Group peer review: a questionnaire-based survey Josephine Beatson, Nola Rushford, George Halasz, Jeanette Lancaster, Shirley Prager

Objective: This paper presents the findings from a questionnaire-based survey of psychiatrists designed to elucidate the positive and negative aspects of group peer review and its perceived place in accountability procedures, and to provide information about how accountability through group peer review might be improved. Method: Three hundred and eighty-eight psychiatrists were surveyed via mailout questionnaire. Demographic data, details of groups, and perceptions of beneficial and detrimental effects of group peer review were sought from group participants and non-participants. Attitudes of participants were compared with those of non-participants.Features of groups related to satisfaction in participants were examined. Results: The majority of the 170 respondents participating in groups regarded peer review as a means of maintaining and improving skills, sharing ideas and methods, receiving constructive criticism and feedback, of educational benefit and an important source of professional accountability. Non-participants, while less positive overall, responded equally that participation in peer review groups would be an effective response to accountability procedures. Potential detrimental effects and problems with the functioning of peer review groups were elucidated. Conclusions: Group peer review contributes significantly to professional accountability and education in well-functioning groups. Further strategies for the facilitation of group functioning and for the processing of problems arising in group peer review need to be developed to optimise its contribution to the maintenance and improvement of professional standards. Australian and New Zealand Journal of Psychiatry 1996; 30:643452 21 Erin Street, Richmond, Victoria, Australia Josephine Beatson MBBS. FRANZCP, Consultant Pqychiatrist Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia Nola Rushford PhD, BSc. BA, Lecturer. Clinical Psychologist Department of Psychological Medicine, Monash University, Clayton, Victoria, Australia George Halasz MBBS. BMedSc. MRCPsych. FRANZCP, Honorary Senior Lecturer, Consultant Psychiatrist . Shirley Prager MBBS, FRANZCP, Honorary Lecturer, Consultant Psvchiatrist 179 Victoria Parade, Fitzroy, Victoria, Australia Jeanette Lancaster MBBS, FRANZCP, Consultant Psychiatrist

In 1991. concern for the Dromotion of accountability in the practice of psychotherapy within psychiatry prompted the Section of Psychotherapy of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to establish a working_party . . on peer review, A review of the literature on peer review was undertaken under the auspices of the Victorian sub-committee of the working party. It revealed that the RANZCP was, in the late 1980s and early 1990s, facing the challenge of developing adequate accountability processes and procedures the American

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Psychiatric Association had faced in the early 1970s. The considerable body of information concerning the American experience made it apparent that if psychiatrists in Australia failed to heed that experience, they could be destined to repeat it. The result would be a system of accountability motivated primarily by cost-cutting, which appears to be the norm in the USA today [2,3]. That such a system raises ethical issues in the context of professional commitment to the provision of adequate patient care is starkly revealed in these accounts of current psychiatric practice in the USA. There was much in the literature to suggest that peer review, well conducted, has the potential to promote ethical practice in psychiatry and to raise professional awareness concerning treatment boundaries and appropriate practice standards

[W. When peer review had been accepted by the medical profession and was seen to contribute to the growth of knowledge and improvement in clinical standards, it included the following components: an educational focus; review by or including true peers; attention to customary practice rather than normative standards; the profession having full input into the planning of the peer review and receiving regular feedback concerning the results of review procedures; and careful attention to the preservation of patient confidentiality in the review process [6]. Potential benefits of profession-driven peer review activities included the promotion of a sentinel effect [6-91, alerting practitioners to increased examination of all their work, and an increased sense of professionalism and professional pride with a decreased sense of isolation 17,101. In Theaman’s words [7, p.4141: ‘Peer review makes collegial accountability a continuing presence in professional practice. If it works well, it will promote a constant self discipline’. When the review process was taken out of the hands of the medical profession in the USA, two serious problems arose. The first related to breaches of patient confidentiality in communications with third-party payers, and the second to loss of professional autonomy as the review process became a bureaucratised system of control of medical practice narrowly focussed on costs while failing to contain them [2]. This system involved considerable professional time in attending to the administrative requirements of what has been called ‘relentless review’ [ 10, p.3181. In the same article, Gabbard et al. quoted a letter to the editor of Psychintric News [ 11, p.261,

which captures the problem in succinct fashion: ‘. . . Psychiatrists, like other physicians often are caught between a professional duty to assert a patient’s need for continued care and a faceless utilisation reviewer who declares that further treatment is not covered because it is not “medically necessary” ’. With these matters in mind, the Victorian subcommittee of the working party undertook a peer review pilot study [I21 in 1992, and invited interested members of the Victorian Section of Psychotherapy to form self-selected groups which would meet on three or four occasions during 1992 to examine and review customary clinical practice. The majority of the 63 participants in this pilot study found that participation in group peer review produced a positive effect on clinical standards and offered a range of benefits broadly contributing to their sense of professionalism and positive professional identity [ 121. Positive responses to the pilot study encouraged the establishment of a peer review program for the Victorian Section of Psychotherapy, expanded to include members of the Child and Adolescent Faculty (Victoria) in 1993 and the Section of Psychotherapy in New South Wales in 1994. Minimal guidelines were provided for participation in the program: self-selection into groups; sufficient frequency of meetings for each member to present their work at least once each year; and groups to pay careful attention to confidentiality and ethical issues. Group meetings were intended to provide a forum for members to present their usual clinical work, or an interesting case, with the primary focus on assessing acceptable standards of clinical care. The review groups were invited to try out both implicit and explicit criteria for assessment. Implicit criteria are based on clinical judgement and experience. Explicit criteria measure the process of care around clearly defined criteria such as the Guidelines for Outpatient Psychiatric Practice prepared by the RANZCP Quality Assurance Committee in 1993. As no additional structure was imposed on the groups, members were free to decide on the level of formality of the meetings, the nature of the presentations (i.e. whether via case presentation. open discussions of clinical issues, or other), the criteria for evaluation, frequency of meetings, and the size of the group. The attendant rationale was that members would discover through experience what did and didn’t ‘work’ as professionally relevant in peer review groups, and a body of knowledge would develop which could be examined at a later date.

J. BEATSON. N. RUSHFORD. G. HALASZ. J. LANCASTER, S. PRAGER

This paper presents the findings from a questionnaire-based survey of members of the Psychotherapy Sections of Victoria and New South Wales and the Faculty of Child and Adolescent Psychiatry in Victoria. The survey was undertaken when the peer review groups had been established for between 1 and 3 years. The aims of the research were, first, to elucidate the process of group peer review in both its positive and negative aspects, second, to determine its perceived place in accountability procedures, and third. to provide information on improvement of accountability through group peer review.

Method All 388 members of the Child and Adolescent Faculty in Victoria and Sections of Psychotherapy in Victoria and New South Wales were surveyed for information about their perceptions of the value, both personally and professionally, of peer review groups. The survey consisted of a questionnaire and two covering letters, one from the chairman and secretary of the Section of Psychotherapy and the other from the coordinator of the Peer Review Group Survey Research Committee, explaining the reasons for the survey. A second mail-out took place 10 weeks after the first. A freepost addressed envelope was included in the survey package. The questionnaire was designed to elicit three types of response. Category A provided descriptive information (20 items) about the groups in which respondents may have participated and their demographics. In Category B, the respondent could indicate the degree to which he or she agreed or disagreed with statements about perceptions and/or experiences of peer review groups (37 items concerning whether they are, for example, an effective response to accountability requirements, a source of support from colleagues. a threat to confidentiality, an educational benefit, or too time consuming.) In Category C, respondents were free to describe their own perceptions andlor experiences of peer review groups (14 items. with provision for up to 50 separate comments), and included questions about reasons for participating or not participating, and beneficial and detrimental effects seen or envisaged from the peer review group process. Confidentiality of response was guaranteed, while still ensuring that a second approach to members who

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had not responded to the first mail-out could be made. The first mail-out was ordered so that consecutive IDS on the questionnaires were mailed to consecutive addresses on a mailing list provided by the College secretariat. An administrative officer collated the ID on a returned questionnaire with the address label and removed the latter from a second list. The officer then attached the remaining labels to the second mail-out envelopes. The list was then discarded. The research officer entering the data had access to the ID only. None of the investigators was in a position to match ID with an individual. The analysis of data was guided by the desire to describe responses to the questionnaire. However, whenever comparisons were made, for example, between participants and non-participants in peer review groups, multivariate analyses were used when distributions of variables met the appropriate criteria [ 131, post hoc comparisons determining where significance, if any, resided: otherwise non-parametric tests were used. Bonferroni corrections [ 141 for the numbers of tests of significance were not applied strictly because of the exploratory nature of the study. In the Results section below, responses to open-ended questions with frequencies 3 ) Frequency To maintain and improve skills For peer and professional supportlcontact To share ideas and methods To receive feedback and constructive criticism To receive help with difficult cases To promote peer review processes Required by hospital or work Necessary part of practice

64 54 48 31 26 24 11 4

Table 4. Reasons f o r non-participation in a peer review group (responsefrequency > 3) Frequency Sufficient professional stimulation/ process elsewhere Time commitments Missed the invitation Difficulty forming a group No groups near me or not suitable Not doing appropriate work

26 22 8

a 8 6

Theoretical orientation was approximately evenly balanced between those with a specific orientation and those without. An agenda for each meeting was used more often than not but, in general, very few participants received written feedback. More than half of the respondents reported that ethical issues were prominent.

Reasons for participation in peer review groups When invited to describe their reasons for participating in peer review groups (Category C items) 119 responded, of whom 60 gave three separate reasons and 46 gave two. The most frequently described reason (54%) was to maintain and improve skills (Table 3). Interpersonal factors included support from and contact with peers, sharing ideas and methods with them, and receiving feedback and help with difficulties. Political issues included recertification, prevention of more serious bureaucratic intervention, and requirement for attendance by employers. Interest in and support of the peer group

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process itself was expressed by 29 respondents. Two mentioned ethical issues as a reason for attending.

Reasons for non-participation in peer review groups Sixty-six respondents gave at least one reason for not participating, 16 giving two and six giving three. Forty-seven percent described potential or past difficulties with establishing or being involved with a group (Table 4). The two major single reasons for non-participation involved already receiving sufficient professional stimulation or participating in a similar process elsewhere (39%). and time constraints limiting availability (33%). Sixty of the respondents stated that they would consider attending in the future, while three stated that they would not. The most frequently mentioned consideration that would influence future attendance was availability of time. The next most frequent response reflected a desire to be part of a group with similar interests (18%).

Table 5. Best and worst features qf peer review groups reported by participants (responsefrequency >3) Frequency Best features Learning, receiving new ideas Peedprofessional support and contact Discussion and help with difficulties and dilemmas Knowing that others have experience with difficult cases Trusting group members Decreased professional isolation Confirming my method with that of other psychiatrists Increased confidence in quality of my work Worst features Too much time required Problems with, or irregular attendance/ involvement by members Anxieties about presentations and orientation Insufficient meeting time, lack of time to discuss issues Group too heterogeneous Occasional frustration and impatience Tensions in early meetings before trust established

54 35

19 12 12 10 4 4 30

12 7 6 4 4 4

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Best and worst features of peer review groups Participants were invited to comment upon the best and worst features of the group peer review process (Table 5). Benefits included appreciation of exposure to new ideas and the learning that took place in groups, the increase in confidence in their own work and a growth in understanding that others also have difficult cases. There was a strong sense of both support and reduction in professional isolation. The worst features included lack of time for preparation and attendance, and negative experiences related to group processes. All respondents were asked specifically for possible detrimental effects envisaged from the peer review group process. Fears that the group process itself, whether due to dysfunctional group members, poor judgement of group members, or personal anxieties, would contribute to erosion of therapeutic standards appeared to have caused the greatest concerns, being mentioned on 102 occasions. Twentyfour respondents cited time and cost. Seven

mentioned that it might give bureaucratic processes the opportunity to interfere in peer review. Nine mentioned a concern that patients could be affected by breach of confidentiality, or by the patient finding out about the peer group process, or by the group blaming the patient.

Case management in peer review groups Turning to consideration of the usefulness and practicality of suggestions on case management given by group members, it was apparent that the majority of the 98 respondents thought highly of the process (Table 6). Eighty-six per cent of the respondents saw the suggestions as considerably or very competent, while 70% agreed that the suggestions were considerably or very able to be implemented.

Anxieties and peer review groups It was relatively common for the 80 participants who responded to the Category B questions on

Table 6. Qualio of case nzanagement siiggestions (percentage of respondents,

Suggestions able to be implemented? Suggestions reasonable? Suggestions competent? Suggestions relevant to your therapeutic perspective? Suggestions give constructive insights into decision-making processes of others?

11

= 98)

Not at all

Somewhat

Moderately Considerably

Strongly

1 2 2

6 3 5

23 11 7

54 58 55

17 26 31

4

3

16

47

30

1

7

11

49

32

Table 7. Anxieties of peer review group participants (percentage of respondents)

I Before participating in peer review group (n = 98) First presentation of your work to the group (n = 98) Later presentation of your work to the group (n = 95) When commenting on others’ case presentations (n = 100)

Not at all

Somewhat

Moderately Considerably

Strongly

12

28

30

19

11

10

27

26

26

11

32

37

22

8

1

26

41

26

7

-

J. BEATSON. N. RUSHFORD, G. HALASZ. J. LANCASTER, S. PRAGER

anxiety to feel some anxiety before commencing participation in a group and on first presentation of a case; on later presentations anxiety diminished (Table 7). Commenting on others’ case presentations also evoked some anxiety. When asked to list other sources of anxiety associated with attending peer review groups (Category C items), 54 participants cited the major sources being fear of public presentations (n = 14), fear of the unknown (n = 91, having a therapeutic orientation different to other members’ (n = 4), fear of criticism or negative evaluation (n = 3), difficulties with individuals in the group (n = 3) and trying to give critical feedback to a colleague (n = 2 ) . Six remarked that their anxiety diminished when trust was established within the group and four commented that there was no anxiety because group members were compatible.

Satisfaction of aims and expectations in joining a peer review group Eighty-one per cent of participant respondents rated their aims in participating in peer review groups as being well or very well met; only one participant reported that aims were not met. Responses to Category B questions concerning their expectations indicated that the groups most successfully ameliorated professional isolation and were a source of support, educational benefits and accountability; they were less successful at providing a source of professional identity (Table 8). Groups with 5-6 members tended to provide more support and were perceived as providing greater accountability than smaller or larger groups. Groups who met more than 20 timedyear tended to be perceived as providing the greatest support, the most educational gains and benefits to psychiatric practice.

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Those groups meeting four or less timedyear were ranked throughout as least satisfying the respondents’ expectations. Groups with a structured format based on case presentations tended to be perceived as offering greater support and a more visible source of accountability than groups with an open format.

Comparison of participant and non-participant attitudes to peer review groups Non-participants were compared with participants on their attitudes rated by Category B questions about peer review groups. Both groups reported equally that participation in them would be an effective response to accountability (80%),would have an ameliorating effect on professional isolation (96%) and would act as a source of professional identity (62%). Neither group saw the peer review process as a source of being judged as inadequate (1 6%). Compared with participants, non-participants tended to underestimate advantages and overestimate disadvantages attendant on participation in peer review groups. Educational benefits were perceived by participants as greater than by non-participants (93% and 84%, respectively, agreeing to some degree; p < 0.028). Participants and non-participants differed significantly in strongly agreeing that the groups would be a source of support from colleagues (52% and 20%, respectively, p < 0.001); were likely to have a beneficial effect on their own practice of psychiatry (71% and 41%, respectively, p < 0.004); or were likely to have a generalised beneficial effect (46% and 17%. respectively, p < 0.006). Non-participants’ greater negativity towards groups, compared with participants, was reflected in stronger disagreement with the Category B items, contending

Table 8. How well peer review groups met participants’ expectations (percentage of respondents, n = 102) Not at all Beneficial to your psychiatric practice Ameliorating effect on professional isolation A source of professional identity A source of support from your colleagues An educational benefit A process of accountability

3 4 12 7 2 8

Somewhat 8 10 18 6 9 13

Moderately

Considerably

Strongly

15 18 31 14 18 18

55 42 30 43 51 36

19 26 9 30 19 25

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that preparation for and participation in a group would be too time consuming (26% and 89%, respectively, p < 0.0001) or too costly ( 12% and 48%, respectively, p < 0.0001) or that group attendance could have a generalised detrimental effect on their psychiatric practice (42% and 6496, respectively, p < 0.024). Differences between participants and non-participants did not meet significance for the perception that groups could be a threat to confidentiality (1 1% and 23%, respectively, p < 0.052), potentially beneficial to the practice of psychiatry (45% and 34% agreeing strongly; p < 0.054) or a source of criticism from colleagues (64% and 4976, respectively; p > 0.05).

Patient confidentiality Fifty-eight per cent of the 180 respondents disagreed with the statement that the group process could be a threat to patient confidentiality, while 14% concurred. Seventy-three per cent considered that informed consent from the patient was unnecessary for presentation of case material, 15% were of the opposite opinion and 12% thought it should be obtained as a matter of course during assessment. The majority of responses reflected a sensitivity to the need for preservation of confidentiality by the group.

The peer review group and re-certification Respondents were asked by what means, if participation in a peer review group was to be used as part of re-certification procedures, assessment should be made. Participants and non-participants favoured assessment by attendance (92% and 8 1 %, respectively) or by internal assessment (81% and 65%, respectively; p < 0.05) and expressed distaste for external assessment (both 77%). Other responses focussed as much upon concerns as upon constructive suggestions for assessment, including not wanting external values placed on groups. Four respondents suggested self-assessment.

Discussion It has been reported in overseas studies that participants in the peer review process were more positive in their attitudes towards peer review than non-participants [6] and that anxieties about the procedure diminished with experience [ 151. The findings from

the present survey support these observations, and offer strong support for the benefits to be gained from profession-driven peer review. These include the maintenance and improvement of clinical skills and standards, constructive criticism, help with difficult cases, educational gains and professional support together with reduction in professional isolation. Participants in the program indicated that personal and professional benefits outweighed disadvantages, and the growth in attendance over the 3 years surveyed confirms that Fellows of the RANZCP have acted on these perceived advantages. Reasons given by respondents for non-participation were clear and related usually to lack of time, or perceived sufficiency of professional monitoring procedures elsewhere. A relative preponderance of the recently qualified among non-participant respondents could help to explain this, given the extent of exposure to supervision during the training and qualification process which may extend into the postgraduation period. In addition, the recently qualified are unlikely to have experienced that sense of professional isolation which commonly arises over time in private practice and leads to a hunger for greater peer contact. Non-respondents to the survey were significantly older than respondents. We have no data for interpreting this lack of response from older Fellows. The lack of information about non-respondents is the major limitation of the study. The majority of respondents to the survey regarded group peer review as an appropriate response to professional accountability requirements. This finding strongly supports the inclusion of group peer review as one of the quality assurance activities forming part of the RANZCP Maintenance of Professional Standards (MOPS) program. The overwhelming preference of respondents for measurement of accountability for peer review groups according to attendance, or according to attendance in combination with assessment internal to the group, warrants comment. It underlines concerns raised in response to open-ended questions about potential damage to a valuable professional activity if external assessment were to be introduced. It reflects concerns raised in overseas studies about the potential for external elements to damage what is valuable in the review process [ 16,171. Newman and Luft [ 171 speak of the power and delicacy of the peer review process. particularly in identifying substandard clinical practices,

J. BEATSON, N. RUSHFORD. G. HALASZ, J. LANCASTER, S. PRAGER

and argue persuasively that ‘merging the functions of reviewing specific cases and reporting on the competency of therapists may destroy the review process’. They note that use of peer review to report on the competency of the presenter is likely to increase defensiveness and lead to presentations aimed at getting a ‘good grade’ but failing to expose clinical realities, with resultant destruction of the educational value of peer review. They also note that their views about the importance of retaining the educational focus of peer review are welcomed by clinicians, and that the program enjoyed fiscal success. Karasu [4] alluded to the need for ethical conduct of the review process itself. Ethical issues were explored in this study to a limited extent, with examination of the need for informed consent from patients, and issues regarding confidentiality. Because of the ethical issues not explored, (e.g. boundary infringements, problems posed by the impaired psychiatrist, by dysfunctional review groups, and by conflicting roles for peer reviewers) further work is required in this area. There has been considerable discussion about the contribution of implicit and explicit criteria to assessment of professional performance. Our findings demonstrate an overwhelming preference among respondents to this survey for the use of implicit criteria for assessment, or implicit criteria with a minor admixture of explicit criteria. It is likely that these results reflect the absence of suitable explicit criteria for evaluation of psychotherapeutic treatments in psychiatry. Clinicians have a responsibility to define and refine standards against which clinical care can be measured. However, even when suitable explicit criteria have been developed, psychiatrists grappling with the unique aspects of each treatment situation, particularly the complex relational aspects of psychotherapeutic treatments. will continue to use professional judgement and experience (implicit criteria) for evaluation, since these alone address the subtle judgements often required. Turning to the important findings related to the characteristics of groups correlating with member satisfaction and perceived contribution to accountability, so critical for the ongoing development of group peer review, it would appear that groups smaller than five do not offer the breadth of experience available in larger groups, while groups larger than six may offer insufficient exposure of individual members for either to provide a sense of genuine pro-

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fessional accountability. Groups meeting four or less times per year would seem to provide insufficient time for the development of group process, with resultant willingness to expose clinical difficulties, out of which the benefits of peer review can arise. The problems posed by dysfunctional groups and group members, unsupportive groups, and clinicians who become anxious and defensive, are prominent in the list of detrimental effects of peer review. It is apparent that attention to these matters must be paid in the further development of peer group review. Strategies for addressing concerns about amateurish case presentations, for dealing with difficult group members, for providing feedback and constructive criticism to presenters within an atmosphere of support, and for addressing the issues involved in dysfunctional groups need to be developed. This could be done via workshops, which could also clarify the deeper layers of ethical concerns. To improve participation rates, the following suggestions are offered: (i) dissemination of information derived from surveys of participants to all members of the College; (ii) practical assistance in the formation of a group to ensure that eligible members are aware of any groups being established near them; (iii) sharing information about what appears to be the optimum structure, size and frequency of meetings for the most satisfying groups; and (iv)workshops aiding the establishment of well-functioning peer review groups. Workshops could also be used to develop strategies for dealing with problems arising in the course of peer review.

Conclusion In conclusion, it is clear that group peer review significantly contributes to professional accountability for participants, when the review is conducted within a well-functioning group after establishment of sufficient group trust through the repeated exposure of complex and difficult clinical problems. Participation in group peer review can be expected to have a ripple effect on the broader body of psychiatrists, raising general awareness of appropriate professional standards and clarifying the boundaries of acceptable practice. The challenge ahead for our College is to ensure the continuing ethical practice of peer review itself, to avoid unrealistic expectations, and to continue the promotion of a group peer review system which

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invites 'warts and all' presentations of clinical work, and thus contributes to professional growth and improvement of standards in a way no 'defensive' presentation can.

4.

5. 6.

Acknowledgements 7.

We gratefully acknowledge the funding providing by the RANZCP Section of Psychotherapy for this survey, and the Federal Committee of the Section for their support and encouragement. We would also like to thank members of the New South Wales and Victorian Sections of Psychotherapy and the Faculty of Child and Adolescent Psychiatry in Victoria for their participation in the study. Encouragement and opportunities for discussion offered by members of RANZCP Quality Assurance Committee are acknowledged with appreciation.

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