1. Brim, Carla MN, PHCNS-BC, CEN

Article Content


Develop a process for staff to recommend patient quality care situations for review as a means to improve both patient safety and systems processes. The secondary goal is to improve staff communication skills and professional behaviors.



The Institute of Medicine's 1999 publication of To Err Is Human has spurred the development of several quality and safety initiatives. The Institute for Healthcare Improvement launched the 100K lives campaign. The Joint Commission has an annual list of national patient safety goals targeting safe patient care practices. Additionally, the Joint Commission links the root cause of most sentinel events to breaks in communication. While these programs focus on system initiatives, the need for staff members to recognize and act on patient quality care concerns must be addressed on a unit level to foster a culture of safety.



This community hospital's shared governance clinical practice team formed 2 years ago. The team has developed several protocols and implemented practice changes. The team selected peer review as a method to improve patient quality care.



An overview of peer review was presented to the emergency department staff during a staff meeting. A simple electronic form was created for case submission. The cases were screened by both clinical manager and clinical nurse specialist (CNS) for appropriateness. The case was then presented to the clinical practice team for final review and approval of peer review. Once approved, the staff involved in the case were called together to search for areas of success and opportunities. The crucial conversations framework was used during case presentations.



Ten cases have been submitted for review. Two were addressed at the system level. One was an individual performance problem. The remaining 7 cases were successfully reviewed by the staff. The outcomes identified ranged from educational opportunities to recognition of outdated policies. Initial reaction to peer review was cautious. Providing safety for the staff during case review sessions was essential to success of the project. This continues to be a successful program for this team.



Patient quality care outcomes are improved when staff are involved in recognizing the areas that need improvement. Potential near misses and system failures were identified prior to untoward patient events as a result of the staff case reviews. The improvement in professionalism and communication by an empowered staff is a secondary gain of the peer review process.


Implications for Practice:

The use of peer review offers the CNS an opportunity to present patient care situations as educational opportunities. Through this venue, constructive feedback is modeled, root causes are explored, and process improvements are identified. Nonpunitive peer review fosters a culture of safety to "speak up" about near misses or system failures.


Section Description

The 2010 National Association of Clinical Nurse Specialists (NACNS) Annual National Conference is planned for Portland, Oregon, on March 3 to 6. More than 375 clinical nurse specialists (CNSs), graduate faculty, nurse administrators, nurse researchers, and graduate students are expected to attend. This year's theme, "CNS as Internal Consultant: Influencing Local to Global Systems," demonstrates the breadth and depth of CNS practice and leadership at multiple levels in organizations and on healthcare.


A total of 142 abstracts were submitted for review, and 58 (not including student posters) were selected for either podium or poster presentations. Again, this year, there is a CNS student poster session; student abstracts will appear in a later issue of the journal. The abstracts addressed CNS practice in all 3 practice domains as described in the Spheres of Influence Framework for CNS Practice. Abstracts emphasized patient safety and quality care outcomes, leadership, CNS education, evidence-based practice, and new ways to shape CNS practice. Topics include CNS work activities incorporated into the 3 Spheres of Influence, the role of the CNS in developing clinical inquiry skills among staff nurses, use of simulation technology, strategies to maintain clinical excellence, the role of the CNS in National Database for Nursing Quality Indicators (NDNQI) activities, and many new and thoughtful ideas to support CNS education, practice, and research. Collectively, the abstracts represent the breadth, depth, and richness of the CNS's contribution to the well-being of individuals, families, and communities, as well as contributing to the advancement of the nursing profession.


The conference abstracts are published to share new knowledge with those unable to attend the conference. As you read each abstract, appreciate the intellectual talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to the health of society through improved outcomes for patients and healthcare organizations. We encourage you to contact individual presenters to network, collaborate, consult, or share your thoughts and ideas on the conference topics.


Watch for next year's call for abstracts and consider submitting for presentation at the next NACNS annual conference scheduled for March 9-12, 2011, in Baltimore, Maryland.