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Improving Health Care Quality and Patient Safety Through Peer-to-Peer Assessment: Demonstration Project in Two Academic Medical Centers

behavioral health examination


Following the Three Mile Island and Chernobyl accidents, nuclear power companies improved safety measurably by embracing peer-to-peer assessment, which enables the sharing of best practices across the industry. Using the nuclear program as a model, Commonwealth Fund–supported researchers tested a peer-to-peer assessment between Massachusetts General Hospital in Boston and Johns Hopkins Hospital in Baltimore. A team from each hospital visited the other to evaluate the organization’s quality and safety program and assess how well the institution reduced patient harm. The researchers focused specifically on hand washing and central line–associated bloodstream infections (CLABSI).

What the Study Found

Hospital leaders and staff described the assessment as helpful and fair, offering “fresh ideas for solutions” focused on “learning and not investigation.” While many hospitals have internal review mechanisms to investigate patient safety issues, the external approach aims to provide more objective, nonpunitive input.

Common safety challenges were identified at both hospitals in the study, including:

  • getting staff aligned around safety goals
  • sharing meaningful and timely performance data
  • consistently employing best practices.

Within three months of the site visits, both hospitals had implemented changes to address opportunities identified during the assessments. Among them were posting CLABSI data to engage staff, prioritizing quality and safety updates at senior management and medical officer meetings, and implementing central line audit procedures in intensive care units.


Peer-to-peer assessment is a promising approach to reducing patient harm. Scaling this tool across the health care industry will require the time and resources necessary to perform assessments and site visits.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


E. Mort, J. Bruckel, K. Donelan et al., “Improving Health Care Quality and Patient Safety Through Peer-to-Peer Assessment: Demonstration Project in Two Academic Medical Centers,” American Journal of Medical Quality, published online Oct. 23, 2016.