|Abstract: ||Background: Available evidence suggests that membership of external peer review programmes can help improve the quality of health care services. However, little is known about how this is achieved and what key mechanisms and contexts are essential for quality improvement.
Methods: I undertook a mixed methods realist evaluation of peer review networks and accreditation schemes in inpatient and community-based mental health services provided by the Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI). Informed by a systematic literature review, I collected qualitative data from coordinators (four focus groups) and participants (122 interviews) of external peer review programmes. I also collected quantitative data from 178 community-based memory clinics and 33 inpatient mental health services to examine whether organisational readiness for change influenced service quality.
Results: Causal mechanisms including sharing and learning, consultation, and engagement of senior management and junior staff were essential for sustained quality improvement. The most salient contexts were type of external peer review and length of membership In accreditation schemes, most changes occurred before or during self-review, and following written feedback for peer review networks. A two-level linear model signalled services with higher baseline readiness for change achieved greater quality improvement through membership of a peer review network, however findings were not statistically significant. Qualitative findings echoed the importance of readiness for change constructs.
Conclusions: Differences in when change occurs between peer review networks and accreditation schemes should be considered by organisations that provide external peer review programmes. Sharing and learning was the main essential causal mechanism of external peer review programmes. To maximise the benefit of participation, this mechanism should be further supported and enhanced. A future of increased competition in healthcare could reduce sharing and learning opportunities; indicating a need to further develop the evidence base for external peer review.|