JANUARY 2011
Northwestern Memorial Hospital Receives
Magnet Redesignation!
peer review, pharmacy peer review, and
nursing peer review. Many other professions
also utilize some form of the peer review
process including accounting, law, engineering,
aviation, and even forest fire management. In
academia, peer review is used in decisions
regarding faculty advancement and tenure.
On Wednesday, December 15, 2010, we
received the official news that Northwestern
Memorial Hospital has been redesignated as a
Magnet hospital for another four years. This is a
significant accomplishment that is shared by
only 3% of hospitals nationally.
The professional medical peer review process
goes back to ancient times and is found in the
Ethics of the Physician written by Ishaq bin Ali
al-Rahwi (854-931) and other Arabic medical
manuals of that time. Documentation of the
patient’s condition was required for each patient
visit. When the patient was cured or expired,
the documentation was reviewed by a medical
council of physicians to determine if the
physician met the prevailing standards of
medical care. Today medical peer review is
commonly used to improve the quality and
safety of medical care and is the process used
to review adverse actions involving clinical
privileges or professional society membership.
This award is a reflection of the caliber of our
nurses, whose hard work and dedication to our
Patients First mission demonstrate every day
that Excellence Matters.
Thanks for all you do to provide exceptional
care. I wish you and your families a joyous
holiday season.
Michelle Janney, RN, PhD, NEA-BC
Senior Vice-President & Wood-Prince Family
Chief Nurse Executive
Introduction
Nursing peer review committees function at the
state level to perform peer review as the
process to fact find, analyze and study events
by nurses to evaluate nursing services, the
qualifications of nurses, the quality of nursing
care provided, the merits of complaints
involving nurses or nursing care and
determination or recommendation regarding a
complaint. Healthcare organizations have also
implemented nursing peer review processes to
evaluate nursing practice in a safe, non punitive
manner in order to improve the practice of
nursing.
This month’s issue of eNursingNow focuses on
professional peer review and how we have
implemented it here at Northwestern Memorial.
Peer review supports our nursing strategic
goals of Leadership and Workforce Supply and
Performance as well as the Continuous
Learning component of our Northwestern
Memorial Framework for Nursing Practice.
Peer Review
Professional peer review is the critical
inspection or examination of an event,
circumstances or facts in order to improve
quality,
uphold
standards,
or
provide
certification. Peer review is widespread within
healthcare and is generally segmented by
discipline, e.g., medical peer review, dentistry
1
Following is a summary of the 23 cases
reviewed to date:
Peer Review at NMH
The guiding principle for nursing quality peer
review is to foster a culture of continuous
learning, patient safety and best practice
through a process that is safe, fair, objective,
confidential, educational, timely in providing
feedback, continuous, and routine. NMH
implemented a formal structure and process for
nursing quality peer review one year ago.
Established as a subcommittee of the hospital
shared leadership Nursing Quality and Patient
Safety Committee, the Nursing Quality Peer
Review Committee (NQPR) is led by Leslie
Klemp, RN, BSN, Chair, Nursing Quality and
Patient Safety Committee.
5 Medication errors:
• Wrong patient
• Wrong route
• Wrong/incomplete dose
3 Falls:
• Failed side rails
• Failed use of bed and TABS alarms
5 Failed vaccinations:
• Incorrect age entered – no order triggered
• 2 IT issues
• 2 Patient Profile not completed
1 Insertion and care of rectal tube
1 Breast milk error
2 Improper use of specialized equipment
6 Patient assessments and monitoring
Nurses selected for membership on the NQPR
Committee are direct care nurses who
demonstrate professional and organizational
core values, interdisciplinary collaboration, and
exemplary performance. Members recognize
and respect the significance of the work of the
committee and its positive impact on nursing at
NMH reinforcing the culture of patient safety,
transparency and teamwork. The process
empowers all team members to contribute to
recommendations for improvement, reduction of
errors, and adherence to accepted standards of
practice. In November, committee members
met with Jay Anderson, Vice President, Quality
and Operations, for a special viewing of
“Chasing Zero: Winning the War on Healthcare
Harm.”
This
inspirational
documentary
reinforced the importance of complete honesty
and transparency in our identification and
review of errors and near misses.
Key Issues Identified:
• 7 Rights / medication administration process
not followed
• High risk fall patients not identified with
adequate precautions taken
• Equipment and technology failures or misuse
• Policy, procedure or protocol not followed
• Delay or failure to escalate
• Inadequate documentation
A primary goal of the NQPR Committee is to
ensure that key issues and lessons learned
identified through peer review are shared with
all nurses at NMH. Watch the Nursing Bulletin
for updates. The committee encourages all
nurses to learn more about nursing quality peer
review in order to better understand and
respect the potential of the process. Feel free to
contact Leslie Klemp (6-6251) or Ann
Schramm, NQPR Director Facilitator, (2-4360) if
you have questions.
Nursing quality peer review cases have been
referred through multiple avenues including
referrals from the quality department, risk
management, safety briefings, nurses, and
other members of the interdisciplinary team.
Cases are reflective of nursing care (individual)
rather than patient care (team/system) and may
include near misses or adverse events, falls,
medication errors, failure to escalate, and
patient or family complaints.
2
Successful Stroke Certification Survey
Although the surveyor did provide the team with
some areas that could be strengthened, the
program received full certification with no
requirements for improvement. The TJC
surveyor commended our program and noted
that the passion and commitment of the entire
team was evident.
A surveyor from The Joint Commission (TJC)
visited NMH on Monday, December 13th, to
recertify our stroke program and to talk with the
team of people who contribute to exceptional
stroke patient care every day. The TJC
surveyor visited the Emergency Department
and two inpatient units to trace the path of the
stroke patient at NMH. In addition to reviewing
the medical records of several patients, she
spoke with staff members and reviewed
personnel and physician credentialing files.
January 2011
Poll Question Results
Functional Mobility
What do you document in the mobility section of the ADL Form or IView when charting the
patient’s daily mobility intervention(s)?
5% 2%
0%
24%
34%
35%
Mobility activities that you and/or the PCT perform with the patient
Observed mobility activities that the patient completes independent of a healthcare provider’s assistance
Observed mobility activities you see performed with the patient by the Physical and/ or Occupational Therapist
A&B
All of the above
None of the above
3