Turning Case Review Inside Out

Stanford Hospital’s Marc and Laura Andreessen Emergency Department (ED) uses a unique case review process that has led to elevated patient care and improved physician satisfaction and trust.

Several years ago, Stanford moved away from the conventional case review method. Typically, case review is centered around peer review of a provider’s performance, often fostering a culture of blame and defense. Stanford takes a holistic view, employing a human factor engineering approach incorporating the “five whys” investigative tool. This methodology involves a thorough investigation, engaging everyone involved in the case in a root cause analysis to identify human/team, system/process, or environmental factors that contributed to unexpected outcomes.

The case review culture evolved from punitive to collaborative, with physicians actively participating in the process. The shift in mindset has led to a significant reduction in cases flagged per month, from an average of 20 to just three or four. “Half of these cases now are self-referrals,” notes Laleh Gharahbaghian, MD, emergency medicine professor and one of the leads of the project. “Because our physicians trust this process. They don’t feel it is punitive. Instead, they want to improve the system and trust they will be given the benefit of the doubt and viewed as part of the solution.”

The results have been transformative. Over 90% of root causes were identified as process or system issues, shifting the focus from blaming physicians to improving care by addressing underlying problems and then making meaningful changes to processes, systems and protocols, technology, and more. This ED’s unique case review process is frequently cited as a Stanford Medicine best practice and has been adopted hospital-wide for all departments.