Nursing Peer Review: Improving Nursing Peer Review: Improving Nursing Practice and Patient Nursing Practice and Patient

OutcomesOutcomes Naval Health Clinic Cherry PointNaval Health Clinic Cherry Point

Sandra Ludwick and CAPT Denise SmithSandra Ludwick and CAPT Denise SmithAAACN Tri-Service Pre-ConferenceAAACN Tri-Service Pre-Conference

Chicago, IlChicago, Il16 April 200816 April 2008

INTRODUCTIONINTRODUCTION

Naval Health Clinic Cherry Point Naval Health Clinic Cherry Point (NHCCP) Location(NHCCP) Location

Organizational ScopeOrganizational Scope

Standard Standard PracticePractice

BACKGROUNDBACKGROUND

NHCCP recognized needNHCCP recognized need Exists for Medical StaffExists for Medical Staff Models available for Nursing Peer ReviewModels available for Nursing Peer Review

Most subjectively basedMost subjectively based Severity and Criticality (SAC) scoring Severity and Criticality (SAC) scoring

componentcomponent Trigger for investigative reviewTrigger for investigative review

BACKGROUNDBACKGROUND

Monitoring ToolMonitoring Tool 12 core indicators12 core indicators 3 to 6 departmental indicators3 to 6 departmental indicators

Universally applicable (military/civilian)Universally applicable (military/civilian)

PDCA (Plan, Do, Check, Act) PDCA (Plan, Do, Check, Act) MethodologyMethodology

CRITERIACRITERIA

Non-punitiveNon-punitive

EducationalEducational

SystematicSystematic

COMPONENTSCOMPONENTS

Policy (ECONS By-Laws/Nursing Policy (ECONS By-Laws/Nursing Policy)Policy)

ModelModel Flow diagramFlow diagram IndicatorsIndicators

Consistent yet flexible processConsistent yet flexible process ScoringScoring

POLICYPOLICY

““The Nursing Peer Review program is The Nursing Peer Review program is a planned, organized and a planned, organized and

comprehensivecomprehensiveprogram to continuously monitor andprogram to continuously monitor andevaluate the nursing care provided toevaluate the nursing care provided to

patients at NHCCP.patients at NHCCP.

The program is designed to promote The program is designed to promote professional growth among nurses professional growth among nurses

and improve patient care.”and improve patient care.”

MODELMODEL

Sll/Patient Safety 2/27/2008

Individual skills and abilities

Professional Performance

Nursing Process

Nursing Peer

Review Model

Provide Feedback

Promote Professional

Growth

Improvement in Patient Care

= process = outcome

FLOW DIAGRAMFLOW DIAGRAMNurse Peer Review Flow Diagram

sll / Patient Safety 2/28/2008

Begin

Do the Process

Check the

Process

Act on Process Results

Define purpose

Identify participants

Gather / research

information

Select general and department specific criteria

Develop competencies

and monitoring tool

Identify benchmark

data

Determine appropriate number of

charts to review

Gain approval of ECONS

Begin to monitor

Identify data trends and take action on them

Determine if process has areas that

break down

Take action and redefine areas of breakdown

Monitor corrections

Report results to Staffing

Effectiveness, ECONS, ECOMS,

BOD, and incorporate into

PARS

End

Develop expanded monitors for

examining / tracking adverse events

Plan Process

NURSE PEER REVIEW FLOW DIAGRAM

INDICATORSINDICATORS

Nursing Process (1 – 5 part question)Nursing Process (1 – 5 part question) Policies and Procedures (1 – 3 part Policies and Procedures (1 – 3 part

question)question) Patient Safety (7 questions)Patient Safety (7 questions) Pain Assessment (1 question)Pain Assessment (1 question) Professional Performance (1 question)Professional Performance (1 question)

Department Specific (3-6 questions)Department Specific (3-6 questions)

SCORINGSCORING

FrequencyFrequencyLike the severity categories, the frequency rating applies to actual Like the severity categories, the frequency rating applies to actual

events and close calls. events and close calls.

HighHigh – Likely to occur immediately or within a short period of time – Likely to occur immediately or within a short period of time MediumMedium – Likely to occur several times in 1 to 2 years. – Likely to occur several times in 1 to 2 years.LowLow –May happen greater than two years. –May happen greater than two years.

How the SAC Matrix LooksHow the SAC Matrix Looks

Severity & Catastrophic Major Moderate MinorSeverity & Catastrophic Major Moderate MinorFrequency Frequency HighHigh 33 3 2 13 2 1 MediumMedium 33 2 1 12 1 1 LowLow 33 2 1 12 1 1

How the SAC Matrix WorksHow the SAC Matrix WorksWhen you pair a severity category with a frequency category for either When you pair a severity category with a frequency category for either

an actualan actualevent or close call, you will get a ranked matrix score (3 = highest risk, event or close call, you will get a ranked matrix score (3 = highest risk,

2 =2 =intermediate risk, 1 = lowest risk). These ranks, or Safety Assessment intermediate risk, 1 = lowest risk). These ranks, or Safety Assessment

CodesCodes(SACs) can then be used for doing comparative analysis, and, for (SACs) can then be used for doing comparative analysis, and, for

deciding whodeciding whoneeds to be notified about the event. needs to be notified about the event.

Adapted (in part) from the VA National Center for Patient Safety 10/2002

1

Safety Assessment Code Matrix

Severity Categories For actual close calls/actual events, assign severity based on the patient's actual condition. Some incidents that occur may have an overwhelming potential for a catastrophic event, but that determination will be left to the discretion of the ECONS.

Catastrophic Major

Patients with Actual: Patients with Actual: Death or major permanent loss of function (sensory, motor, Physiologic, or intellectual) not related to the natural course of the patient's illness or underlying condition (i.e., acts of commission or omission). Suicide (inpatient or outpatient) Rape Hemolytic transfusion reaction Surgery/Procedure on the wrong patient or wrong body part Infant abduction or infant discharge to the wrong family

Permanent lessening of bodily functioning (sensory, motor, physiologic, or intellectual) not related to the natural course of the patient's illness or underlying conditions (i.e., acts of commission or omission). Disfigurement Surgical intervention required Increased length of stay or level of care of 3 days or more

Death or major permanent loss of function that is a Direct result of injuries sustained in a fall; or associated With an unauthorized departure from an around-the-clock treatment setting; or the result of an assault or other crime

Moderate Minor Patients with Actual: Patients with Actual: Increased length of stay or higher level of care for No increased length of stay or increased level

CHART AUDITSCHART AUDITS

RandomRandom Peer ReviewersPeer Reviewers

DATA INPUT TOOLDATA INPUT TOOL

Patient Identifier Month

Department Nurse(s)

Category Ple Yes No N/A

Nursing Process a) Age specific plan of care demonstrates collection of patient data through

assessment; implementation; evaluation; adjustment, if appropriate;

and discharge instructions

Policies and a) Adherence to departmental policies/procedures; Command instructions;

Procedures BUMED and DOD instructions (note specifics in comment section)

Patient Safety a) Demonstration of patient identification

b) Effective communication through verbal/telephone orders, standardized

abbreviations, critical lab reporting and handoffs

c) Medication safety and reconciliation addressed and documented

d) Contact or respiratory infection identified and documented, if appropriate

e) Prevention of patient falls through assessment, if appropriate

f) Encouragement of patient involvement in care

g) Identification of patient risk such as suicide, if appropriate

Pain Assessment a) Patient is assessed and monitored for pain reduction using 1:10 scale

Professional a) Assistance is obtained when situation goes beyond nurse's

Performance scope of practice (note specifics in comment section)

b) Evidence of critical thinking skills

Department Specific

Reviewer SAC Score

() ECONS review required

COMMENTS:

DATA INPUT TOOLDATA INPUT TOOLNursing Peer Review Form Nursing Peer Review Form

Month: Month:

Year:        Year:       

Department:           Department:          

Patient Identifier:Patient Identifier:Nurse (s):Nurse (s): 1) 1) 2) 2) 3) 3) 4) 4) 5) 5)

NURSING PROCESSNURSING PROCESS

a)a) Age specific care demonstrates collection of patient data through assessment; implementation; Age specific care demonstrates collection of patient data through assessment; implementation; evaluation; adjustment, if appropriate; and patient education.evaluation; adjustment, if appropriate; and patient education.

Yes   Yes   oo No   No   oo N/A     N/A     oo    

SAC SAC

POLICIES AND PROCEDURESPOLICIES AND PROCEDURES

a)a) Adherence to departmental policies/procedures; Command instructions; BUMED and DOD Adherence to departmental policies/procedures; Command instructions; BUMED and DOD instructions (note specifics in comment section)instructions (note specifics in comment section)

Yes   Yes   oo No   No   oo N/A      N/A      oo

SACSAC

PATIENT SAFETYPATIENT SAFETY

a)a) Demonstration of patient identificationDemonstration of patient identification

Yes   Yes   oo No   No   oo N/A      N/A      oo

SACSAC

DATA FINDINGSDATA FINDINGS

Aggregate and Aggregate and report findingsreport findings

Review processReview process

Departmental Nursing Peer Review Over Time

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Aug '06 Sept Oct Nov Dec '06 Jan '07 Feb Mar Apr May June July

Month

Per

cen

t C

om

plia

nt

OR ED IPCU L&D

OR Avg = 99.8%

ED Avg = 87.5%

IPCU Avg = 88.2%

L&D Avg = 86.4%

Overall avg = 92.2%

Staff ing change

Limited ED staff ing began in May due to BRAC conversion, prohibiting data collection. IPCU and L&D began conversion in June, thus July data is based

Nursing Peer Review Percent Compliance Improvement

4.5%4.0%

1.4%

15.1%

2.5%

36.0%

Nsg Proc

Pol & Proc

Pt Safety

Pain Assess

Prof Per

Dept Spec*

IMMEDIATE RESULTSIMMEDIATE RESULTS

Examples of immediate “flags” during Examples of immediate “flags” during process implementation included:process implementation included: IPCU - Pain assessments / re-assessmentsIPCU - Pain assessments / re-assessments L&D - Breastfeeding during first hour of lifeL&D - Breastfeeding during first hour of life UCC - Medications UCC - Medications

PROCESS CHANGESPROCESS CHANGES

NPR = Constant work in processNPR = Constant work in process Item #1 (Nursing Process) wording reflects Item #1 (Nursing Process) wording reflects

change from hospital to ambulatory status change from hospital to ambulatory status – no inpatient discharges– no inpatient discharges

Item #2 (Policies and Procedures) wording Item #2 (Policies and Procedures) wording should be changed to NHCCP Nursing should be changed to NHCCP Nursing policies – encompasses DOD, BUMEDpolicies – encompasses DOD, BUMED

Item 3c (Patient Safety) wording should Item 3c (Patient Safety) wording should remove “and reconciliation” as it is a remove “and reconciliation” as it is a provider functionprovider function

CURRENT RESULTSCURRENT RESULTSNPR Department Volume Over Time

0

10

20

30

40

50

60

70

80

90

100

Aug'06

Sept Oct Nov Dec'06

Jan'07

Feb Mar Apr May June July Aug Sept Oct Nov Dec'07

Jan'08

Month

Nu

mb

er C

har

ts R

evie

wed

OR/ASU

ED/ICC

FCC

FHP

WH

N = 1596

NPR Compliance Rate by Department

94.8

90.7

100

93.6

96.6

86

88

90

92

94

96

98

100

102

ASU FCC FHP ICC WH

Department

Co

mp

lian

ce R

ate

Aggregated Nursing Compliance Rate Over Time

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Aug'06

Sept Oct Nov Dec'06

Jan'07

Feb Mar Apr May June July Aug Sept Oct Nov Dec'07

Jan'08

Month

Perc

en

t C

om

plian

t

Average Rate = 93.2%

BRAC

COMPARING RESULTSCOMPARING RESULTS

Naval Hospital Camp LejeuneNaval Hospital Camp Lejeune Fort Knox Army Fort Knox Army

WHERE DO WE GO FROM WHERE DO WE GO FROM HERE?HERE?

Continue to “tweak” the monitoring Continue to “tweak” the monitoring tooltool

Continue staff educationContinue staff education Gain more staff involvement in Gain more staff involvement in

processprocess Drill down staff results to identify goal Drill down staff results to identify goal

opportunities opportunities Continue to share program with Continue to share program with

interested facilitiesinterested facilities