Trending Topics

Implementing a peer-review process

How to develop and systematically use a quality review process to improve patient safety


Building and utilizing a robust CQI, performance improvement and peer review program helps to ensure high-quality care for all patients.

Photo/Getty Images

EMS is transitioning from a transport service to a highly reliable, data-driven and performance-measured component of the healthcare system. But, can you relate to this situation?

“I’ve always had a passion for making patient care better,” says Darick Day, director of clinical services for Washington County Ambulance District in southeast Missouri. “When I started my most recent adventure, we had no CQI and no education program. There was no on-boarding process nor standardized education for new providers. There was no annual competency process on the clinical side. We did long-distance transfers without ventilators, and our clinical protocols didn’t require waveform capnography for intubated patients. The billing department did the only chart review to determine what was billable. I remember locking myself in our board room with a year’s worth of charts, reviewing them one by one to identify clinical issues. It was the only way to assess where we were. We walked into the perfect storm of terror.”

Where to begin? The agency started by setting its Mission Statement and Core Values to ensure it was patient-centered. Day advised, “We committed ourselves to a simple principle: any time we make a decision, we ask, ‘is this what is best for the patient?’ If the answer is yes, we move forward. If the answer is no, we take a time out and revisit the issue. We started from scratch with our clinical program. Our medical director was very involved and supportive of our mission and values. We reviewed, revised and developed all of our Clinical Practice Guidelines and a Policy Manual that addressed clinical care as our top priority. We built our initial and recurrent education program from the ground up. We implemented a robust CQI process that ensures 100% chart review. We utilized our CQI process to drive our recurrent education program.”

Adding a peer-review process

St. Charles County Ambulance District in eastern Missouri added a robust peer-review process to help support its quality improvement program. Peer review is simply providers with similar competencies evaluating the care provided to the patient. John Romeo is a paramedic and registered nurse who had been involved in a nursing peer review program at the hospital where he worked. He was impressed with the effectiveness of the program. It changed the hospital’s culture in caring for patients, so he wanted to do the same when he switched his career to EMS. While the district historically had good quantitative and qualitative QI work, they wanted a more robust feedback mechanism whereby paramedics could provide feedback to one another. The program’s ultimate goal is to deliver the right care at the right time to achieve the best outcome for the patient.

In 2014, Romeo presented the peer review committee idea to the district Steering Committee, explaining the Committee’s purpose, membership make-up, and member requirements. Upon approval, committee members were selected, including paramedics from each shift, the part-time transfer division, and a training officer liaison. The medical director and medical officer are advisors, participating only in situations where specific expertise is needed. Each committee member must sign a confidentiality agreement.

Over the past seven years, the program has been reviewed and improved. The lessons learned from the review have led to individual provider improvement, as well as system and process improvements. The district uses the feedback to focus its training on specifically identified opportunities for improvement. The face-to-face outcome discussions between the committee chair and individual providers are best practices among providers conducting peer review. This process enhances the district’s patient safety culture and environment, supporting its purpose to deliver the right care at the right time with the best patient outcomes and helps meet the district’s Mission of providing extraordinary healthcare to the community they serve.

Patient safety organizations

The mantra of EMS Agenda 2050 is a people-centered vision for the future of Emergency Medical Services. A pillar of the vision is that in the future, “EMS will be inherently safe.” It describes a concept for an evidence-based, data-driven EMS that is integrated with the rest of the nation’s health care system. Building and utilizing a robust CQI, performance improvement and peer review program helps to ensure high-quality care for all patients. “This really isn’t rocket science – any EMS agency can do it, but it takes focus and a lot of work,” Day noted.

Participating in a patient safety organization (PSO) helps sell involvement in QI and peer review to providers. It also gives the frontline a voice and a streamlined approach to report unsafe conditions and near misses. The 2005 Patient Safety and Quality Improvement Act provides protection and confidentiality for patient safety and quality analysis and deliberation for any licensed health care provider. Romeo added, “If it wasn’t for the federal protections that are allowed through the PSO, we would not even be having these conversations. It allows us to focus on prevention, sharing and learning in a protected environment.”


As part of its year-long Road to Reliability learning series, the Center for Patient Safety is offering a webinar, “Advanced QI, Process Improvement & Peer Review,” on Feb. 17 at 1 p.m. CST. Darick Day will help you improve patient care by explaining how to develop and systematically use a quality review process. John Romeo will share the real-life ups and downs that occur when developing and implementing a peer-review process.

Visit the CPS’s “The Road to High Reliability” for additional information and to register

Plan now for national Patient Safety Awareness Week March 14-20. Highlight and celebrate your organization’s ongoing efforts to provide safe patient care by downloading a free toolkit from the Center for Patient Safety which will be available soon. The Toolkit contains posters, social media graphics and tips to make the week a success at your organization. Together, we are better, stronger and safer!


Pictured: Darick Day, BS, EMT-P, CCP-C, FP-C; and John E. Romeo, BSN, RN, EMT-P, FP-C

Courtesy Photos

About the speakers

Darick Day, BS, EMT-P, CCP-C, FP-C, is the director of clinical services for Washington County Ambulance District located in southeast Missouri. He oversees the clinical program for the agency which provides critical care level services in both the prehospital and interfacility environment. He serves as the primary instructor for a local community paramedic program while also teaching the Fundamentals of Critical Care transport. This is a 20-week long critical care program designed to prepare both paramedics and RNs for the world of critical care transport. He also provides education to other local EMS agencies and is an active speaker in regional EMS events.

John E. Romeo, BSN, RN, EMT-P, FP-C, is the deputy chief – medical officer for the St. Charles County Ambulance District in St. Peters, Missouri. He has served as lead instructor for St. Louis Community College and has previous critical care and emergency nursing experience.

He earned a Bachelor’s of Science Degree in Nursing from the University of Missouri St. Louis and completed his paramedic at IHM Health Studies Center. He completed the IHM UMBC Critical Care EMT-P program and earned a community paramedic certificate from Maryville University. He recently achieved recognition from the International Board of Specialty Certification as a certified flight paramedic. He has completed the Management of EMS program at the National Fire Academy and the Ambulance Service Manager Program.


Learn more about how to institute and measure quality improvement initiatives with these resources:

The Center for Patient Safety is the expert in EMS patient safety, dedicated to providing timely solutions and resources to improve patient safety and the quality of healthcare delivery. Established in 2005, CPS is an independent, not-for-profit organization that envisions a healthcare environment safe for all patients and healthcare providers, in all process all the time.