Nursing Peer Review Process

1
Nursing Peer Review Process
Overview

• Linkage to BPE/BP/Finance A nursing peer review
  process supports NMHs strategic objectives to
  provide the Best Patient Experience and employ
  the Best People because it creates a professional
  environment that assures quality care, creates a
  culture of safety, continuous learning and
  increased teamwork. In addition, a nursing peer
  review process links to the Henderson Framework
  for Practice.
• Problem Statement Peer review, as a form of
  self-regulation, is a recommended professional
  requirement in nursing. Currently, nursing does
  not have a formal structure for peers to review
  each others practice. There are processes for
  the review of general nursing practice issues
  through the Nursing Professional Practice
  Committee and for the review of system errors via
  the review of sentinel events, but the addition
  of clinical peer review would provide nursing
  with a vehicle to review the practice of
  individuals and groups and make recommendations
  for enhanced outcomes.
• Goal/Benefit A Nursing Peer Review Committee
  would advance nursings ability to advance a
  culture of patient safety, analyze nursing
  errors, minimize the reoccurrence of errors, and
  increase adherence to accepted standards of
  practice. Our overall goal is to establish a
  Nursing Peer Review Process and Committee to
  review nursing practice issues at NMH, track
  issues identified, and determine the outcomes of
  action taken as a result of peer review
• Scope The scope of this project includes peer
  review of staff nurse practice issues for nurses
  across NMH. All specialty areas will be included.
  The intent is to implement the peer review
  process by August, 2009. Peer review of APN
  practice is outside the scope of this committee.
• System Capabilities/Deliverables Deliverables
  will include (1) A set of guiding principles
  (2) A structure and process for peer review (3)
  Education materials and (4) A peer review
  committee charter.
• Resources Required Human resources for the
  development of clinical peer review, the support
  of the resultant structure, and the education and
  implementation of the committee.

Milestones Description Date (mo/yr) D
Charter development/Review of Lit 2/094/09 D
Form team/Hold 1st meeting /Review
data 4/09 MA Develop peer review process
using 6 steps in 4/096/09 Diaz
article I Educate members of peer review
nursing 7/09 quality committees
I Implement peer review process 8/09 C
Review cases after six months 2/10

• Key Metric(s) Numbers of cases reviewed by the
  Nursing Peer Review Committees will be tracked as
  well as the common issues identified and how they
  were addressed. We will also track recurrence of
  errors.

Executive Sponsor Michelle Janney RN, PhD,
NEA-BC Sponsor Deb Livingston, RN, MSN, NE-BC
Process Owner Ann Schramm, RN, MSN, NEA-BC,
Facilitator/Katie Doyle, RN, MSN, Chair of
Nursing Quality Patient Safety Committee
Improvement Leader Sue Morby, RN, BSN (Loyola
Graduate Nursing Student)