Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

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In pursuit of high reliability, numerous organizations have promoted Just Culture, but its impact has never been assessed. This report combines data from a longitudinal survey-based study of clinical peer review practices in a cohort of 457 acute care hospitals with 43 measures from the Hospital Compare database and interprets them in relation to the long-term trends of Agency for Healthcare Research and Quality (AHRQ) data on the Hospital Survey of Patient Safety Culture. In all, 211 of 270 respondents (79%) indicated that their hospital has adopted Just Culture. More than half believe that it has had a positive impact. Just Culture implementation and its degree of impact are associated with somewhat better peer review process, but not with objective measures of hospital performance. Non-Punitive Response to Error has consistently been the lowest scoring category (45% positive) in the AHRQ database. Widespread adoption of Just Culture has not reduced reluctance to report or the culture of blame it targets.

Prior research has shown wide variation in clinical peer review program structure, process, governance, and perceived effectiveness. This study sought to validate the utility of a Peer Review Program Self-Evaluation Tool as a potential guide to physician and hospital leaders seeking greater program value. Data from 330 hospitals show that the total score from the self-evaluation tool is strongly associated with perceived quality impact. Organizational culture also plays a significant role. When controlling for these factors, there was no evidence of benefit from a multispecialty review process. Physicians do not generally use reliable methods to measure clinical performance. A high rate of change since 2007 has not produced much improvement. The Peer Review Program Self-Evaluation Tool reliably differentiates hospitals along a continuum of perceived program performance. The full potential of peer review as a process to improve the quality and safety of care has yet to be realized.

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