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Peer reviews in nursing are historically used to gauge performance within an individual's scope of practice or as a tool to evaluate a sentinel or adverse event. Quality of care measures, clinical pertinence, and evaluating standards of care have begun as parallel strategies to replace the former uses in assuring the right care at the right time in the right setting.
In the past decade, preventing harm and enhancing quality has initiated major redesigns in the delivery of care. These continue to be defined and redefined as evidence-based practice emerges.
Transparency, objectivity, and system approaches are becoming more effective in changing practice and defining safe quality care. Thus, moving away from an individual focus to an organizational one warranted a new innovative direction that would instead focus on identifying best practices, opportunities for change, and systems designs that contributed to providing safe, high quality care.
The Professional Enhancement Process (PEP) a vehicle by which staff nurses could employ to analyze not only their practice but also the health care weave of each patient encounter and be a more viable way to evaluate quality care was developed. Professional Enhancement Process provides staff opportunities to gain insight into how care is delivered and managed in a nonpunitive positive and comprehensive way.
Since the Institute of Medicine's (IOM) "To Err is Human"1 and its following report "Crossing the Quality Chasm: A New Health System for the 21st Century"2 called for major redesigns in the way we deliver care, prevent harm, and enhance quality, health care systems have been challenged to retool with evidence-based practice patterns and align these to efficiency, safety, and accountability. Following in the heels of these watershed reports the Institute of Health care Improvement (IHI) launched 100,000 Thousand Lives Saved and the 5 Million Lives from Harm campaigns to raise awareness, craft solutions, and transform care (Institute of Healthcare Improvement.3,4 Further efforts to address unsafe care and inconsistent or lack of quality care can be seen with the Joint Commission safety goals; each of which parallel and build upon those areas which were first identified in the IOM reports and other subsequent health care findings.5
Currently, measuring quality has taken many forms. Quality of life measures, satisfaction, medical errors, infection rates, injuries, and other indicators of quality are pursued, reviewed, studied, analyzed, and reported.6-8 Numerous collection models, a variety of reviews both internal to the agency and external from national depositories are employed to capture quantitative as well as qualitative data. These help to establish benchmarks, identify outcomes, and develop standards of care and practice.9 One salient database is the National Database of Nursing Quality Indicators (NDNQI) of which our organization participates. In the 2010, results we consistently were above in foundations of quality care and staffing and resource adequacy.10 These elements are more nursing patient care centered. Thus, these data provide an excellent vehicle to gauge what direct care nurses (DCNs) believe about the system, the unit, and the competency of their peers to deliver patient care.
In concert with NDNQI, there exist local efforts of assessing provider appropriate care. These efforts are mainly via the peer review process. Hospitals have traditionally used peer review to address findings from sentinel events and root cause analyses (RCA). The overall process assist in identifying the factors that may have contributed and or increased the risk of an event occurring.11,12
Although nursing is part of the RCA process, discipline specific peer reviews are also conducted. In these instances, reviews are done by a coworker. This less complicated-yet highly effective-method calls for a colleague/peer review of charts to identify whether care was delivered in a comprehensive and professional manner. Although touted as a less formal review, peer to peer reviews were many times perceived as subjective and were thought to result in a reprimand or some other punitive action from their supervisor and or nurse manager (NM).13
As a Magnet facility, we recognize that for learning to take place and practice to improve the environment in which we deliver care needs to be transparent, foster professional development, and support evidence-based practice. Therefore, any perceptions of subjectivity and or negative consequence may color current efforts and hinder potential opportunities for change in practice to occur and patient outcomes to improve.
With these aims in mind, a workgroup was formed consisting of staff nurses, educators, NMs, and advance practice staff as well as the nurse executive of the Nursing Education Department. A union representative who is also a staff educator was invited to participate. Our workgroup was committed to developing a process that would be viewed as a pragmatic vehicle to enhance practice in an objective nonthreatening way.
As the traditional methods are mostly outcome driven, a new innovative direction was identified to change the focus to the nursing process. This approach aims at identifying evidence-based (EBP) and best practices, opportunities for change, and systems designs that contributed to providing the right care, in the right setting, at the right time.
The process that was developed was coined the PEP. The name was carefully chosen to reflect a positive and professional process versus a potential disciplinary mechanism that was based on a wrongdoing. Professional Enhancement Process provides staff opportunities to analyze their practice in this nonpunitive and cogent way. Thus, PEP may be a better means to gain insight into how care is delivered and managed.
Major differences in this approach are traditional peer reviews are conducted as a result of a patient injury or sentinel events and are initiated upon alleged deviations from standards of care (SOC). Organizations typically use outcome directed reviews to identify accountability. Whereas, the PEP from a nursing practice standpoint is based upon reviewing standards of practice (SOP) for process variations and system barriers. In addition, the former is reactive, whereby the later is proactive. Another major difference is the PEP creates best-practices, which will drive change from a professional perspective rather than from a mandatory direction.14,15
The structure bases the review on 5 components: safety, comfort, education, and the nursing and medical plans of care. This structure guides the reviewers to evaluate the elements of practice that address these areas. Direct care nurses, advance practice nurses, and management are part of each review team and this interface provides opportunities to add to our body of knowledge, share best practices, and provide a forum for professional growth and analysis.
Input was elicited from all stakeholders so that acceptance of the PEP would be assured. All Shared Governance Councils of which there are 5, as well as the Nurse Management Forum, and members of the Advance Practice Committee reviewed the PEP throughout its development. A pilot was also conducted so that the tool, process, and ease of use could be evaluated. Two inpatient areas one of which was an intensive care unit and a primary care outpatient area were chosen to represent the majority of units. However, all units were encouraged to individualize their tool especially more unique areas such as the emergency room or the operating room. The PEP was officially launched in April 2009. Each unit is expected to do at least one per year. Unit schedules were distributed along with an assigned facilitator so that no 2 units from a similar practice area would be simultaneously conducting one.
As each unit completes PEP, their summary and findings will be reported to the nurse executive for quality. Major themes will be extrapolated, data will be generated that will then be shared with all the Shared Governance Councils. Items of concern or opportunities for improvement as well as successes and best practices that may need to be further addressed or adopted can be designated to the appropriate council. For example, PEPs may uncover consistent gaps in practice across many units, or conversely, discover optimal practices that other units may wish to explore. Therefore, each council would review the findings and create actions that are specific to their council's charge that would lead to resolution and or system integration.
Although there are a variety of peer reviews, we believe this approach to gain insight into our practice will be well received and meaningful. Especially, as the review summary is based upon processes and not people. Furthermore, the PEP allows sharing of best practices when identified and facilitates identification of organizational issues that may be impacting on many areas. Thus, staff can relate to the findings in a more significant way.
Currently, because it is a yearly requirement, there are limited data on the utilization and the outcomes of using the PEP to evaluate a peer's practice. A compounding factor is as the PEP was implemented there was a concurrent expectation to conduct clinical reviews. However, the units that have performed PEP report a positive experience among the team, the unit, and the manager.
Future plans are to combine the PEP with the mandatory clinical review process. As an organization that is committed to safe patient quality care, we recognize that there are many approaches to review and evaluate care for appropriateness and whether they meet established benchmarks. Moreover, we anticipate that our NDNQI scores will consistently meet or exceed benchmarks in these data points especially those elements that reflect the NDNQI Nursing Foundations for Quality Care.6
The emergence of quality systems to identify, develop, and implement EBP, provide care that is safe and reliable, and one that holds providers accountable, and systems responsible have emerged as expectations for 21st century health care. Vehicles such as peer reviews either traditional or nontraditional are well established methods which seek to unravel and make transparent processes that contribute to poor patient/family outcomes and organizational dysfunction.
Nurses' input into processes that elucidate practice and identify practice that is based upon evidence will help to create an environment that keeps patients safe and as importantly provide DCNs with ownership and investment.
1. . To Err is Human: Building a Safer Health System. Washington, DC: National Academy; 1999. [Context Link]
2. . Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy; 2001. [Context Link]
3. . 100,000 Lives Saved, 2005. http://www.ihi.org. Accessed July 22, 2009. [Context Link]
4. . 5 Million Lives Campaign, 2006. http://www.ihi.org. Accessed July 22, 2009. [Context Link]
5. . Performance Measurement Initiatives, 2009. http://www.Jointcommission.org/PerformanceMeasurement. Accessed July 20, 2009. [Context Link]
6. . National database of Nursing quality indicators, 2002. http://www.nursingquality.org. Accessed August 31, 2009. [Context Link]
7. Benner Z, Salathiel M. The nurse's role in CMS quality indicators. Medsurg Nurs. 2009;18(4):242-246.
8. Doherty L. Nurses urged to help develop indicators for measuring quality. Nurs Stand. 2008;23(12):10. [Context Link]
9. deVos M, Graafmans W, Kooistra M, Meijboom B, Van Der Voort P, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care. 2009;21(2):119-129. [Context Link]
10. . National Database of Nursing Quality Indicators. Published 2010. http://www.nursingquality.org[Context Link]
11. Bry K, Stettner B, Marks J. Patient safety: through the eyes of your peers. Nurs. Manag. 37(6):20-24. [Context Link]
12. Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual Patient Saf. 2009;35(1):36-42. [Context Link]
13. Shannon S, Foglia M, Hardy M, Gallagher T. Disclosing errors to patients: perspectives of registered nurses. Jt Comm J Qual Patient Saf. 2009;35(1):5-12. [Context Link]
14. Donabedian A. Explorations in Quality Assessment and Monitoring. Ann Arbor MI: Health Administration; 1980. [Context Link]
15. Nuckols T, Bell D, Paddock S, Hilborne L. Comparing process-and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139-145. [Context Link]
peer review; root cause analysis
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