"We simply want to improve intensive care medicine"

Interview with Prof. Elke Muhl, President of the German Interdisciplinary Association of Intensive Care and Emergency Medicine (German: Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V.), DIVI

Something we learned from nuclear power plants: since 2010, peer reviews are being conducted in German intensive care units. These voluntary peer reviews are primarily intended to improve the quality of intensive care medicine.


Photo: Prof. Elke Muhl

Prof. Elke Muhl; © DIVI

Ultimately, it is not just the patient, but also the hospital that benefits from this.

Professor Elke Muhl is the spokesperson for the National Governance Working Group for this process. At MEDICA.de, the DIVI President explains the execution and objectives of these peer reviews.

Professor Muhl, peer reviews have prevented several accidents caused by reactor trips at nuclear power plants over the past few decades and serve as a model. Why does this process also make sense in intensive care units?

Elke Muhl: Approximately 2.1 million patients per year are treated at intensive care units in Germany – suffering from acute life-threatening diseases and a significant percentage of organ failure. It is vital for these patients to receive the best possible treatment in these facilities. If that is not the case, there are consequences affecting subsequent conditions and secondary complications and perhaps even mortality rates. In this respect, you can definitely compare the risk situation in an intensive care unit to a nuclear power plant. This is why it is so important for us to emphasize quality in this instance.

How does a peer review work and who is in the review team?

: The ward that would like to conduct this type of process first indicates this to its respective medical association, which in turn organizes a peer review team. The team consists of a critical care nurse, a critical care physician and usually a representative of the medical association. The peers undergo training beforehand where they learn what and how they need to inquire and audit for a review.

The ward receives a questionnaire with 52 questions about structure, process and outcome quality and a questionnaire with ten quality indicators. The team at the ward looks at the quality it provides, which is something that is only rarely done in everyday life. The peer review team receives the filled out questionnaires, so it is able to obtain some pre-information. It then visits and surveys the ward on one day. The peers ask questions about the questionnaires, talk to the employees and look at operational procedures and documentation. They check whether staff is really informed about certain proceedings and was not just claiming this in the questionnaire. There is a final review with nurse management at the end of the day. As a follow-up, the peer review group conducts an on-site analysis in which the ward’s strengths, opportunities, weaknesses and risks are being rated and the percentage of quality indicators implemented at the ward assessed. One important thing to note here is that wards never receive 100 percent! Otherwise, we would not have a need for improvement.

Photo: Patient in intensive care unit

The quality of care is vital for the patients in intensive care unit; © Tyler Olson/ panthermedia.net

The ward that requested the peer review subsequently receives this report. It is very important that the report is confidential. Ward management is supposed to communicate it to their team and determine where there is a need for improvement and the steps they want to take.

This is a report that is only used internally.

: That’s correct. However, the peer review groups also visit each other within the nationwide network. This resulted in an unexpected trickle-down effect of the process: intensive care units exchange their knowledge on how such quality factors can be best implemented. After all, copying is permitted in this case and even preferred. How did others do this and why does it work better for them? How can we manage to do the same?

What is the goal of the German Medical Association and the DIVI with these peer reviews?

: We simply want to improve intensive care medicine. The people, who work in intensive care units, want to do a great job in intensive care medicine. We want to support them with this process to achieve high quality.

Why are we doing this? We know that in terms of specific measures in intensive care medicine and other medical areas the evidence doesn’t reach practical experience 100 percent of the time. We simply want to increase this percentage so that the patient also gets the best possible treatment as a result.

How often are peer reviews conducted in Germany?

: More than 100 German intensive care units have already had a peer review. We have trained over 700 peers in this area. The process is already being implemented in other areas such as transfusion medicine. There are also efforts to introduce the process in neonatology as well as children and adolescents medicine. You could conduct these types of peer reviews in all areas with defined quality indicators. This is why the German Medical Association would like to expand this field.

Peer reviews are also widely used in the Netherlands, Scandinavia and the U.S. in the health care sector. Several commercial enterprises in the health care field such as private hospital companies also use similar processes.

Ultimately, it is primarily patients, who benefit from these types of quality inspections. What advantages do peer reviews have for hospitals?

: Since staff is involved in this process from the start, their motivation to improve the quality of their work is high. The success of the ward then becomes the success of the entire hospital. The bottom line is that the hospital benefits from shorter hospital stays, lower rates of ventilator-associated or hospital-acquired pneumonias and a lower number of nosocomial infections. This process is also very cost-efficient. The hospital can also promote transparency and doesn’t need to be afraid of letting others review its intensive care unit. However, the point is not to highlight the best out of 30 intensive care units. This is not a benchmarking process.
Photo: Michalina Chrzanowska; Copyright: B. Frommann

© B. Frommann

The interview was conducted by Michalina Chrzanowska and translated by Elena O'Meara.