A step-by-step guide to peer review

Nurse Manager Website, July 5, 2006

When a negative patient outcome triggers an organization to evaluate the clinical care given by a nurse, the organization might perform an informal review of the case to determine whether the nurse practiced within the standard of care. However, this method lacks a formal, clearly defined process to systematically evaluate clinical nursing care--a requirement of the ANCC Magnet Recognition Program®.

"Nurses traditionally review [a case] if there's a clinical care concern, but what they haven't done is formalize a process," says Laura Harrington, RN, MHA, CPHQ, practice director at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, specializing in educational and consulting services.
A formal, centralized approach to incident-based peer review is an ongoing, nonpunitive mechanism for nurses to examine quality of care by evaluating the nurse based on the legal standards of nursing practice. It can allow for educating the nurse when necessary (e.g., retraining or policy review), Harrington says.

Using a multiphased approach, she recently worked with nursing leadership, medical staff leadership, and quality management at Prince William Hospital (PWH) in Manassas, VA, a 170-bed community hospital, to design an incident-based peer review process. Nurse leaders recognized that PWH needed a clearly defined peer review process to achieve several goals, including improved patient outcomes and enhanced nursing performance. PWH will apply for ANCC Magnet Recognition® in 2007.

"Prior to nursing peer review, each nurse's practice was evaluated by the nurse's immediate supervisor," says Christine Claunch, VP, RN, BS, vice president of nursing at PWH. "Once the nursing director identified a practice issue, patient care outcomes were discussed in the traditional supervisor-nurse encounter."

According to Claunch, PWH needed a process to allow other departments (e.g., medicine, risk management, etc.) to address nursing care concerns, questions, or examples of excellence.

Phase #1: Set up a centralized structure
The first step that PWH took toward nursing peer review was to design a centralized committee. Harrington recommends forming an unbiased, centralized peer review committee that is either part of the responsibility of a shared governance council or a stand-alone committee.

To achieve this, Harrington suggests identifying various clinical areas that should be represented and developing a committee charter to define the roles and responsibilities of the committee (e.g., protecting confidential information using state regulations).

Phase #2: Plan the process
"What organizations should do is try to parallel the nursing process with the medical staff process to be consistent," says Harrington. PWH has had a formal medical peer review process in place for four years.

If facilities don't have a medical staff policy in place, they should create a case review screening tool to outline what needs to happen in a case review (e.g., how to identify a case, how to track the findings, and when to refer cases to other hospital committees). Harrington suggests that facilities create a flow chart to outline the process.

Harrington also says organizations must review their state board of nursing's rules and regulations when designing their peer review process to identify whether the state nursing board requires peer review.

When a case is flagged for review by the nursing peer review committee, the committee should measure the nurse's performance against the nursing expectations that are set. "Most institutions have a code of conduct in place, but they will want to expand it to include technical quality of care, patient safety, patient rights, quality of service, resource utilization, peer relationships, and contributions to the hospital and the community," says Harrington.

Source: HCPro's Advisor to the ANCC Magnet Recognition Program®, April 2006, HCPro, Inc.

MAGNE(TM), MAGNET RECOGNITION PROGRAM®, and ANCC MAGNET RECOGNITION® are trademarks of the American Nurses Credentialing Center (ANCC). The products and services of HCPro, Inc. and The Greeley Company are neither sponsored nor endorsed by the ANCC.