PEER

 ASSESSMENT  EXAMPLE  
NOTE:    The  example  that  we  have  chosen  is  an  individual  provider  characteristic  which  may  have  
contributed  to  Grace's  death.    This  example  is  NOT  specific  to  teamwork  or  communication  defects.    
To  be  clear,  students  are  to  develop  strategies  that  address  the  teamwork  and  communication  errors  
that  occurred  in  Grace's  Story  (highlighted  in  yellow  in  the  Peer  Assessment  description).    We  have  
also  cited  research  in  this  example.    While  citing  research  is  a  best  practice,  we  are  not  expecting  it  
and  it  will  not  be  part  of  the  grading  rubric.  

Question  1  of  6:  Propose  the  first  of  two  interventions  to  mitigate  the  contributing  factor  based  on  
strategies  to  improve  teamwork  and  communication  in  healthcare  that  were  discussed  in  the  first  peer  
assessment.    List  what  you  will  do,  who  will  lead  the  intervention,  and  when  you  will  follow-­‐up  on  the  
intervention’s  progress.    Please  limit  your  response  to  300  words.  

Defect:    Sleep  deprived  surgeon  

Justification:  Over  the  past  several  years,  studies  have  found  that  sleep  deprivation  effects  
clinical  performance  and  may  be  a  contributing  factor  in  healthcare  errors  (Nurok,  M.,  2010).  
Despite  changes  in  the  duty  hours  of  physicians  in  training,  there  has  only  been  little  change  in  
physician  working  hours.      

Intervention  #1    

Policy  Development  (weak  patient  safety  intervention):  The  team  recommends  that  a  new  
policy  be  developed  that  minimizes  consecutive  operating  hours  of  the  primary  surgeon.    This  
can  be  accomplished  by  limiting  and  prioritizing  the  rescheduling  of  the  on-­‐call  surgeon's  
elective  surgeries  the  following  day  (Nurok,  M.  et  al,  2010).      

Goal:  To  limit  the  number  of  continuous  surgical  hours  for  one  physician  unless  the  patient  
condition  requires  it.  

Leader  of  Intervention:  The  Chairwoman  of  the  Department  of  Surgery  will  lead  the  team  that  
will  draft  the  new  policy.      

Timing  of  Follow-­‐Up  on  Intervention:  Once  the  policy  has  made  it  through  Hope  Hospital's  
policy  approval  process,  the  following  3-­‐  month  surgical  on-­‐call  schedule  will  provide  for  the  
potential  re-­‐scheduling  needs.    

Question  2  of  6:  For  your  first  intervention,  identify  at  least  one  strategy  for  leading  change,  as  
identified  in  week  4,  that  you  would  suggest  to  the  person  leading  this  change  to  ensure  their  
intervention  is  successful.    Please  limit  your  response  to  200  words.  

Leading  Change  Strategy:    An  interdisciplinary  team  that  includes  key  stakeholders  such  as  the  
OR  personnel  responsible  for  scheduling  operations  will  be  led  by  the  Chairwoman  of  the  
Department  of  Surgery.    The  goal  of  the  team  is  to  ensure  the  new  policy  minimizes  the  chance  
 that  surgeons  are  involved  in  operative  care  beyond  a  24  hour  period  while  maintaining  
operating  room  operations.    

Question  3  of  6:  For  your  first  intervention,  describe  how  you  will  know  you  have  reduced  the  risk  of  
harm  to  patients?    Identify  at  least  one  process  of  care  or  outcome  measure  for  your  first  intervention  
to  determine  whether  the  intervention  has  been  implemented  effectively.  Please  limit  your  response  to  
200  words.  

Process  Measure:    The  Chairwoman  of  the  Department  of  Surgery  will  select  a  small  group  
(pilot)  of  surgeons  across  varying  disciplines,  for  example  orthopedics,  to  measure  the  impact  of  
the  new  policy.    Using  an  established  sleep  deprivation  measurement  tool  such  as  the  Stanford  
Sleepiness  Scale,  on-­‐call  surgeons  will  be  evaluated  prior  to  implementation  of  the  24  hour  
restriction  and  after  implementation  of  the  24  hour  restriction.        

Question  4  of  6:  Propose  the  second  of  two  interventions  to  mitigate  the  contributing  factor  based  on  
strategies  to  improve  teamwork  and  communication  in  healthcare  that  were  discussed  in  the  first  peer  
assessment.    List  what  you  will  do,  who  will  lead  the  intervention,  and  when  you  will  follow-­‐up  on  the  
intervention’s  progress.    Please  limit  your  response  to  300  words.  

Defect:    Sleep  deprived  surgeon  (You  may  use  the  same  error  or  defect  or  choose  a  second  
one.)  

Justification:  Over  the  past  several  years,  studies  have  found  that  sleep  deprivation  effects  
clinical  performance  and  may  be  a  contributing  factor  in  patient  errors  (Nurok,  M.,  2010).    
Although  there  is  limited  evidence  in  support  of  surgeon's  self-­‐assessment  of  their  level  of  
fatigue,  the  American  College  of  Surgeons  suggests  that  surgeons  need  to  be  educated  about  
the  detrimental  effects  of  sleep  deprivation  (www.facs.org).  

Intervention  #2  

Education  and  Training  (weak  patient  safety  barrier):    A  blended  learning  educational  module  
will  be  developed  that  provides  didactic  evidence,  an  online  module,  and  a  simulated  surgical  
task  in  support  of  understanding  the  impact  of  sleep  deprivation  on  surgical  performance.  

Goal:  Develop  an  educational  module  that  provides  a  deeper  understanding  of  the  effect  of  
sleep  deprivation  on  surgical  performance.    This  training  will  be  provided  to  all  appropriate  
operating  room  personnel.  

Leader  of  Intervention:    The  Director  of  Professional  Development  will  collaborate  with  the  
physician  expert  in  Sleep  Medicine  who  has  agreed  to  participate  as  Physician  Champion  for  the  
project.  

Timing  of  Follow-­‐Up  on  Intervention:    The  completed  educational  module  including  the  
scheduling  of  didactic  and  simulated  sessions  will  occur  within  12  weeks.    
Question  5  of  6:  For  your  second  intervention,  identify  at  least  one  strategy  for  leading  change,  as  
identified  in  week  4,  that  you  would  suggest  to  the  person  leading  this  change  to  ensure  their  
intervention  is  successful.    Please  limit  your  response  to  200  words.  

Leading  Change  Strategy:    Hope  Hospital  professional  development  staff  will  develop  the  
educational  package.    A  physician  expert  in  Sleep  Medicine  has  agreed  to  participate  as  
Physician  Champion  for  the  project  and  will  kick-­‐off  the  training.    That  presentation  will  be  video  
recorded  and  integrated  into  an  online  module  that  can  be  reviewed  at  any  time.    

Question  6  of  6:  For  your  second  intervention,  describe  how  you  will  know  you  have  reduced  the  risk  of  
harm  to  patients?    Identify  at  least  one  process  of  care  or  outcome  measure  for  your  second  proposed  
intervention  to  determine  whether  the  intervention  has  been  implemented  effectively.  Please  limit  your  
response  to  200  words.  

Process  Measure:    A  survey  will  be  developed  to  assess  operating  room  personnel  knowledge  
and  attitudes  towards  sleep  deprivation  and  surgical  performance.    The  survey  will  be  
administered  prior  to  the  training  and  again  at  two  weeks  after  the  training.    The  survey  will  be  
repeated  at  three  months  after  the  intervention  to  assess  for  knowledge  decay.