BMJ Qual Saf doi:10.1136/bmjqs-2011-000470
  • Viewpoint

Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry

  1. Daniel W Hudson5
  1. 1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  3. 3Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
  4. 4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  5. 5U.S. Nuclear Regulatory Commission, Office of Nuclear Regulatory Research, Division of Risk Analysis, Rockville, Maryland, USA
  1. Correspondence to Dr Peter Pronovost, Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd floor, Baltimore, MD 21231, USA; ppronovo{at}
  1. Contributors PP contributed to the concept, drafting and critical revision of the manuscript, and provided technical and administrative support, and supervision. DWH contributed to the concept, drafting of the manuscript, and data analysis and interpretation. Both authors approved the final version submitted for publication.

  • Accepted 12 April 2012
  • Published Online First 5 May 2012


Healthcare has made great efforts to reduce preventable patient harm, from externally driven regulations to internally driven professionalism. Regulation has driven the majority of efforts to date, and has a necessary place in establishing accountability and minimum standards. Yet they need to be coupled with internally driven efforts. Among professional groups, internally-driven efforts that function as communities of learning and change social norms are highly effective tools to improve performance, yet these approaches are underdeveloped in healthcare. Healthcare can learn much from the nuclear power industry. The nuclear power industry formed the Institute of Nuclear Power Operators following the Three Mile Island accident to improve safety. That organization established a peer-to-peer assessment program to cross-share best practices, safety hazards, problems and actions that improved safety and operational performance. This commentary explores how a similar program could be expanded into healthcare. Healthcare needs a structured, clinician-led, industry-wide process to openly review, identify and mitigate hazards, and share best practices that ultimately improve patient safety. A healthcare version of the nuclear power program could supplement regulatory and other strategies currently used to improve quality and patient safety.


  • Competing interests Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the National Institutes of Health, RAND, and The Commonwealth Fund for research related to measuring and improving patient safety; honoraria from various hospitals and healthcare systems and the Leigh Bureau to speak on quality and safety; consultancy with the Association for Professionals in Infection Control and Epidemiology, Inc.; and book royalties for authoring Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Mr Hudson adds the following disclaimer: This journal article was prepared, in part, by an employee of the United States Nuclear Regulatory Commission on his or her own time apart from his or her regular duties. The Nuclear Regulatory Commission has neither approved nor disapproved its technical content.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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