A Comprehensive Departmental Care Review Model: Requirements, Structure, and Flow

David M. Nestler, Torrey A. Laack, Lori Scanlan-Hanson, Casey M. Clements, Annie T. Sadosty, Laura E. Walker

Research output: Contribution to journalArticlepeer-review


Background: The Institute of Medicine, the National Patient Safety Foundation, and The Joint Commission have advocated for increased systematic care review to inform future quality improvement. Developing a system to efficiently gather meaningful feedback, review care, and identify areas for improvement can take years to construct. Yet, these systems are vital to reducing future medical error. Context, History, and Development: In this article, the authors present a refined intradepartmental system of retrospective care review. The team created and iteratively improved this model for more than 10 years. Herein, key aspects and benefits of the system are described. Care Review System: A successful care review system should include a broad catchment for cases to review, direct input from multidisciplinary staff involved in each case, a standardized evaluation and feedback process, a system to translate identified gaps into practice improvement, and development of a psychologically safe space for discussions to occur. Resources required to build this system include a quality specialist, a panel of physician and nurse reviewers, and administrative assistance. Blinding cases and electronic blinded polling technology can enhance participation and reduce bias in case assessment. Conclusion: The authors believe that this process for care review can help hospital systems of varying resource levels produce high-quality case review and thereby activate practice improvement to prevent downstream medical errors.

Original languageEnglish (US)
Pages (from-to)503-509
Number of pages7
JournalJoint Commission Journal on Quality and Patient Safety
Issue number8
StatePublished - Aug 2021

ASJC Scopus subject areas

  • Leadership and Management


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