Susan Morby, RN, BSN, NE-BC
Loyola Graduate Student
Agenda
• Define peer review
• Retaining professional status
• Importance of peer review
• NMH’s current process
• Pros and cons
• Ethical and legal
considerations
• Next steps
What is Clinical Peer Review?
The evaluation of the delivery of nursing care in an objective and
nonjudgmental manner when analyzing causative factors
involved in medical errors with potential untoward events (Diaz,
2008).
An organizational effort whereby practicing professionals review
the quality and appropriateness of services ordered or
performed by their professional peers (American Nurses
Association (ANA), 1988).
Relates to the identification of appropriate and willing peers for
obtaining feedback on performance on a particular activity
(Gopee, 2001).
A process for evaluating performance and strengthening group
communication, which also helps to maintain the integrity and
self-governance of the nursing unit (Brooks, Olsen, RiegerKligys, and Mooney, 1995).
Defining Attributes of Peer Review
1.
2.
3.
4.
5.
6.
Nursing care must first be delivered
A peer evaluates the care and is someone of equal
standing in terms of education level, professional
experience and/or employment status
Evaluation is measured against professional standards
of practice
Non-biased feedback is given to the nurse that
delivered the care in a way that promotes professional
development through positive communication
Evaluation is objective from the committee
The goal of peer review is to develop individuals and
systems
Morby Concept Analysis, 2009
Nursing as a Profession
Requirements to be a profession:
 Has a unique body of knowledge
 Has controlled entry into the group
 Demonstrates autonomy
 Respect of the community
 Self regulation (Hood & Leddy, 2006)
Professions that Utilize Peer Review
Medicine
Accounting
Engineering
Publishing
Why is Peer Review Important?
 To reinforce the self-regulating nature of the nursing profession
 Has potential to create a culture of safety (Diaz, 2008)
 Can be a mechanism through which the profession acts to
assure quality nursing care (ANA, 1988)
 Can increase teamwork, creativity and a sense of ownership
amongst nurses (Brooks, et al, 1995)
 Meets the ANA’s Peer Review Guidelines
 “Each nurse must participate with other nurses in the
decision-making process for evaluating nursing care.”(ANA,
1988)
 Helps to maintain standards of nursing care
 Provide evidence for change or needs for knowledge in practice
protocols to improve care
 Transparency in nursing
Recommended Practice
 ANA’s Guidelines for Peer Review
 ANA’s Social Policy Statement
 ANCC’s Magnet Accreditation requirement
American Nurses Association (1988). Peer Review Guidelines.
American Nurses Association (2003). Nursing’s Social Policy
Statement (2nd Edition). Washington, DC: American Nurses
Publishing.
American Nurses Credentialing Center (2008). Application for Magnet
(3rd Edition).
Physician Peer Review at NMH
Cindy Barnard,
Two types of cases:
Incident-based peer review
Criteria-based peer review
Pros and Cons of clinical peer review…
Pros
Increase in professional accountability
Growth and development of nurses
Increases in the quality of care in
measurable and meaningful ways
Creates a culture of inquiry
Safer care through use of professional
standards (Diaz, 2008; ANA, 1988; ANA, 2003; Brooks et al, 1995)
Cons
Feelings of apprehension and failure in
nurses (Mantesso, Petrucka, &
Bassendowski, 2008)
Fear of punishment by the reviewee
Fear of retribution by the reviewer
Biased feedback motivated by competition
Hindsight bias (Masso, 2004)
Legal and Ethical Considerations
Health Care Improvement Act of 1986
Civil liability of those participants in peer review
Medical Studies Act
 Discoverability of records or documents
created in the process of review and evaluation
Code of Ethics, ANA
Examples of Cases Referred to Peer
Review Committee…
 Grievances
 Sentinel and serious events
 Case referrals from other committees or
people
 Criteria based screens
NMH Peer Review Charter
Linkage to Best Patient Experience and Best People
Problem Statement: Currently, nursing does not have a formal structure that
enables peers to evaluate the delivery of nursing care. Peer review would
enable nurses to identify strengths and opportunities.
Goal/Benefit: Advance nursing’s ability to foster a culture of patient safety,
provde recommendations for improvements, minimize re-occurence of errors,
and increase adherence to accepted standards of practice.
Scope: All nursing areas, including specialties. Does not include APN’s.
Deliverables: A set of guiding principles, a structure and process for peer
review, and education materials
Timeframe: 1/09 – 2/10
Key metric: # of cases reviewed, common issues, and re-occurence of errors
Future Discussion Points
 Organizational wide vs. departmental vs.
unit-based?
 Incident based cases vs. criteria based
cases (or both)?
 Scoring vs. mapping
 Who is on the peer review committee(s)?
 Who can refer cases?
 Criteria for cases accepted for peer review
 What type of training is required for the chosen
clinical peer review committee?
Next steps at NMH…
• Develop
peer review steering committee
• Review data and develop guiding principles
• Educate Peer Review Committee Members
• Launch Clinical Peer Review Committee(s)
Taking On Peer Review
Opportunity to…
 Improve nursing care
 Improve documentation
 Improve communication
 Improve systems
 Elevate the nursing profession
 Make patient care higher quality and safer
 Build teams
 Broaden knowledge
References
American Nurses Association (1988). Peer Review Guidelines.
American Nurses Association. (2001) Code of ethics for nurses with interpretive statements.
Washington, DC: American Nurses Publishing.
Brooks, S., Olsen, P., Rieger-Kligys, S., & Mooney, L. (1995). Peer review: An approach to
performance evaluation in a professional practice model. Critical Care Nursing Quarterly, 18(3),
36-47.
Diaz, L. Nursing peer review: Developing a Framework for Patient Safety. (2008). The Journal of
Nursing Administration, 38(11), 475-479.
Gopee, N. (2001). The role of peer assessment and peer review in nursing. British Journal of Nursing,
10(2), 115-121.
Hood, L. J. & Leddy, S. K. (2006) Leddy and Pepper’s Conceptual Basis of Professional Nursing (6th
Ed). Philadelphia: Lippincott Williams and Wilkins.
Institute of Medicine . (2001). Crossing the Quality Chasm: A New Health System for the 21st century.
National Academies Press.
Kohn, LT, Corrigan, JM, Donaldson, MS. (Eds). (2000). To Err is Human: Building a Safer Health
System. Institute of Medicine, National Academy Press.
Mantesso, J. Petrucka, P. & Bassendowski, S. (2008). Contining professional competence: Peer
feedback success from determination of nurse locus of control. The Journal of Continuing
Education in Nursing, 39(5), 200-205.
Masso, M. (2004). Peer review of adverse events – a perspective on Macarthur. Australian Health
Review, 28(1), 26-32.
Meeting Agenda 6/12/09 Meeting
I.
Recap of background information from
1st Steering Committee meeting
II. Establish Guiding Principles
III. Discuss membership options and
considerations
IV. Identify types of cases for review
V. Review Ranking vs. Mapping Options
VI. Discuss next steps for 6/26/09 meeting
Guiding Principles
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Equitable
Objective
Confidential
Ethical
Purpose to improve quality and safety of
patients
 Meet professional standards
General Membership Considerations
 How many members on the committee?
 How many need to be present to consider the
meeting viable?
 Elected or appointed?
 How long is a term?
 Do you stagger membership?
 Types of members
 Staff
 Leadership
 Educators
 How do keep committee members peers?
House-wide Peer Review Committee
 Major considerations
 One committee would be manageable in
regards to training, data collection, follow-up
 Would need representation from varying
specialties
 Which specialties?
How do you get sufficient representation, without
making the committee too large?
• Core group with additional members as needed (ad hoc)?
• Is one person from each specialty enough?
 How many cases can they review?
 More potential for power
Departmental Peer Review Committee

Separate Departments or Combinations?
 If combining, which departments are similar enough to
combine?
 More training, data-collection, follow-up required
 Increases the amount of members that are familiar with
the practice discussed
 Increases the amount of nurses that are familiar with the
peer review process
 Increases the amount of cases reviewed annually
 The closer to the microsystem that quality work is done,
the more effective it will be
 Who will be responsible for each committee?
Types of cases
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Unanticipated codes
Falls (resulting in significant patient harm?)
Stage II-IV hospital acquired ulcers
medication errors (type would have to be defined)
Unexpected transfer to ICU
Unexpected Codes outside of ICU
Return to surgery
Referrals from physician peer review
Referrals from risk management & quality
Sentinel events (already doing a root cause?)
28 Never events
Patient/family complaints
Referrals from any member of the interdisciplinary team
Occurrence reports
Cases that do not meet core measures
Scoring/Ranking vs. Mapping
 Definition for Scoring/Ranking
 Definition for Mapping
Scoring/Ranking
 Ranking is used for NMH’s physician peer
review
 Scoring is the most commonly used way
to communicate findings of committee
 Communicates the findings in a clear and
concise way
 Those that use a scoring or ranking
system admit that it is difficult
Mapping

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Not commonly used
Potential for more useful feedback
Plot the findings on a grid
Guides the next steps
Less personal, more about prevention
and improvement
Examples of Scoring/Ranking
NMH’s physician ranking system
Examples of Scoring/Ranking
 Levels
 Level I: Case was routine and committee found
that acceptable care was given
 Level II: Non-routine case with acceptable care
provided
 Level III: Denotes questionable care with
further review of nursing practice required
 Level IV: Care rendered was unacceptable
when measured against the standard of care
Examples of Scoring/Ranking
 Select one option from each list:




No quality concerns
Minor quality concerns
Significant quality concerns or behavioral issues
Documentation issues



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No additional peer review needed
Education/orientation
Referral to director
Other
Examples of Scoring/Ranking
 Rating 1: Acceptable routine care
 Rating 2: Acceptable non-routine care
 Rating 3: Questionable care with need for
follow-up
 Rating 4: Unacceptable care
Examples of Scoring/Ranking
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Opportunity to improve nursing care
Opportunity to improve documentation
Opportunity to improve communication
Opportunity to improve systems related to
nursing
 Opportunity to improve systems not
related to nursing
Examples of Scoring Ranking
Outcome:
1. No Harm
2. Temporary Harm
3. Permanent Harm
4. Death
Affect on Patient Care:
1. Care not affected
2. Increased level of monitoring/observation
3. Additional treatment/intervention
4. Life sustaining treatment/intervention
Documentation:
1. No issue with documentation
2. Documentation does not substantiate
clinical course and treatment
3. Documentation not timely to communicate
with physician
4. Documentation not timely to communicate
with other professionals
5. Documentation illegible
6. Assessment documentation inadequate
Issues:
1. No problem identified
2. Disease course contributing factor
3. Patient/Family non compliant
4. Issue with nursing plan of care
5. Issue with nursing skills
6. Issue with critical thinking
7. Issue with communication
8. Issue with patient assessment/reasses
9. Issue with patient observance
10. Issue with policy compliance
11. System or process problem
12. General nursing standards issue
13. Other
Overall Nurse Care:
1. Nursing care appropriate
2. Nursing care controversial
3. Nursing care inappropriate
Examples of Mapping
IOM
Competencies
Patient Care
Knowledge
Interpersonal
and Comm.
Skills
Professionalism
System-based
practice
Safe
Timely
Effective
Efficient
Equitable PatientCentered
Examples of Mapping
Next Steps
6/26 Steering Committee Meeting