Implementing a Nursing Peer Review Process
by Valerie J. Hunt, PhD, RN
Ms. Hunt is Senior Vice President, Patient Care Services, for North Shore Medical Center, in Massachusetts
Successful collaboration between nurses and physicians has
a positive impact on nursing and physician satisfaction,
can reduce errors, and assists in the achievement of quality
clinical outcomes for the patient.1-2 Unfortunately, for many
organizations, the culture of collaboration does not extend into
the examination of adverse events and health care errors.
In 2006, as part of an effort to further enhance physician-
nurse collaboration across its health care delivery system,
North Shore Medical Center (NsMC) embarked on a new peer
review process to have its Nursing Division examine clinical
cases which had previously been discussed at NsMC’s Patient
Care Assessment (PCa) Committee from the medical (i.e.,
physician) perspective.
While the PCa Committee’s case reviews had long provided
an opportunity to identify nursing issues and system problems
related to the cases discussed, its mission (and time constraints)
limited the opportunity for an in-depth, thoughtful examina-
tion of nursing practice, recognition of practice patterns, and
determination of nursing action steps to mitigate patient
problems. Thus, by creating a nursing peer review forum, NsMC
more comprehensively addresses the nursing and systems issues
related to clinical cases with compromised or adverse outcomes.
That process, in turn, enables nursing to be better prepared for
collaboration with physicians during the PCa forum.
Nursing Peer Review Sessions
The Nursing Peer Review Committee comprises nursing
representation from management, education, clinical prac-
tice, performance improvement, and patient safety. Cases are
usually referred to the Committee by nurses, but may also be
referred by physicians, performance improvement personnel,
or customer service representatives. The nursing peer review
process begins with a review of the clinical case conducted
by a nurse leader who includes input from staff and others as
appropriate. When a case is reviewed and presented by a staff
nurse, the nurse manager, educator, or clinical nurse specialist
provides coaching and consultation. The consultation is also a
mechanism for a second level review of the case.
The case review opens with a narrative description of the oc-
currence clearly identifying any actual or potential nursing
problems, followed by a nursing history and assessment. The
hospital course consists of a detailed chronology of events and
the related timeline. Next, a preliminary assessment is docu-
mented; this identifies the factors contributing to the outcome
and any adverse events for the patient. An action plan includes
steps taken to address or mitigate patient problems. The writ-
ten report of the case analysis is presented to the full Nursing
Peer Review Committee (which meets monthly and typically
reviews two or three cases per 90-minute session).
Upon completion of the presentation, committee members
discuss the case, with discussion points documented in the
meeting minutes and recorded in the second part of the case
review format. Also included are any additional steps or recom-
mendations to the action plan from the Committee. For each
case, the Committee determines and records a single severity
index score, which is used to guide action plan priorities (see
Figure 1).
From the minutes of the meeting and the individual case
summary reports, a nursing database has been compiled of
all clinical cases presented. This database contains the nursing
practice issues identified and a summary of system improve-
ments and nursing actions taken. For the Nursing Division,
the database provides documentation of the comprehensive
work completed on professional practice issues and serves as
a guide to set future direction for improvements in nursing
practice and team collaboration.
Figure 1
Nursing Peer Review
Peer Review Session
Narrative Description (statement of occurrence/actual, or potential problem)
Nursing history and assessment
■■
Hospital course (includes chronology/timeline)■■
Preliminary assessment (factors contributing to outcome)■■
Action plan■■
Post Review Session
Discussion Points from Nursing Peer Review
Nursing peer review additions to action plan
■■
Severity Index Score: ■■
0: Acceptable standard of care
1: Minor variation from standard of care
2: Major variation from standard of care
Figure 2
Tips/Strategies in Implementation of
Nursing Peer Review Process
Include representatives from nursing education, nursing practice, performance 1.
improvement, patient safety, nursing management, and nursing research on
the committee.
Establish a non-punitive, “just culture” environment in which members are 2.
encouraged to actively participate.
Use evidence-based practice, review of the literature, and national benchmarks 3.
to guide case discussions and practice changes.
Provide coaching and second level review to nurses analyzing and presenting cases.4.
Document themes/patterns detected in patient cases.5.
Establish a database of nursing problems identified and action steps/ 6.
recommendations taken to address problems.
FORUM
May 2008
14
CRICO/RMF
