions. The groups used guidelines, deV
defining the criteria/targets for desirable performance eloped in consensus meetings of experienced
Observing practice and evaluating care GPs, and various review methods (such as
selecting or developing instruments and procedures for data collection audiotaped consultations, self recording, and
and analysis practice visits). At first there was intensive
-collecting data on practice performance guidance, which gradually was reduced. All
analysing these data: comparing performance with targets, looking at 332 doctors involved in the education of
comparisons with colleagues and at trends undergraduates and postgraduates were
giving understandable and well organised feedback to each other targeted with written information, telephone
Planning and implementing changes cells, and meetings where opinion leaders and
identifying areas for change; selection of individual or practice goals for doctors who had already experienced peer
improvement review, explained the programme. Thus, the
identifying specific problems and barriers to achieving these approach was gradual and personal entailing
improvements between one and two years' preparation.
planning actions and selecting strategies to implement changes and Altogether, 234 GPs (71"/O) were involved,
solve problems
carrying out this plan working in 22 groups: each group ran for at
least 12 months and participation in the
Follow up meetings was, on average, 80%)o. After a pilot
analysing progress/success period in which the method was further
-analysing barriers, when no progress has been made developed (see box 1) the programme was
further planning evaluated; complete evaluation data were
Bo(x I Structure of peer review and quality improvement cycle available for 131(5 6%) participants.
The GPs' opinions of the meetings were
generally very positive; specific problems with
Conaenusz developnment- a structured process the peer review process in the first phase were
aimed at developing agreement on criteria and problems of investment of time; receiving
targets for improvement
criticism, meeting criteria, and making prac-
EvalutationM of petforn-iiance/audit
- emphasis on tical arrangements for participation. Although
setting criteria and targets for clinical most of these problems gradually decreased
performance, collecting data, evaluating care, with time, the problems of meeting per-
and presentation of feedback formance criteria and criticising colleagues
Practice visits - observation in the practice by a gradually increased. The participants reported
colleague with an emphasis on evaluating many changes in their performance due to the
premises, practice management and peer review, as well as an increase in their self
performance, and implementing changes confidence and satisfaction in working as a
Inidustrnal quality circle - emphasis on identifying GP. When asked about the factors most
and defining quality problems and finding important in bringing about changes in per-
concrete solutions to these problems formance (by selecting one factor out of 12
and adding extra factors if necessary) they
Smiiall group education - continuing medical indicated as the most important factors
education or skills training on specific subjects
in a peer review group exchanging practice experiences with
colleagues, awareness of gaps in performance,
Box 2 Somuie peer review methods and being informed about new guidelines for
practice performance (table 1).
experience or training, peers may be Actual changes in the performance of a
colleagues of the same or different disciplines group of 43 GPs before the programme and
working together in a practice (for example, 6-12 months afterwards were also measured.'
doctors, nurses, receptionists, managers, mid-
wives, etc) or hospital unit or they may be
care providers working together in local or Table I Most important factors in peer reviezv process
regional unidisciplinary or multidisciplinary that influenced change among 131 general practitioilerS
groups. Facto"
Exchanging practice experiences With colleagues
Experience of peer review in primary Awareness of gaps in performance 24
care Being informed on new guidelines 21
Learning how to evaluate performance 9
How should peer review be initiated and Discovering that colleagues have failings too 7
managed in primary care? The different Learning about practice routines of colleagues
Other factors
models that have been tried in the past decade
may help care providers in primary care to
Total 1()(
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Quality improvement by peer review 149

A trained observer visited the participants at performance and in promoting change in

their surgeries and collected data on consul- practice routines. Finally, when asked whether
tations. For each GP 30-35 consultations and they would continue with peer review in the
400-700 specific medical activities were next year 82% of the GPs were certain of
assessed, using the consensus guidelines. continuing and 15% stated that they would
Changes were found in history taking, patient probably continue.
education, involving patients in the consul-
tation, follow up, and prescribing drugs. PEER REVIEW IN UNITED KINGDOM
The results of the first study were so positive A model for small group peer review was
that the Dutch Association of GPs decided to developed in the North of England Study of
make peer review in local groups compulsory Standards and Performance.29 The emphasis
as part of a new quality assurance and in these groups was on standard setting. In all,
recertification scheme. Local GP groups are 92 practitioners from the district took part, in
now being prepared for this new task, with 10 small groups, each of which set a standard
training in leading and supervising peer review for one of five common childhood conditions
being provided for group representatives, each (acute cough, acute vomiting, bedwetting,
representative receiving three training sessions itchy rash, and recurrent wheezy chest). The
on chairing group sessions, how to set up a members of each group also received a
peer review programme, and an introduction standard devised by another group for another
to specific methods for peer review. Once each of the five conditions. Participants who set a
has started to work with their own group clinical standard proved to change their pres-
further meetings are held to discuss any cribing patterns in directions consistent with
problems which emerge. The national those standards and maintained the changes
guidelines for general practice care, published for up to two years. Four of these groups were
in 1989, form the basis of the peer review observed and recorded during a total of 19
methods which are used in the training.34 meetings.36 Features of the structure, the task,
This new approach to implementing peer and the functioning of the group showed an
review was evaluated in the south eastern part influence on the educational experience of the
of the Netherlands.35 In all, 28 GPs from this group members. Care providers taking part in
district have so far been trained to lead peer peer review groups were proved to require
groups; 218 participant GPs from their specific skills to facilitate meetings, such as
groups (response 85%) completed evaluation leadership skills, communication skills, and
questionnaires after one year in the peer skills to manage conflict and resolve problems
group. Overall the programme was evaluated in the groups.
very positively and 90% of participants
thought it valuable for the daily work of GPs. EXPERIENCE IN REPUBLIC OF IRELAND
Less than 10% did not particularly value the In the Republic of Ireland a network of part
experience. Asked to evaluate the supervisory time GP tutors has been developed in the past
role of their trained group representative, the decade.37 Each tutor serves the 60-80 GPs in
participants generally judged their leader his or her local area and facilitates and
positively, although there were criticisms organises ongoing small group continuing
about handling disagreements in the group, medical education and peer review. Full
supervising the time schedule, application of national coverage has been recently achieved,
methods, and stimulating self responsibility in and almost 70% of the 1900 GPs in Ireland
the group members (table 2). The GPs were have agreed to participate in the small group
asked to compare four well known methods sessions. The government funds the tutors for
for quality improvement and education for 2 to 3 days' work a week and tutors receive
GPs with regard to their perceived effective- regular training to maintain their skills in
ness: peer review in small groups, local facilitating. A small group review method is
continuing medical education meetings, used to assess performance - sometimes in
national or regional courses, and meetings relation to explicit guidelines - with the
between GPs and hospital specialists. Only intention of changing the doctor's per-
GPs who had recent experience with the formance. Case discussions, small scale data
methods were involved in the analysis. Peer collection, video consultation analysis,
review was evaluated as being much more practice visits, and simulated problems are the
(2-3 times) effective than the other methods most important methods used; others include
in increasing the awareness of the GPs' own practice activity analysis, use of external expert
resources, and hands on skills teaching. The
Table 2 Opinions on group leader among 218 group participants. Figures are methods are continuously refined, particularly
percentages the methodology for implementing changes in
practice performance and for follow up. A
Very good Good or acceptable Moderate or poor project is currently being undertaken, which
Not dominating, distant role 32 59 9 tries to relate specific peer review activities to
Creating a safe atmosphere 30 64 6
changes in prescribing.
Clear arrangements for meetings 30 56 14
Emphasis on informal contact 26 60 14
Sufficient involvement of all participants 23 69 8 GERMAN EXPERIENCE
Supervision of the time schedule 19 63 18
Stimulating self responsibility 19 66 15 Peer review ('quality circles') became fashion-
Information on programme 18 75 7
able in ambulatory care in Germany at the end
Instructions on exercises 16 73 11
Adequate application of peer review methods 14 71 15 of the '80s.38 Projects aimed at experimenting
Solving disagreements in group 10 64 26
with small group review started in various
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150 0(Gi, l

locations in the past five years, and in 1993, 16

different peer review projects were recorded Attenitionl to group finI7Ction71inig - creating a
constructive and open atmosphere
across Germany, with about 400 to 450
participating doctors in ambulatory care, DisClf~lssl7g expectationis and fcar
participants
covering various methods (practice activity should be offered the opportunity to express
analysis, videotaped consultations, chart audit, their feelings and these should be taken
case analysis, etc) and topics (asthma, seriously; arrangements on the manner of
diabetes, low back pain, doctor-patient com- conduct and on giving mutual criticism are
helpful
munication, etc). This development is under-
pinned by new rules and guidelines issued in Offering %trCtrc - giving insight into the
1993 from the Association of Sickness Fund programme and the review methodologies and
Doctors (KBV), which make obligatory using well designed methods that arc clearly
internal quality improvement by professionals understood by the participants
in ambulatory care, by peer review or quality Discsnsing the ains of peer revie~c - it should be
circles.,"' University academic departments of made clear that peer review is an educational
general practice in Hannover and G6ttingen exercise, a method for achieving improvements
support the development with a training in care for patients with mutual support for
course for group supervisors or moderators in care providers
implementing peer review in local or regional Box 3 AIlechaL isms)i for iiprovig1 ,'roup IlotivitliOll
groups of doctors. About 200 care providers
from ambulatory care have so far been trained
to perform this role (J Szecsenyi, personal pate by colleagues whom they respect, and
communication). A handbook" and a video- experienced participants should be available to
tape on principles and methods of peer review provide information on the peer review
support this course. process and to answer questions. The develop-
ment of the peer group based quality improve-
Setting up peer review ment programme in general practice in the
Setting up peer group review succesfully Republic of Ireland provides a good example
requires good preparation and management. of how to set up peer review (M Boland,
Experiences in Europe have provided useful personal communication). Firstly, all key
indicators of important points for recruitment people in one district were visited, during
of GPs, promoting a positive attitude towards which practice problems and educational
peer review, the methodology of peer review, needs of potential participants were discussed.
stimulating change in performance, and the Then they were invited to start an
organisation of the process. experimental peer review group. These first
participants spent time developing the
RECRUIT MENT AND IMO IIVATION methods for peer group review and then each
Care providers are often motivated but at the started their own peer review group. Box 3
same time somewhat hesitant to participate in shows some of the factors which can improve
peer review, for several reasons. Generally, the motivation of the participants in the peer
most care providers work alone and are only group.
partly accountable to others. Participation in
peer reviews gives colleagues the opportunity P'LIR RI'IEW METlHOD)OI (XGY
to look at an individual practitioner's work and Getting stuck with the process and the
offer their criticism, which, although it may be methods of peer review is a potential pitfall.
helpful and even positive, may also evoke For example, a group may restrict its actions
resistance - owing to fear of being shown up to one phase of the peer review process only
in front of others, fear of discovering weak- and, say, develop consensus criteria of targets
nesses, or fear of being branded as bad care without evaluating whether the criteria are
providers. Other problems relate to the followed, or the group may be continually
process of setting criteria and changing perfor- involved in gathering, analysing, and
mance. Many practitioners will not be willing exchanging data but have little idea of the
to relinquish their clinical freedom in direction of change. This is likely to create an
managing patients and their problems; there atmosphere of non-commitment. The effect is
may also be uncertainty about the procedures similar if data are aggregated in a way that
and methods of peer review and whether peer does not provide specific information for indi-
review will lead to worthwhile results. Partici- vidual practices or care providers. Some
pants may also introduce all kinds of practical groups may work too long on the same subject
and financial objections, which may partly be or use the same method again and again; as a
the result of a certain amount of resistance, result the process eventually becomes tedious.
and they may, erroneously, see peer review as Further piftalls are having meetings without a
a method of assessing and controlling their clear programme and participants' lack of
performance rather than an approach to specific skills for peer review, such as
continuous improvement and learning. communicating in a group or resolving
All these objections should be taken into conflicts, when the meetings are likely to
account when peer review activities are being become chaotic and unsatisfying."m
promoted. Thorough preparation and moti- Experience from the projects in the
vation of care providers is crucial: small scale Netherlands, the Republic of Ireland, and
or model projects are an appropriate way to Germany suggests the importance of varying
start; care providers should be asked to partici- the peer review methods used and the topics
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Quality improvement by peer review 151

discussed. A well designed programme for six part in the peer review. Is the peer review a
or 12 months with variation of topics and well personal reflection on individual performance
tested methods and with clear arrangements or do deviations of the agreed criteria imply
on each participant's responsibilities will the need for corrections, with colleagues
stimulate motivation and involvement.2 39 acting as a superintending body?
Each meeting should have a more or less fixed It is also crucial to allow sufficient time for
structure - to help participants to concentrate change within the peer review process - at
on the content rather than the method or the least the same as that given to setting criteria
structure of the meeting. Specific, well or to the audit of actual care. Time should be
delineated topics should be selected, which set aside for identifying the barriers to change,
can be handled in a relatively short time to which may be related to the care providers and
prevent the peer review becoming boring. A their characteristics but more often to the
group may even address several topics at the setting in which they work" 27; for developing
same time. For instance, setting targets for a plan for improvement with specific inter-
diabetes care may be started while imple- ventions; for managing the change process
mentation of improvements in the organ- well; and for evaluating the results. Giving
isation of prevention takes place. each other support to achieve changes is a
Peer review demands specific participants' crucial aspect of the peer review process. This
skills - for example, in selecting suitable includes discussing alternatives, demon-
problems, handling guidelines and criteria, strating new skills to each other, collaboration
setting objectives for improvement, applying on seeking solutions for specific problems
methods for data collection, giving and faced by some of the participants, reminding
receiving adequate feedback, constructively and stimulating each other, and also rewarding
communicating and working as a group, each other for achieving the targets. These are
developing and implementing plans for all important opportunities for making peer
change, and giving mutual support in review an effective as well as a pleasurable
achieving these changes. When the group first experience.
gets together time should be allocated for
training of these skills by using simple, non- ORGANISATION, STRUCTURES, AND
threatening examples so that participants gain CONDITIONS
confidence. Specific attention should be given Finally, to manage peer review well, and to
to handling disagreements - for instance, on stimulate motivation and involvement of the
the selected topics, the criteria for good participants, certain organisational conditions
quality, or the necessary changes in practice. have to be fulfilled, as follows.
Finally, it is important not only that * A long term plan of meetings, the topics to
aggregated data (at the group, practice, or be discussed, and arrangements for
department level) are used for peer review but attendance
also that individual performance is discussed * Continuity: regular meetings, preferably
critically. It may seem threatening in the once a fortnight or once a month
beginning, but will be much more satisfying in * Clear arrangements for coordination,
the long run. responsibilities of each participant, home-
work, minutes, etc
PROCESS OF CHANGE * A quiet, task-oriented location, with
One of the great difficulties is in using equipment and materials available
guidelines and criteria, adhering to them, and * Sufficient time for working (about two hours
achieving agreed changes in practice per- without major disturbances) and for informal
formance. Participants who may have worked contact before and after the meetings.
for many years in isolation and without
feedback on their style of working will each Facilitating and supervising peer review
have developed their own guidelines for good Groups or teams which start with peer review
practice. They accept that care providers can generally need supervision at the beginning.
each have their own way of tackling problems, One of the participants should have some
and being faced with different approaches and leadership skills, should know how to handle
having mistakes pointed out is often not the group functioning, and should be able to
appreciated or may even be denied (for structure the programme and apply various
example, "guidelines don't apply to everyday peer review methods. Training courses for
practice, every patient is different and requires peer group leaders or moderators have been
a different approach, my patients are pleased successfully set up in Europe, and participants
with my way of doing things"). in these courses proved to be sufficiently
In many peer review groups there is a non- skilled and prepared for their task after a short
committal attitude to changing performance course and regular follow up meetings.
that is difficult to break down. Even when Another important condition for imple-
deviations from agreed criteria are admitted, menting peer review in local and practice
there may be a reluctance to draw conclusions. settings is that it should fit within the normal
Colleagues tend not to question each other on structures for supporting care providers and
this and quickly accept that personal practices on quality assurance and continuous
preferences differ and that everyone may medical education. Special facilitators
continue to act according to that preference. attached to these structures may be available
To help counter this tendency, participants to provide information, materials, methods
may be asked to clarify their aims in taking and support in setting up peer review. In the
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152 GrR'(1

Netherlands there is a structure for quality 8 Mittman B, Tonesk X, Jacobson P. Implementing clinical
practice guidelines social influence strategies and
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1983.
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Quality improvement by peer review in

primary care: a practical guide.
R Grol

Qual Health Care 1994 3: 147-152

doi: 10.1136/qshc.3.3.147

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