Iterative Redesign of Peer Review Through a Human Factors Lens
Tracks
Room 1
| Wednesday, December 2, 2026 |
| 2:10 PM - 2:30 PM |
| Plenary Room - Grand Central |
Overview
Dr. Lisa Shieh
Speaker
Dr. Lisa Shieh
Stanford University School Of Medicine
Iterative Redesign of Peer Review Through a Human Factors Lens
Abstract
Aim: Peer review is required for hospital accreditation, yet traditional processes often poorly fit clinician and organizational needs. Clinicians experience cognitive and emotional burden, while reviews often emphasize individual performance over contributing system factors. We applied human factors principles to redesign our departmental peer review process to improve psychological safety, identify system contributors, and support organizational learning.
Methods: We analyzed four redesign phases of the Stanford Department of Medicine peer review committee (2013–present) and nine years of taxonomy data (2017–2025). Each phase was evaluated against three design principles: standardized review, clinician psychological safety, and systems-based analysis. Cases were coded using Human Factors and System/Process taxonomies based on the Safety Event Classification (SEC) and Serious Safety Event Rate (SSER) Patient Safety Measurement System for Healthcare (2011). Referred quality improvement action items (n=281) were tracked longitudinally.
Results: Phase 1.0 (2013), in which clinicians presented cases directly to the committee, was cognitively taxing and adversarial. Phase 2.0 introduced an interview-by-proxy model with “Just Culture” categorization, reducing clinician anxiety. Phase 3.0 (2021) embedded a dedicated quality improvement representative, routing system findings to hospital stakeholders and formalizing Human Factors and System/Process taxonomies. Leading human factors contributors were Communication and Information Processing (54; 23%), Situational Awareness (44; 19%), and Normalized Practice (33; 14%). Leading system contributors were Structure (47; 45%) and Process (25; 24%). Phase 4.0 includes planned balanced feedback letters and communication of implemented system changes to providers.
Discussion/Implications: Peer review is itself a human task requiring intentional design. Applying human factors principles transformed our process from an individual-focused evaluative exercise into one better aligned with clinician needs, system learning, and institutional improvement.
Methods: We analyzed four redesign phases of the Stanford Department of Medicine peer review committee (2013–present) and nine years of taxonomy data (2017–2025). Each phase was evaluated against three design principles: standardized review, clinician psychological safety, and systems-based analysis. Cases were coded using Human Factors and System/Process taxonomies based on the Safety Event Classification (SEC) and Serious Safety Event Rate (SSER) Patient Safety Measurement System for Healthcare (2011). Referred quality improvement action items (n=281) were tracked longitudinally.
Results: Phase 1.0 (2013), in which clinicians presented cases directly to the committee, was cognitively taxing and adversarial. Phase 2.0 introduced an interview-by-proxy model with “Just Culture” categorization, reducing clinician anxiety. Phase 3.0 (2021) embedded a dedicated quality improvement representative, routing system findings to hospital stakeholders and formalizing Human Factors and System/Process taxonomies. Leading human factors contributors were Communication and Information Processing (54; 23%), Situational Awareness (44; 19%), and Normalized Practice (33; 14%). Leading system contributors were Structure (47; 45%) and Process (25; 24%). Phase 4.0 includes planned balanced feedback letters and communication of implemented system changes to providers.
Discussion/Implications: Peer review is itself a human task requiring intentional design. Applying human factors principles transformed our process from an individual-focused evaluative exercise into one better aligned with clinician needs, system learning, and institutional improvement.
Biography
Lisa Shieh, MD, PhD, is a clinical professor of medicine and hospitalist in the Department of Medicine. She earned a MD from Harvard Medical School and PhD in medical engineering from the Massachusetts Institute of Technology. She moved to California, where she did her residency in internal medicine at Stanford Hospital and later joined the faculty
Dr. Shieh is currently the medical director for quality at Stanford Healthcare (SHC), the inpatient physician improvement leader in the Department of Medicine and the medical co-director for the unit base medical director program.
At SHC, Dr. Shieh was the inaugural winner of the SHC 2018 Excellence in Quality and Safety Award. Her interests also include mentoring and teaching learners about QI and patient safety. She is currently the medical director of Quality Improvement programs for Graduate Medical Education
Dr. Shieh also has an interest in patient safety and high value care. She is the chair of the department of medicine’s peer review committee and has led many projects to decrease length of stay, readmissions, and appropriate utilization of resources. Her work also involves integrating AI into clinical pathways to improve clinical rescue and decrease clinical deterioration.
