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2020 Sentara Healthcare

System Nursing Peer Review Toolkit

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Overview

Peer review is accepted as an appropriate mechanism by which to monitor professional behavior and facilitate professional development. The American Nurses Association (ANA) has supported the process of peer review since the late 1980s. The primary purpose is to help ensure the quality of nursing care through safe deliverance of standards of care and evidence-based practices. The ANA definition of nursing peer review proposed in 1988 still applies today: “Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice. Peer review implies that the nursing care delivered by a group of nurses or an individual nurse is evaluated by individuals of the same rank or standing according to established standards of practice.” Use of the following six peer-review practice principles helps ensure consistent, evidence-based approach to peer review.

1. A peer is someone of the same rank.2. Peer review is practice-focused.3. Feedback is timely, routine, and a continuous expectation.4. Peer review fosters a continuous learning culture of patient safety and best practice.5. Feedback is not anonymous.6. Feedback incorporates the nurse’s developmental stage

Sentara Healthcare nurses have defined and designed a consistent structure and process for Nursing Peer Review (NPR). NPR is based on a universal commitment of peer review as a non-punitive evaluation of an individual nurse’s performance for the purpose of identifying opportunities to improve care as part of our just culture. Peers are defined as an individual practicing in the same profession and having expertise in the appropriate subject matter.

A special thank you and recognition goes towards our nursing colleagues at Sentara Virginia Beach General Hospital (SVBGH). These nurses were the first to launch a NPR process and have sustained and enculturated NPR for over a decade. Their generosity in sharing their information through the system Nursing Professional Practice Council will benefit all Sentara Nurses and the patients in their care. The information in this toolkit is a guide for best practice standardization of nursing peer review in the acute care settings. The content is maintained and overseen by the System Nursing Professional Practice Council.

2019 NPPC Chair, Marybeth Baber, MBA, MSN, RN, NEA-BC Director Patient Care Sentara Leigh2020 NPPC Chair, Tess Bilyeu, BSN, RN-BC Manager of Professional Practice Sentara Leigh HospitalNPPC Sponsor, Susan Winslow, DNP, RN, NEA-BC System Director of Professional Practice

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Table of Contents

Topic PageNursing Peer Review Overview 2Table of Contents 3Nursing Peer Review Flowchart 4Nursing Peer Review Charter Template 5-6Nursing Peer Review Referral form 7Nursing Peer Review Guidelines 8-10Nurse Peer Review Case Study Preparation Guidelines 11Nursing Peer Review Scoring Tool 12Nursing Peer Review Member Role and Responsibilities 13Nursing Peer Review Member Agreement 14Nursing Peer Review Executive Sponsor Role 15Nursing Peer Review Chair Role 16Nursing Peer Review Tracking and Trending spreadsheet 17-19Agenda Template 20Minutes Template 21Nursing Peer Review Timeline Template 22Nursing Peer Review Sample Annual Report 23-25Nursing Peer Review Definitions 26Nursing Scope and Standards of Practice 27Nursing Peer Review References 28

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Nursing Peer Review FlowchartThe following flowchart visualizes the NPR process.

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Nursing Peer Review (NPR) Charter Template

The use of a standardized Charter for Nursing Peer Review is strongly suggested. A sample outline is displayed below. Committees are advised to review and revise annually.____________________________________________________________________________

Work Group/Team Name: Sentara XXX Nursing Peer Review Committee (NPR)

Date Launched: XXX Revised: XXX

Purpose: The purpose of NPR is to maintain standards of nursing practice in a non-punitive manner while encouraging peer support and evaluation in order to improve patient care.

Key Deliverables: Improve patient outcomes.

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Identify learning opportunities for nursing. Promote nursing excellence. Enhance nursing image and professionalism. Support and encourage nurse autonomy and accountability. Facilitate a sensitive and caring peer review interaction. Improve Patient experience Improve nursing culture, engagement, and teamwork, and satisfaction.

Workgroup Leadership: Chair: The committee chair conducts monthly meetings for Peer Review. Executive Sponsor: An executive sponsor will provide leadership for NPR outcomes. Mentor/Facilitator: The committee has an expert non-voting facilitator member. Members are unit/department representatives that work at the point of care delivery.

Reporting Relationships: Formal system structure: NPR reports out to the System Nursing Professional Practice

Council which is accountable to the Nursing Executive Council Formal divisional structure:

Logistics: Meeting date: Routine monthly meetings will be established lasting no longer then 90

minutes All meetings will be face to face and information will remain confidential. All members will sign a conflict of interest statement and confidentiality statement. All conversations and interactions will be consistent with the standards of service and

etiquette of the organization

Workgroup Composition: Members are direct care RN unit/department representatives as primary role. Membership includes representatives from each clinical department. All nursing peer review members are the voting members of the committee. All new NPR members will be paired with a mentor (experienced NPR member) for

initial case reviews and presentations. Members will adhere to member roles and responsibilities.

Processes: Any staff member with concerns about the quality of nursing care can make case

referrals to the committee. All meetings will be face to face and information will remain confidential.

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Cases are to be reviewed in a timely manner and be presented at the appropriate meeting.

All case reviews will be conducted in a timely manner with a goal of completion for a routine case within 90 days and for a complicated case within 120 days.

Guidelines for nursing practice are based on ANA Code of Ethics and ANA Nursing Standards and Scope of Practice.

NPR will report case review findings and recommendations to the department head or manager responsible for the area of care involved and the Chief Nursing Executive. NPR will report to the System NPPC Council and the XXX Divisional Council on peer review activities and action.

The NPR will monitor trends and report findings to CNE.

(All NPR forms and templates are available for download on the NPPC SharePoint site)

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NPR Referral form

The use of a standardized confidential form for Nursing Peer Review is strongly suggested. The form contains protected information and as such much be treated as privileged and confidential. A sample outline for hospitals in Virginia is displayed below.

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CONFIDENTIAL – FOR QUALITY IMPROVEMENT PURPOSES ONLY(Insert divisional name)

Nursing Peer Review Referral

Patient Name/MR#: Date Reported: Occurrence Date: Nurse(s) involved: Charge Nurse:

Referral source: Check the corresponding box□ Physician □ Physician Peer Review □ Quality □ Clinical Nurse/Staff□ Risk Leadership/Management □ Other

Referral issue:

Case summary:

Key issues for Nursing Peer Review Council:Please complete above, and return to XXX at Sentara.com. If you have questions, please e-mail, or call xxx-xxxx. NPPC “Privileged and Confidential pursuant to Va. Code Annotated Section 8.01-581.17. To be used for Quality Improvement purposes only, and not to be printed, copied or otherwise distributed for any other reason”


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NPR Guidelines

Process Nursing peer case review is conducted by the NPR committee on an ongoing basis and reported for quality assurance purpose to the appropriate council, committee, or person for review and action. Nursing peer review cases will be identified using the following sources: employees, nursing practice councils, medical staff members, Risk Management, Patient Safety, patients or family, Physician Peer Review Committee, or leadership. Cases selected for review include those related to: Quality of care, Technical errors, Documentation, Risk issues, or Complaints. Once a case has been identified for review, the case review process will be initiated and time frames will be followed.

Structure NPR is practice focused on safety, quality, and service excellence in nursing practice using ANA scope and standards of practice, formal Sentara policies and procedures, board of nursing guidelines and evidence-based practice to create recommendations. Peer review fosters a continuous learning culture of patient safety and best practice. In a learning organization, the focus is shifted away from individual learning to organizational learning. The NPR culture questions the “we’ve always done it that way” mentality and helps change these norms. This change can help create and support policies and procedures and help unlearn unsafe processes

Membership The NPR peer is someone of the same rank, meaning direct care nurses to direct care nurse. NPR is not a managerial process – professionals correct their own practice. The facilitator is not a voting member; the facilitator helps us connect with the proper team/ person. Staff nurses act as professionals when they review their own nursing practice. Prior to the meeting, the nurse completes a narrative and should be ready to present. NPR members have an open discussion about the case. NPR then uses evaluation tools and creates recommendations.

Facilitator The facilitator will receive the referral and assign the case to the appropriate NPR committee member. The manager is notified. The managers are not present for the interview, but the facilitator can be present for the interview. If NPR cannot get in contact with the involved nurse, the facilitator helps us make a connection. The facilitator can help find policies for the case. The facilitator helps make a realistic goal and then keeps track of the case to close the loop. Open cases are reviewed until closed.

Referrals Anyone can refer a case. Completed referrals are sent to the NPR facilitator. The facilitator gives the case to a specific nurse to review the case. The facilitator will also screen the referral to deem appropriateness (for example, the patient is not involved (nurse to nurse or unit to unit) or the case does not involve a nurse.) Each nurse will be referred a case and all nurses should go through a rotation. Some exceptions apply, like usually specialty units review their own unit or are available for help.

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Review Process Feedback is timely, routine, and a continuous expectation. Cases are assigned each month and presented the following month. NPR members interview the involved nurses to get additional information that might not have been in the chart. Feedback is not anonymous. This can be uncomfortable. Effective team learning comes from dialogue. ANA Code of Ethics calls us to use respectful communication with an open exchange of views to preserve practice integrity and safety. Lessons learned often identify process improvement opportunities that will be referred to the proper forum or council. Lessons learned are shared with a specific nursing leadership council. NPR incorporates Benner’s novice to expert continuum. This helps guide recommendations as a new nurse is still learning and might need more education. Lessons learned and recommendations are turned into SBARs and a newsletter for the nurses.

Review Process The assigned nurse reviews the entire chart. All important parts of the chart are to be included in the narrative, like MAR, Doc Flowsheet, Notes, labs, Vital Signs, MD notes, and anything else that is specific to the case. Parts of the chart that support the case review, are to be printed and included in the case file. Printed information can be summarized or a direct quote in the narrative. Involved nurses should be interviewed. Sometimes there are other issues that are not included in the chart. All key issues on the referral form should be resolved. The associated practice standard is identified that is involved in the case. The standard may be a Sentara policy, a specialty nursing organization’s recommendations, or recommended best practice from an evidence based practice database. The NPR reviewer will investigate the case and prepare for presentation as per the guidelines of the Nursing Peer Review Committee. The case will be presented during the following NPR committee, no less than 2 weeks and no more than within 90 days. Exceptions may occur based on case complexity or reviewer availability.

Conflict of Interest: A conflict of interest exists if a member of the NPR is not able to render an unbiased opinion. Automatic conflict of interests would result if the nurse on the peer review committee is the nurse under review. Relative conflicts of interest are due to the reviewer either being involved in the patient’s care or having a familial relationship with the nurse involved, and similar situations. It is the obligation of the individual reviewer to disclose to the NPR the potential conflict. The responsibility of the peer review body is to determine whether the conflict would prevent the individual from participating or the extent of the individual’s participation. Individuals determined to have a conflict may not be present during peer review discussions or decision other than to provide information if requested.

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Membership Representation NPR members represent multiple specialty areas. The ideal NPR council size is 10-12 nurses from all over the hospital: ER, OR, women’s services, critical care, and med/ surg. Members should be professional, respected, and trustworthy. Members should be experienced and proficient in their area of expertise (at least 1 years of experience); consideration of a novice (less than 2 years’ experience) member could be considered with a defined peer mentor co-assigned for interviewing processes. Members cannot be a manager (Team Coordinators, Nurse Managers, and Nurse Directors). Recommendations are based on evidence. We value other members input, even if we disagree. Members act as resources for peers. Members continue to develop professionally and share compassion for nursing with other members and out units. Demonstrate interpersonal and group work skills.

Scope of Authority The goal of NPR is to review the case, create recommendations and lessons-learned, and send our recommendations to the appropriate department to help improve patient care. Just culture is a non-punitive environment. It encourages nurses to report all clinical errors and near-misses without fear of repercussions so they can learn from the experience. NPR reviews cases to find out if there is a nurse specific issue, unit specific issue, policy issue, documentation issue, or a practice issue. NPR respects and maintains confidentiality, especially when interviewing co-workers. The peer review committee analyzes the incident to arrive at the nursing opportunities. Each case is scored using the appropriate scoring tool to help determine a plan of action. A report of the committee’s findings and recommended actions is prepared and submitted to the CNE and appropriate department head. Divisional and system trending is maintained.


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Nurse Peer Review Case Study Preparation Guidelines

1. Narrative summary of the event: (may need copies of the specific pertinent data)a. Include relevant clinical details noting any actual or potential nursing issuesb. Details of involved staff interviewsc. Timeline of event

2. Review of staffing effectiveness:a. Skill mix- include an assessment of the nurses’ level of expertise using

Benner’s Novice to Expert modelb. Actual vs appropriate staffing levels based on staffing gridc. Supervision of staffd. experience

3. Communication breakdownsa. Nursesb. Physicians to nursesc. Other departments involved

4. Equipment issues:a. Staff competencyb. Effectiveness of equipment

5. Medications:a. Related patient monitoringb. Staff knowledge of medicationc. Medication administration process

6. Clinical care standards: (what standard was the nurse being held to at the time of the event?)

a. ANA Code of Ethicsb. ANA Nursing Scope and Standards of Practicec. DNV Regulatory Standardsd. Related hospital policies and procedures- compliance and availabilitye. Professional Specialty Nursing Organization standards such as INS, AACN, etc.

7. Physical Layout:a. Placement of patient on the nursing unit

8. Information management:a. Availability of current comprehensive information to make appropriate

assessments and care decisions9. Summary and conclusions:

a. Was the standard of nursing practice met?


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NPR Scoring ToolThe following tool is used by the Nursing Peer Reviewer to assess and rate the event.


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NPR Member Roles and Responsibilities

Members will:1. Be professional, respected, and trustworthy.2. Be experienced and proficient in their area of expertise.3. Value others and exhibit interdisciplinary collaboration.4. Act as a resource to their peers.5. Show evidence of ongoing professional development.6. Show personal humility, integrity, and compassion.7. Demonstrate interpersonal and group work skills.8. Engage in active attendance at meetings with participation in problem solving.9. Review agenda prior to meeting and research established standards of practice.10. Disseminate critical information to unit-department staff as agreed to by NPR

leadership.11. Be responsible for contributing toward positive team function, application of active

communication skills and creating a learning environment with colleagues. 12. Champion evidence-based practice standards in area of expertise for clinical

standardization of best practices.13. Demonstrate respect for colleagues, patients, and families.14. Proactively plan coverage with manager to attend meetings to represent input as

expected.

Selection of Member:NPR members are recruited based on expressed interest in participation. Members may indicate ongoing desire to serve. Managers must be aware and support the team member’s involvement. Terms are at the discretion of the division.

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NPR Member Agreement

The use of a formal signed agreement of member responsibilities is suggested. A sample outline is displayed below.______________________________________________________________________________Nursing Peer Review Members Responsibilities

Division

Date

Members of the XXX Nursing Peer Review Committee are responsible to participate in fostering a culture of continuous learning, patient safety, and best practice by demonstrating confidential, caring, authentic, supportive and transparent principles in case reviews.Responsibilities and expectations include:

Attends at least 80% of the meetings. Center the decision making process on ANA Nursing Scope and Standards of Practice,

ANA Code of Ethics, Board of Nursing guidelines, and organizational policies and procedures.

Decisions will be made by quorum voting. Have open, direct, respectful, and timely communication. Utilizes SharePoint site to stay abreast of information related to minutes, agendas, and

related documents. Conveys information from each meeting back to appropriate unit. Come prepared for committee sessions. Complete follow up work as assigned. Be receptive to feedback, constructive criticism and value diverse opinions. Assure that every colleague knows the purpose, structure and process of NPR. Demonstrate an understanding that each colleague is a unique, multi-dimensional

person with hopes, dreams and goals. Celebrate successes.

I understand my responsibilities as a Nursing Peer Review member at SXXX and I make a commitment to my colleagues to take these responsibilities seriously and follow them to the best of my ability.

_____________________________________ ____________________[Signature] (Date)

(All NPR forms and templates are available for download on the NPPC SharePoint site)Executive Sponsor Roles and Responsibilities

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1. Provide clear direction and linkages to strategic goals to group.2. Report or provide access to data pertinent to team.3. Develop a strong partnership with the chair providing active leadership mentoring.4. Help to set the agenda in partnership with the chair.5. Contribute management knowledge to decision making.6. Use expertise to balance staff and patient needs with realities of business.7. Invite and support interdisciplinary members.8. Secure or clarify project resources related to goals and projects of team.9. Ensure use of evidence-based findings to support recommendations.10. Champion executive level awareness and buy-in.11. Act as formal liaison to Nurse Executive Council.12. Monitor adherence to all confidentiality and protected information.13. Celebrate successes through recognition of achievements and lessons learned.

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NPR Chair(s) Role and Responsibilities

The Chair will coordinate meetings, communicate activities, role model effective communication skills, and facilitate the development and work of the NPR committee on an ongoing basis under the mentorship of the executive sponsor.

1. Guide planning and prioritizing annual strategic goals.2. Establish monthly agenda and disperse to members before meeting in a timely fashion.3. Facilitate meetings according to guidelines.4. Establish a process for minutes and timekeeper for each meeting.5. Maintain current roster of members; replace members missing significant meetings.6. Use evidence-based findings to support recommendations.7. Ensure agendas, minutes, rosters, meeting times, and information is communicated. 8. Help to build consensus by ensuring all voices are heard.9. Trend and track referrals and lessons learned.10. Prepare a year-end report summarizing accomplishments and actions.

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Nursing Peer Review System Tracking and Trending spreadsheet

Each quarter the NPR chair will enter divisional cases on the system NPR spreadsheet found on the NPPC SharePoint site. No specific HPI is to be included. NPPC will review once per quarter to assess for trended events and emerging opportunities for learning.

Data entry utilizes a SharePoint form housed on the NPPC SharePoint site. One thing to note is that there is no “other” option when building the form contents; please use the” Specify your own value:” check box and use the free text box for your answer.

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To download data from the webform select ‘System Nursing Peer Review Referral’ under “List” on the left side of the home page, ‘List’ from “List Tools”, and then ‘Export to Excel’.


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NPR Agenda

Tips for creating a useful meeting agenda

Agendas are the framework, blueprint or roadmap that supports meeting and helps group achieve desired outcomes.

Create agenda with input from members a few weeks before the next meeting. Allot specific amounts of time on the agenda for each item. Priority items first. Identify activities that will be required for each item. Allow more time for items that will need more dialogue. Start and end each meeting on time. Appoint a timekeeper to help. Timekeeper informs

group of where they are on time in a particular agenda item. Follow up items should include who will do it, what will they do and when will they do it. Building accountability for assignments to be completed.

________________________________________________________________________Template

Committee Name: Date and Time:

Minutes to be taken by:Timekeeper:

Format (live, WebEx, conference call):

Time Agenda item/Topic Responsible party or lead

Safety Story, Moment of Excellence, Recognitions, New members

Confirm confidentiality of discussion; Approval of minutes

Monthly report update

NPR case discussions

Case distribution

Roundtable/ New Business

Summary and review of action items from meeting

Adjournment:Clarification of next meeting date, time, and location Please forward agenda items to xxx by xxx

(All NPR forms and templates are available for download on the NPPC SharePoint site)NPR Minutes Template

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Date, Location, and Time of Meeting

Attendees (include credentials and title) Note if Present, Excused, or Absent

Topic Discussion Issue/Outcome

Safety Story, Moment of Excellence, Recognitions, New membersConfirm confidentiality of discussion; Approval of minutes

Monthly report update

NPR case discussions

Case distribution

Roundtable/ New Business

Summary and review of action items from meeting

Adjournment: next meeting date, time, and location. forward agenda items to xxx by xxx


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NPR TimelineNPR reviewers use a timeline to write down the timeline of the case review. It helps for the group to put it into perspective and better understand what should/could have happened.

Peer Review Comparative Timeline

RN Reviewer: _________________

MRN: ________________________

Notes: Month/Year:

Date

Time Actual (what did happen)

Intended (what should have happened)

Source

Questions/Comments

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Sample NPR Annual Nursing Executive Summary Date

Key Updates: Xx cases reviewed in 2019 (x% increase from cases reviewed in 2018)Xx cases reviewed in 2018 (x% increase from the cases reviewed in 2017)

Summary of Lessons Learned:Peer Review Process

Utilization of new timeline during case discussions emphasizing what happened, and what should have happened

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Nursing Opportunities

Non-voting member representing education added to Peer Review membership as a resource to educational needs

Summary of Case Trends

Medications o Awareness around transplant medications and when it is appropriate to hold

them and when they can be administered IV. o Question possible safety implications that could harm the patients such as “why

is ASA or heparin ordered on a patient with bloody stools?”o When holding a medication, must have a physician order to hold.

DKA o Early resuscitation of DKA patients involves aggressive fluid replacement. o Endocrinology should be included in the treatment plan for managing patients

on insulin pumpso Glucose coverage should be addressed preoperatively and postoperatively

Stroke o Patients with a change in neuro status must have a BEFAST exam performed o Understanding of Stroke Mimics and Stroke Chameleons

MRT o Awareness that an MRT should be called when questioning patient presentation

before the patient deteriorates o An MD order is not needed to call an MRT

Vital Signs o Know that if data not validated, data is lost forever o Understanding of importance of the Vital Sign Alert (VSA)o Any collection of abnormal vital signs including temperature readings or lack-of,

nursing will take action, assess patient, document and notify doctor

Communication o Clarify with the physician when admitting labs are not ordered on patientso Listen to family concerns who know the patient best o Reminder that Respiratory Therapist are an important part of the patient care

plan

Documentation 24

o Documentation must reflect the patient story and presentation o Document content of all conversations with physicians o Understand that documentation reflects the care given to patients

Referrals to Committees: Professional Practice:

Documentation of Intake and Output Survey to develop process improvement plan for accurate I&O Documentation

WOCN: Clarification necessary for appropriate use of LDSs for wound

documentation Nursing Leadership

Extensive discussion to determine if additional education is necessary carrying for hypothermic patients.

Education: SBAR for LDA’s for skin/wound assessments Handoff Tip Sheet: Electrolyte Replacement Trends (hyperlink to Electrolytes) Handoff tip Sheet: Diabetes Trends (hyperlink to Diabetes)


Definitions

Peer review. A collegial, systematic, and periodic process by which registered nurses are held accountable for practice and which fosters the refinement of one’s knowledge, skills, and decision- making at all levels and in all areas of practice (ANA, 2015, p 89).

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References(The following references are available in the Sentara Library SKOR in the NPR folder)

American Nurses Association. (1988). Peer Review Guidelines. American Nurses Association: Kansas City, MO.

American Nurses Association (ANA). (2015). Nursing: Scope and Standards of Practice (3rd ed). Silver Spring, MD: ANA.

American Nurses Association (ANA). (2015). Guide to the Code of Ethics for Nurses. Silver Spring, MD: ANA.

Barr, F. (2010). Nursing peer review: Raising the bar on quality. American Nurse Today, 5(9), 46-48.

Benner, P (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley, p 13-34. http://www.health.nsw.gov.au/nursing/projects/Documents/novice-expert-benner.pdf

Grootendorst, M. (2015). Stepping up professional practice: Implementing nursing peer review. American Nurse Today, 10 (12).

Haag-Heitman, B. & George, V. (2011). Peer Review in Nursing: Principles for Successful Practice. Sudbury, MA: Jones and Bartlett.

Haag-Heitman, B. & George, V. (2011). Nursing peer review: Principles and practice. American Nurse Today, 6(9), 48-53.

Morby, S., & Skalla, A. (2010). A human care approach to nursing peer review. Nursing Science Quarterly, 23(4), 297-300.

Shepard, L. (2011). Creating a foundation for a just culture workplace. Nursing, 41(8), 46-48.

Spiva, L., Jarrell, N. & Baio, P. (2014). The Power of Nursing Peer Review. JONA, 44(11), 586-597.

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