Clinical Peer Review

1. Clinical Peer Review Susan Morby, RN, BSN, NE-BC Loyola Graduate Student

2. Agenda • Define peer review • Retaining professional status • Importance of peer review • NMH’s current process • Pros and cons • Ethical and legal considerations • Next steps

3. 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, Rieger-Kligys, and Mooney, 1995).

4. Defining Attributes of Peer Review • 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

5. 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)

6. Professions that Utilize Peer Review • Medicine • Accounting • Engineering • Publishing

7. 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

8. 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).

9. Physician Peer Review at NMH • Cindy Barnard, • Two types of cases: • Incident-based peer review • Criteria-based peer review

10. Pros and Cons of clinical peer review…

11. 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)

12. 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)

13. 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

14. Examples of Cases Referred to Peer Review Committee… • Grievances • Sentinel and serious events • Case referrals from other committees or people • Criteria based screens

15. 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

16. 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?

17. 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)

18. 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

19. 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.

20. Meeting Agenda 6/12/09 Meeting • Recap of background information from 1st Steering Committee meeting • Establish Guiding Principles • Discuss membership options and considerations • Identify types of cases for review • Review Ranking vs. Mapping Options • Discuss next steps for 6/26/09 meeting

21. Guiding Principles Equitable Objective Confidential Ethical Purpose to improve quality and safety of patients Meet professional standards

22. 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?

23. 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

24. 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?

25. Types of cases 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 Lawsuits

26. Scoring/Ranking vs. Mapping • Definition for Scoring/Ranking • Definition for Mapping

27. 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

28. Mapping • 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

29. Examples of Scoring/Ranking • NMH’s physician ranking system

30. 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

31. Examples of Scoring/Ranking • Select one option from each list: • No quality concerns • Minor quality concerns • Significant quality concerns or behavioral issues • Documentation issues • No additional peer review needed • Education/orientation • Referral to director • Other

32. 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

33. Examples of Scoring/Ranking • 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

34. Examples of Scoring Ranking

35. Examples of Mapping

36. Examples of Mapping

37. Next Steps • 6/26 Steering Committee Meeting