JONA Volume 44, Number 11, pp 586-590 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
The Power of Nursing Peer Review Lee Anna Spiva, PhD, RN Nicole Jarrell, MSN, RN Pamela Baio, MSN, RN This article describes how an integrated healthcare system created a nursing peer-review structure to empower nurses to make practice changes and enhance professional accountability. A nursing peer-review committee and tools supporting the process were developed and implemented. Nursing peer review is an evaluation of professional nursing practice, including identification of opportunities to improve care, by individuals with the appropriate subject matter expertise to perform the evaluation.1 Nursing peer review engages and empowers clinical nurses to make nursing practice changes based on the peer-review findings. A peer-review process was developed to provide nurses with a structure to evaluate their practice at a 5-hospital system located in the Southeastern United States. Prior to implementing the nursing peer-review process, a system-level review of clinical cases was referred to an advanced practice RN to conduct a root-cause analysis. If a formal case review was held, it would be from an uninvolved equivalent nursing unit from a different hospital in the system. Two to 3 cases were referred annually in this manner with nurses expressing dissatisfaction with the process. The system shared governance council raised concerns and wanted to enhance professional accountability among the nursing division through nursing peer review. A task force, Author Affiliations: Director of the Center for Nursing Excellence (Dr Spiva), WellStar Health System, Atlanta; Nurse Manager (Mrs Jarrell), WellStar Windy Hill Hospital, Marietta; Clinical Nurse Leader (Mrs Baio), WellStar Kennestone Hospital, Marietta, Georgia. The authors declare no conflicts of interest. Correspondence: Dr Spiva, WellStar Health System, Center for Nursing Excellence, 2000 South Park Place, Atlanta, GA 30339 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000130
586
including nurses from each hospital, was formed to create a peer-review structure followed by implementation at each hospital based on organizational size and resources. Task force members came to consensus on developing a nursing peer-review committee (NPRC), case review templates, and standardized tracking tool. An overview of the NPRC structure, findings, and lessons learned will be provided as well as the flow for the process (Figure 1).
Nursing Peer Review Committee The NPRC responsibilities are to review clinical cases in a nonpunitive manner. The NPRC consists of clinical nurses from departments including but not limited to inpatient, outpatient, interventional radiology, and surgical services. Each hospital has a designated NPRC coordinator, a nurse responsible for screening the appropriateness of case referrals using a decision tree. If a case is determined appropriate for a formal review, the unit manager on which an incident occurred is notified that the case will be reviewed. The coordinator tracks meeting attendance and records the action plans resulting from reviews. Committee members serve a 1- to 2-year term rolling supporting consistency and phased turnover. Ad hoc members include quality and patient safety, risk management, wound care, respiratory therapy, rehabilitation, pharmacy, and medical staff. NPRC members and coordinators are trained on how to conduct a case review using the case review template, preparation of a timeline of chronological sequence of events, how to lead a meeting and maintain confidentiality, and how to provide constructive feedback and coaching. Case referrals are submitted using a referral form (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A343) and submitted to the NPRC coordinator via e-mail or hard copy. Case referrals have been obtained through multiple sources
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Nursing Peer Review Committee Process and decision tree. Reprinted with permission from WellStar Center for Nursing Excellence.
including incident reports, risk management, medical and nursing staff, patients, and families. The coordinator sends an acknowledgement letter to the referring
JONA Vol. 44, No. 11 November 2014
individual to acknowledge the case referral to the NPRC (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A344).
587
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The coordinator utilizes the case review template (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A345) to assist with the initial review of the referred case and includes identifying practice issues, adequacy of documentation, determination if the alteration caused patient harm, and recommendations for either NPRC review or manager follow-up based on the review findings. When cases are not appropriate, feedback is provided as to why to decrease inappropriate referrals. The case review template and timeline are completed and distributed 1 week prior to the regularly scheduled meeting so NPRC members arrive to the meetings with baseline knowledge of the case. The formal case review is conducted during scheduled 1-hour monthly meetings. The formal case review attendance includes nurses directly involved in the incident/care of the patient, nurse peers, NPRC members, and ad hoc members as deemed appropriate. A peer is defined as an RN in a clinical setting who is in a position to observe and evaluate performance of another nurse. The coordinator presents the case for team discussion and evaluation of nursing standard of care/practice issues, nursing documentation, and overall nursing care. Identified issues are documented along with follow-ups, unit action plan, and meeting attendance (see Document, Supplemental Digital Content 4, http://links.lww.com/JONA/A346). Once the case has been reviewed, findings are communicated with the manager and addressed at shared governance meetings where lessons learned are provided (Figure 2). Managers are responsible for nurses to attend and participate in the review and implement the NPRC recommended action plan. Following each formal case review, the coordinator enters case review findings into a password-protected electronic tracking tool.
Findings Case review data from all 5 hospitals were abstracted from the electronic tracking tool. Thirty-eight of 53 referred cases were formally reviewed by the NRPC. Reasons the cases were not reviewed included complaints, cases involving 1 employee, or disciplinary action was needed. Referral sources included nurse leaders (n = 29), quality and patient safety (n = 18), clinical nurses (n = 3), and customer service (n = 3). From the case reviews, issues were identified with standards of care, nursing documentation, and overall nursing care (Table 1). Nursing care was questionable for 23 cases based on standards of practice or policies, inappropriate for 3 cases, and deemed appropriate for 12 cases. Policy noncompliance, ineffective communication, and lack of documentation were similar to other trends noted in the literature as con-
588
tributing factors to the questionable and inappropriate outcome cases.2-4 Positive practice changes have resulted from the NPRC recommendations and action plans. Communication issues were found to be the most common practice issue identified, and to improve handoff communication, nurses conduct bedside shift report at the patient’s bedside. The following exemplars describe cases reviewed by the NPRC that could have resulted in potential adverse patient outcomes. Prior to admission to our hospital, a care coordinator screens the appropriateness of patient admissions using a screening tool. Once the admission is confirmed, the care coordinator validates the information and provides a preliminary report to the clinical nurse. In a late evening patient admission, several communication gaps were identified. A patient was admitted with an unfamiliar medical equipment with no mention of the equipment in the hospital-to-hospital handoff report or in the admitting orders.
Based on the NPRC recommendations, the care coordinators’ screening tool was modified to capture the presence of less common medical equipment. Prior to admission, the nurse will be able to review the admission screening tool and identify key areas when receiving report from the sending facility that need attention for follow-up. Another communication gap involved a transferring facility failing to communicate that a patient required dialysis resulting in a missed renal consult in a timely manner. Through communication between the admission nurse and dialysis nurse, the oversight was identified. At the facility, dialysis treatments are scheduled based on renal consult orders. In this case, the dialysis nurse made accommodations and dialyzed the patient instead of waiting until the following week, which was seen as a positive recovery strategy; however, the issue highlighted a systems issue.
Based on the NPRC recommendations, the admission screening tool was modified to include notification to the dialysis nurse. By doing so, a double check was added to avoid missed treatments.
Lessons Learned In the initial stages, issues were identified with NPRC meeting attendance. This issue was addressed by nursing leaders through reinforcing the importance with participants in their areas. At the beginning of the project, the manager of the nurse and that of the unit involved both attended the meeting, As the process matured, nurses identified that having their manager present sometimes affected their comfort in expressing their thoughts or concerns about the case and
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 2. Nursing peer review lessons learned. Reprinted with permission from WellStar Center for Nursing Excellence.
JONA Vol. 44, No. 11 November 2014
589
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Number of Practice Issues Identified Ineffective communication Failure implement appropriate interventions Lack follow-up Critical thinking gaps Physical assessment gaps Policy noncompliance Lack of knowledge Lack of care planning Improper technique or skill Lack of delegation/supervision Lack of documentation Late documentation Documentation unreadable
29 24 23 22 22 20 16 14 7 8 27 19 3
reasons leading to the outcome. In support, the recommendation was made that managers be excused from the proceedings.
We also found nurses directly involved in the incident/care of the patient needed to be present for the review. Questions that surface during the review can be immediately answered and discussed in a timely manner versus later follow-up conversations. Nurses have expressed that their anxiety is reduced because they are present to hear what is being discussed and can actively participate rather than being informed of the outcome after the review. We believe the key to the success of this initiative has been in the role of the coordinator by ensuring that nurses are made to feel welcome and supported during the process and who maintains the nonpunitive environment. In summary, nursing peer review can be used to confront and correct practice issues and improve patient outcomes. Having a dedicated NPRC to review cases ensured cases were reviewed in a timely manner and provided a standardized process across multiple hospitals supporting patient care quality.
References 1. Harrington LC, Smith M. Nursing Peer Review: A Practical Approach to Promoting Professional Nursing Accountability, Marblehead, MA: HCPro, Inc; 2008. 2. Fujita L, Harris MM, Johnson KG, Irvine NP, Latimer RW. Nursing peer review: integrating a model in a shared governance environment. J Nurs Adm. 2009;39(12):524-530.
590
3. Hitchings KS, Davies-Hathen N, Capuano TA, Morgan G, Bendekovits R. Peer case review sharpens event analysis. J Nurs Care Qual. 2008;23(4):296-304. 4. Thielen J. Failure to rescue as the conceptual basis for nursing clinical peer review. J Nurs Care Qual. 2014;29(2): 155-163.
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
The Power of Nursing Peer Review Lee Anna Spiva, PhD, RN Nicole Jarrell, MSN, RN Pamela Baio, MSN, RN This article describes how an integrated healthcare system created a nursing peer-review structure to empower nurses to make practice changes and enhance professional accountability. A nursing peer-review committee and tools supporting the process were developed and implemented. Nursing peer review is an evaluation of professional nursing practice, including identification of opportunities to improve care, by individuals with the appropriate subject matter expertise to perform the evaluation.1 Nursing peer review engages and empowers clinical nurses to make nursing practice changes based on the peer-review findings. A peer-review process was developed to provide nurses with a structure to evaluate their practice at a 5-hospital system located in the Southeastern United States. Prior to implementing the nursing peer-review process, a system-level review of clinical cases was referred to an advanced practice RN to conduct a root-cause analysis. If a formal case review was held, it would be from an uninvolved equivalent nursing unit from a different hospital in the system. Two to 3 cases were referred annually in this manner with nurses expressing dissatisfaction with the process. The system shared governance council raised concerns and wanted to enhance professional accountability among the nursing division through nursing peer review. A task force, Author Affiliations: Director of the Center for Nursing Excellence (Dr Spiva), WellStar Health System, Atlanta; Nurse Manager (Mrs Jarrell), WellStar Windy Hill Hospital, Marietta; Clinical Nurse Leader (Mrs Baio), WellStar Kennestone Hospital, Marietta, Georgia. The authors declare no conflicts of interest. Correspondence: Dr Spiva, WellStar Health System, Center for Nursing Excellence, 2000 South Park Place, Atlanta, GA 30339 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000130
586
including nurses from each hospital, was formed to create a peer-review structure followed by implementation at each hospital based on organizational size and resources. Task force members came to consensus on developing a nursing peer-review committee (NPRC), case review templates, and standardized tracking tool. An overview of the NPRC structure, findings, and lessons learned will be provided as well as the flow for the process (Figure 1).
Nursing Peer Review Committee The NPRC responsibilities are to review clinical cases in a nonpunitive manner. The NPRC consists of clinical nurses from departments including but not limited to inpatient, outpatient, interventional radiology, and surgical services. Each hospital has a designated NPRC coordinator, a nurse responsible for screening the appropriateness of case referrals using a decision tree. If a case is determined appropriate for a formal review, the unit manager on which an incident occurred is notified that the case will be reviewed. The coordinator tracks meeting attendance and records the action plans resulting from reviews. Committee members serve a 1- to 2-year term rolling supporting consistency and phased turnover. Ad hoc members include quality and patient safety, risk management, wound care, respiratory therapy, rehabilitation, pharmacy, and medical staff. NPRC members and coordinators are trained on how to conduct a case review using the case review template, preparation of a timeline of chronological sequence of events, how to lead a meeting and maintain confidentiality, and how to provide constructive feedback and coaching. Case referrals are submitted using a referral form (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A343) and submitted to the NPRC coordinator via e-mail or hard copy. Case referrals have been obtained through multiple sources
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Nursing Peer Review Committee Process and decision tree. Reprinted with permission from WellStar Center for Nursing Excellence.
including incident reports, risk management, medical and nursing staff, patients, and families. The coordinator sends an acknowledgement letter to the referring
JONA Vol. 44, No. 11 November 2014
individual to acknowledge the case referral to the NPRC (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A344).
587
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The coordinator utilizes the case review template (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A345) to assist with the initial review of the referred case and includes identifying practice issues, adequacy of documentation, determination if the alteration caused patient harm, and recommendations for either NPRC review or manager follow-up based on the review findings. When cases are not appropriate, feedback is provided as to why to decrease inappropriate referrals. The case review template and timeline are completed and distributed 1 week prior to the regularly scheduled meeting so NPRC members arrive to the meetings with baseline knowledge of the case. The formal case review is conducted during scheduled 1-hour monthly meetings. The formal case review attendance includes nurses directly involved in the incident/care of the patient, nurse peers, NPRC members, and ad hoc members as deemed appropriate. A peer is defined as an RN in a clinical setting who is in a position to observe and evaluate performance of another nurse. The coordinator presents the case for team discussion and evaluation of nursing standard of care/practice issues, nursing documentation, and overall nursing care. Identified issues are documented along with follow-ups, unit action plan, and meeting attendance (see Document, Supplemental Digital Content 4, http://links.lww.com/JONA/A346). Once the case has been reviewed, findings are communicated with the manager and addressed at shared governance meetings where lessons learned are provided (Figure 2). Managers are responsible for nurses to attend and participate in the review and implement the NPRC recommended action plan. Following each formal case review, the coordinator enters case review findings into a password-protected electronic tracking tool.
Findings Case review data from all 5 hospitals were abstracted from the electronic tracking tool. Thirty-eight of 53 referred cases were formally reviewed by the NRPC. Reasons the cases were not reviewed included complaints, cases involving 1 employee, or disciplinary action was needed. Referral sources included nurse leaders (n = 29), quality and patient safety (n = 18), clinical nurses (n = 3), and customer service (n = 3). From the case reviews, issues were identified with standards of care, nursing documentation, and overall nursing care (Table 1). Nursing care was questionable for 23 cases based on standards of practice or policies, inappropriate for 3 cases, and deemed appropriate for 12 cases. Policy noncompliance, ineffective communication, and lack of documentation were similar to other trends noted in the literature as con-
588
tributing factors to the questionable and inappropriate outcome cases.2-4 Positive practice changes have resulted from the NPRC recommendations and action plans. Communication issues were found to be the most common practice issue identified, and to improve handoff communication, nurses conduct bedside shift report at the patient’s bedside. The following exemplars describe cases reviewed by the NPRC that could have resulted in potential adverse patient outcomes. Prior to admission to our hospital, a care coordinator screens the appropriateness of patient admissions using a screening tool. Once the admission is confirmed, the care coordinator validates the information and provides a preliminary report to the clinical nurse. In a late evening patient admission, several communication gaps were identified. A patient was admitted with an unfamiliar medical equipment with no mention of the equipment in the hospital-to-hospital handoff report or in the admitting orders.
Based on the NPRC recommendations, the care coordinators’ screening tool was modified to capture the presence of less common medical equipment. Prior to admission, the nurse will be able to review the admission screening tool and identify key areas when receiving report from the sending facility that need attention for follow-up. Another communication gap involved a transferring facility failing to communicate that a patient required dialysis resulting in a missed renal consult in a timely manner. Through communication between the admission nurse and dialysis nurse, the oversight was identified. At the facility, dialysis treatments are scheduled based on renal consult orders. In this case, the dialysis nurse made accommodations and dialyzed the patient instead of waiting until the following week, which was seen as a positive recovery strategy; however, the issue highlighted a systems issue.
Based on the NPRC recommendations, the admission screening tool was modified to include notification to the dialysis nurse. By doing so, a double check was added to avoid missed treatments.
Lessons Learned In the initial stages, issues were identified with NPRC meeting attendance. This issue was addressed by nursing leaders through reinforcing the importance with participants in their areas. At the beginning of the project, the manager of the nurse and that of the unit involved both attended the meeting, As the process matured, nurses identified that having their manager present sometimes affected their comfort in expressing their thoughts or concerns about the case and
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 2. Nursing peer review lessons learned. Reprinted with permission from WellStar Center for Nursing Excellence.
JONA Vol. 44, No. 11 November 2014
589
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Number of Practice Issues Identified Ineffective communication Failure implement appropriate interventions Lack follow-up Critical thinking gaps Physical assessment gaps Policy noncompliance Lack of knowledge Lack of care planning Improper technique or skill Lack of delegation/supervision Lack of documentation Late documentation Documentation unreadable
29 24 23 22 22 20 16 14 7 8 27 19 3
reasons leading to the outcome. In support, the recommendation was made that managers be excused from the proceedings.
We also found nurses directly involved in the incident/care of the patient needed to be present for the review. Questions that surface during the review can be immediately answered and discussed in a timely manner versus later follow-up conversations. Nurses have expressed that their anxiety is reduced because they are present to hear what is being discussed and can actively participate rather than being informed of the outcome after the review. We believe the key to the success of this initiative has been in the role of the coordinator by ensuring that nurses are made to feel welcome and supported during the process and who maintains the nonpunitive environment. In summary, nursing peer review can be used to confront and correct practice issues and improve patient outcomes. Having a dedicated NPRC to review cases ensured cases were reviewed in a timely manner and provided a standardized process across multiple hospitals supporting patient care quality.
References 1. Harrington LC, Smith M. Nursing Peer Review: A Practical Approach to Promoting Professional Nursing Accountability, Marblehead, MA: HCPro, Inc; 2008. 2. Fujita L, Harris MM, Johnson KG, Irvine NP, Latimer RW. Nursing peer review: integrating a model in a shared governance environment. J Nurs Adm. 2009;39(12):524-530.
590
3. Hitchings KS, Davies-Hathen N, Capuano TA, Morgan G, Bendekovits R. Peer case review sharpens event analysis. J Nurs Care Qual. 2008;23(4):296-304. 4. Thielen J. Failure to rescue as the conceptual basis for nursing clinical peer review. J Nurs Care Qual. 2014;29(2): 155-163.
JONA Vol. 44, No. 11 November 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
