Quality Assurance Spotlight: Peer Review

by Andrew Capehart, APS TARC Lead

Peer review is defined as “evaluation of scientific, academic, or professional work by others working in the same field.” The phrase is often associated with journal articles or published research studies, but it also refers to a process where professionals evaluate each other’s work product. In social services circles, it often involves a committee or group of individuals who review and discuss each other’s work and its use as a quality assurance mechanism may be undervalued.

Quality assurance in APS can involve examining both policy and practice, although practice may be somewhat more difficult since it is harder to define standards for it. For instance, checking to see if an investigation was initiated within required timeframes may be simpler than evaluating if an investigator took all the actions available to ameliorate maltreatment, such as whether the client referred to the proper services that are available for the geographic area.

The value of peer review is in the use of peers, who have a similar perspective to the caseworker.  For example, the services available in rural areas are often quite different than those in an urban one. Is the person reviewing the case familiar with those available services? When thinking about peer review as a quality assurance mechanism, it’s important that true peers are used, that is, those who really understand the challenges, resources, and dynamics in an area.

Quality assurance is one of the most frequently noted requests for technical assistance from the APS TARC. Measuring quality of casework is important as the population of older adults and adults with disabilities rises and programs struggle for funding. Justification for that funding is important and being able to demonstrate a high quality of work is paramount. Peer review, as one tool in your greater toolbox for quality assurance, may be a good mechanism for determining that your clients receive the best service available.

The APS TARC recently posted a query to our listserv for information on APS programs who are utilizing peer review and we received several responses. I also had the pleasure of meeting with the Central Ohio Area Agency on Aging about their peer review process, which has been in place for some time.

Peer Review Content & Process

A common thread among all the processes observed was the use of a tool to guide the review. The tool, in the form of a checklist, includes compliance with policy requirements such as:

• Was there collaboration with/reporting to law enforcement or other investigative agencies?
• Was information gathered from collateral contacts?
• Was there review of external documentation, such as medical or financial records?
• Was there completion of formal assessments for risk or cognitive capacity?
• Were timeframes for investigation initiation, substantiation/confirmation of allegations, and completion of case notes adhered to?

Each of these checklists contained four options for each area identified: Yes, No, Not Applicable, and Comments. When a peer reviewer looks to see if financial documents were gathered and reviewed, they can check the “Not Applicable” box for cases where financial exploitation was not alleged or discovered. Use of such a checklist ensures consistency and efficiency in the process of review.

Reviewing and evaluating APS casework can be tricky. Not only does APS investigate multiple and sometimes disparate forms of maltreatment, from financial exploitation to sexual abuse, but these forms of maltreatment can occur concurrently. Actions taken for a self-neglect case may be quite different from those taken for a physical abuse one. For this reason, any documents that guide a peer review process may need to incorporate checking for actions depending on the maltreatment. Additionally, simple scoring of areas can be incorporated for items that may apply regardless of the maltreatment, such as completion of investigation timeframes.

When it came to the selection of cases for peer review, APS agencies reported random sampling of both open and closed cases. One state requires that eight cases, one from each member on a team, be selected for review at a time. Half of these cases must be open, and half closed at the time of review, ensuring an even split of active and inactive cases. Another state requires a selection of cases among open & closed, substantiated & unsubstantiated cases, all of which must come from a 12-month period. Another state carries out their peer review process monthly, and another does so on an annual basis.  

There was some variation among who comprised the membership of the review team, though most incorporated both investigators/caseworkers and supervisors. Some even require the participation of each investigator/caseworker for a round of peer review per year. Anonymity was incorporated into the process for at least one program, who de-identified the reviewer whose comments would be reviewed by a colleague.

Benefits of Peer Review

Peer review, in addition to being a process to measure quality, can also serve as an instructive process for investigators/caseworkers. Unless receiving a case that a colleague previously worked on, most investigators/caseworkers likely have little opportunity to read each other’s case documentation. This can be particularly helpful for case notes, where the style, clarity and level of conciseness can vary considerably. The opportunity to see how a colleague documents a case can create an effective teaching moment for a worker.

APS case documentation can be very complex. Clients who experience polyvictimization, with concurrent forms of maltreatment, may have case records with many contacts, home visits, and external documents from a plethora of sources. Careful review of one case may take time and supervisors who must review all cases can find themselves overwhelmed. Peer review, used in conjunction with supervisor review, can help to alleviate some of the burden involved in individual supervisor reviews. Peer review provides an opportunity to look for patterns and for more experienced workers to pass on insights from their experience. 

If you are a state APS program and would like to request technical assistance from the APS TARC, reach out to us anytime.
 
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